Safety First

OK, folks, raise your hands. Who's in favor of teenage pregnancy? How about teenage abortion? Childbirth?

Although the rate is declining, each year 600,000 American teenagers become pregnant; 30% will become pregnant at least once before the age of 20. According to the National Campaign to Prevent Teen and Unplanned Pregnancy, in 2010, births by teenage mothers cost the country $9.4 billion in health care, public assistance and lost income due to reduced educational attainment, to say nothing of the long-term public health and social costs to teenage mothers and their children.

Dr. Gina Secura and her colleagues at the Contraceptive CHOICE Project in St. Louis have published a case study of the effects of offering free long-term contraceptives to teenage girls. The participants were 1404 adolescents between 14 and 19 who were enrolled in the program between 2007 and 2011. They were recruited via referral from clinics, community flyers and word of mouth. To participate in the study, they had to be sexually active or say they were planning to be, and not want to become pregnant.

All participants received a standard counseling session in which the risks and benefits of alternative contraceptive methods were reviewed and questions answered. After making a choice, participants were provided with their chosen contraceptive option free of charge. Followup interviews were conducted by telephone at three months, six months and every six months thereafter for the next two or three years (depending on when they enrolled). They received a $10 gift card for each completed survey. The one, two and three year followup rates were 92%, 82% and 75%. Rates of pregnancy, birth and abortion were compared both to their age cohort in the general population and their sexually active age cohort (since enrollment was limited to those who were or planned to be sexually active). Here are the data, reported as the number of pregnancies, births and abortions per 1000 in the population.

	CHOICE Project	U. S. Population	Sexually Active Teens
Pregnancy	34.0	57.4	158.5
Birth	19.4	34.4	94.0
Abortion	9.7	14.7	41.5

Comparing the CHOICE participants to sexually active teens in the general population—the more appropriate comparison group—shows that they became pregnant and gave birth at 21% the national average, and had abortions at 23% the national rate. The CHOICE Project reduced unwanted pregnancy more for older (18-19) than younger (14-17) girls, and more for African-American than White participants.

The project was effective primarily because the majority of participants—68.4% of the older and 77.5% of the younger girls—chose long-acting reversible contraceptive (LARC) methods, either the hormonal or non-hormonal IUD or the etonogestral implant, rather than birth control pills, rings, patches or injections. These methods don't require participants to remember to reuse them and have a close to zero failure rate. But fewer than 5% of teenagers in the general population use LARCs. The researchers report that most of their participants had never even heard of them.

The study doesn't separate the effects of counseling, the contraceptive method, or the fact that the contraceptives were free, and it's likely that all these factors played a role. Other limitations of the study include its less than 100% response rate, its reliance on self-report data about pregnancies, the possibility that the followups reminded some participants to use their contraceptives, and the requirement of parental consent for the 14 to 17-year-olds, who may have been at lower risk of pregnancy than those whose parents did not consent. These drawbacks may be balanced by the high percentage of African-American (60%) and poor teenagers in the CHOICE Project, who are at greater risk of unintended pregnancy than the general population.

Rarely do we have a chance to report a study that is so effective in solving an important social problem, and that provides such a vivid reminder of the superiority of prevention over remediation. The cost of these birth control methods varied, with the LARCs being more expensive—$400 to $1000 depending on the method and the individual. To this must be added the costs of recruitment, counseling and followup. All of this is a pittance compared to the medical and social costs of unwanted pregnancy. We have the technology; what we lack is the political will.

In theory, the Affordable Care Act requires insurance companies to cover all forms of contraception with no co-pay, but there is no reason for insurance companies to publicize this option.  And there are other problems:

• Doctors probably don't follow as good a script as the CHOICE Project counselors, and are not as aggressive in recruitment and followup. In general, doctors get paid less for time spent talking to patients than other activities.
• Teenagers, who are usually covered by their parents' insurance, may not seek contraceptives because the visit will show up on their parents' statements.
• According to the National Health Interview Survey, 18.4% of Americans aged 18-64 were uninsured during the first three months of 2014. Girls from uninsured families are probably at greater risk of unwanted pregnancy than those whose families are insured.

The Secura study argues strongly for a single-payer health care system, not only to guarantee that everyone is covered, but also because government can prescribe a uniform set of procedures to be followed by doctors when discussing birth control with teenagers.

Newspaper articles about the Secura study mention anticipated resistance from conservatives who believe that providing teenagers with contraceptives encourages sexual activity. But these articles fail to mention that research doesn't support the claim that education about contraceptives encourages teenagers to have sex. (That would be rude.) In fact, the reverse is true. Comprehensive sex education is associated with delayed or reduced sexual activity.

You may also be interested in reading:

No Longer in Mourning

Freedom Of . . . /Freedom From . . .

Living Downstream

A Nous la Liberte

Each week, Dr. Aaron Carroll, one of the bloggers at The Incidental Economist, releases a 5-10 min video called "Health Care Triage," in which he discusses current issues in health. This week's installment will be of special interest to single payer advocates, since it concerns the French health care system, which he considers the best in the world. You may not know whether to laugh or cry.

In previous weeks, Dr. Carroll has also discussed the Canadian system--not as good as France's, but much better than ours. He often discusses empirical issues, such as whether organic food is better for your health. If you sign up, You Tube will send you an e-mail each time a new video in this series is released.

You may also be interested in reading:

Conceptualizing Health Care Policy

The Oregon Health Experiment: The Gift That Keeps On Taking Away

Be prepared for a barrage of conservative criticism of the Affordable Care Act (ACA) that may be assumed to have negative implications for single-payer health care as well.

As I've noted before, the Oregon Health Experiment is a randomized control group design, far superior to most health care research. In 2008, Oregon hoped to expand Medicaid, but didn't have enough money, so they held a lottery. They invited everyone who was eligible to apply. Of the 90,000 applicants, 30,000 were randomly selected to receive Medicaid, while the losers became eligible for the control group. In previous data analyses, it was found that the Medicaid group spent 35% more on health care than the control group. They visited primary care physicians (PCPs) and were admitted to hospitals more often, and spent more on prescription drugs. They were also healthier and freer of financial worries, although most of the health differences are not statistically significant due to insufficient sample sizes in the study.

A new analysis by the Oregon research group reports that the Medicaid participants were also more likely to visit the emergency room (ER). Specifically, during their first 18 months on Medicaid, they made an average of 1.43 ER visits compared to 1.02 in the control group—a 40% difference.

This should not have been a surprise. If you reduce the cost of a service, people are more likely to use it. However, some ACA proponents claimed that Medicaid expansion would save money by reducing ER use. Although the ER accounts for only 4% of health care spending, an ER visit is more expensive than visiting a doctor. The pro-ACA argument was that if patients established a relationship with a PCP, they would have a place to go for medical care and these doctor visits would prevent potential emergencies. For example, Health and Human Services Secretary Kathleen Sebelius said in 2009:

Our health care system has forced to many uninsured Americans to depend on the emergency room for the care they need. We cannot wait for reform that gives all Americans the high quality, affordable care they need and helps prevent illnesses from turning into emergencies.

It is important to note that these results are not due to the fact that Medicaid provides health insurance for poor people. Private health insurance patients are also more likely to use the ER than the uninsured.

Increased ER use might not be seen as a problem if the visits were real emergencies. However, the study found ER use to be higher even for non-urgent care that should ideally have been treated by a PCP. These results could be used by the opposition to suggest that single-payer might cause an massive influx of people outside the ER waving torches and pitchforks and demanding free care.

There are several considerations that may place these results in clearer perspective.

• The time frame of the study, 18 months, may not have been sufficient to change uninsured people's lifelong habits of going to the ER every time they were sick. A three-year study of Romneycare in Massachusetts found an estimated 5-8% reduction in ER use.

• Medicaid expansion could have been accompanied by education regarding when to go to the ER and when to visit your PCP. Of course, some may argue that education is not enough and should be supplemented by punishment, such as a co-payment, for “inappropriate” ER use.

• Taking a broader view, the problem may be with the health care system rather than the patients. PCPs tend to be available Monday through Friday from 9 to 5—times that are inconvenient for most employed people. You can't always get same-day appointments with a PCP. A 2012 survey by the Commonwealth Fund found that in the US, only 35% of PCPs see patients after hours. In nine European countries and Canada, the average was 80%.

This study is one of a growing number that show that providing health insurance to the uninsured alone does not save money. The ACA contains some cost controls, such as the Independent Payment Advisory Board, which may eventually reduce costs. Single payer eliminates the cost of private insurance, which will save much more. Other changes may be needed. One of them may be asking PCPs to become more consumer-friendly by seeing more patients on evenings and weekends.

You may also be interested in reading:

Big News From Oregon--Not All of It Good

Tom Corbett to PA's Working Poor:  "Drop Dead"  Part 1.  Medicaid Improves Health and Saves Lives

Letters, . . . We Get Letters

When it comes to persuading the Pittsburgh Post-Gazette to publish my letters, I'm batting about .050. My one success, almost ten years ago, was a note about music. Of course, newspapers get many letters, and it's their right to choose which ones to publish. Ordinarily, I wouldn't bore you by griping about their decisions. However, I've managed to persuade myself that my latest experience may be of interest to other letter writers, so I'm going to risk playing the fool.

My story begins on December 8, when the P-G published Molly Rush's letter advocating single payer health care. This was followed on December 16 by a reply from Jim Roth—a pharmaceutical salesperson(!)—implying that single-payer is too costly and denies health care to some citizens. If you're going to continue, you should stop and read Mr. Roth's letter.

The next day, I wrote the following:

Mr. Roth notes that all countries with single-payer finance it with a value added tax. However, the type of tax used to fund health care is irrelevant. The important point is that single payer costs those countries considerably less than our complex system of public and private insurance. According to a 2013 report of the Organization for Economic Cooperation and Development (OECD), the US currently spends on average $8,508 per person each year on health care, compared to an OECD average of $3,322. Yet the US is 26^th out of 40 OECD countries in life expectancy. The amount Americans spend on health care due to the combined burden of taxes, insurance and out-of-pocket costs would be greatly reduced under single-payer.

Mr. Roth claims that people in single-payer countries have longer wait times for elective surgery and are sometimes denied such care. This depends on the country and what you consider “elective surgery.” US insurance companies also refuse to cover some elective procedures. However, if these were serious problems, you would expect residents of single-payer countries to be dissatisfied with their country's health care system. A 2013 survey by the Commonwealth Fund compared consumer satisfaction in the US to nine European countries and Canada, all with single-payer. Americans were by far the most dissatisfied,with 75% saying the system needs fundamental changes or should be completely rebuilt.

Finally, Mr. Roth suggests that we could lower health insurance costs by allowing it to be sold across state lines. It is true that if some states were to deregulate health insurance and if residents of any state were allowed to buy that product, premiums might come down. But those people would be buying insurance with little value should they become seriously ill. The Affordable Care Act is intended to prevent exploitation of consumers by establishing a baseline definition of adequate health insurance.

Of course, the primary purpose of single-payer is not just to save money, but to save the lives of some of the millions of Americans who are currently uninsured.

On December 29, the P-G published two replies to Mr. Roth. Both offered primarily anecdotal evidence suggesting that at least one family—the author's—had lived in a single-payer country and was satisfied with their health care system. The main difference between them is that the first referred to the British system and the second the Dutch. While both were well-written and persuasive, I thought they were redundant, and might have been better supplemented by my data referring to larger numbers of people and countries.

It's possible my letter was rejected because it is poorly written or exceeds their 250-word limit. However, Mr. Roth's letter, at 318 words, also breaks this rule, as do many others they publish. They could easily have edited my letter. Clearly, exceeding the word limit was a mistake. In retrospect, I should have dropped the third paragraph.

My hypothesis, based on this and other previous experiences, is that my letter was rejected because it contained too much data. Imagine an experiment in which parallel letters to the editor are sent to a random sample of newspapers. Both letters would make exactly the same points, but one would support each point with research, while the other would support them with anecdotes or merely claim that these were the author's personal opinions. My guess is that fewer of the data-driven letters would be published.

I have two possible, though somewhat inconsistent, explanations for my hypothesis. The first assumes that the editors wanted to present the single payer argument sympathetically. It's based on a common cognitive error known as the base-rate fallacy. People find anecdotal evidence more persuasive that statistical base rates, even though the base rates summarize data from larger, more representative samples. The people who made the decision may have found the two letters they published to be more persuasive than mine.

My second explanation makes the reasonable assumption that the gatekeepers at the P-G are opposed to single-payer. If so, they may assume that my inclusion of data makes the letter too persuasive. That is, they may be willing to acknowledge that there are some Pittsburghers who favor single-payer, but it may be unrealistic to expect them to publish statistics suggesting that the arguments of single-payer advocates are factually correct.

I hope I'm wrong. I really want to encourage the use of research evidence to change the health care system, and society in general, for the better. If this strategy is counterproductive, that's genuinely disturbing.

You may also be interested in reading:

Death By Anecdote, Part 1

Are You Feeling Lonely?

Where's the Outrage?

Drs. Peter Ubel, Amy Abernethy and Yousuf Zafar, all medical doctors, published an editorial in The New England Journal of Medicine entitled “Full Disclosure—Out-of-Pocket Costs as Side Effects.” An abbreviated version by Dr. Ubel appeared as an op-ed in The New York Times as “Doctor, First Tell Me What It Costs.” They argue that, just as doctors typically discuss negative side effects of drugs and medical treatments with their patients, they should also discuss the financial cost of drugs and medical treatments before the patient makes a decision. These costs should be treated as a potential side-effects because stress from the threat of financial ruin can adversely affect the patient's health. They note that cost is sometimes not discussed because both patients and doctors are too embarrassed to bring it up.

Some examples of costly decisions are given.

• Bevacizumab (or Avastin), a drug which extends the lives of colorectal cancer sufferers an average of five months beyond chemotherapy alone, has a median price of $44,000. A patient on Medicare would be responsible for 20% of that cost, or $8800.

• A breast cancer patient with a high deductible health insurance policy faces average out-of-pocket costs of $55,000—obviously, more than the life savings of most Americans. A person with a high deductible plan faces a bill of $40,000 for myocardial infarction, and $4,000 per year for management of “uncomplicated” diabetes. (Meanwhile employers are increasingly shifting workers to insurance policies with higher co-payments and deductibles.)

The authors state four reasons it would be beneficial for doctors to inform patients in advance of the cost of treatment. My comments on each are in parentheses.

1. Informing the patient of the cost of treatment may cause some patients to switch to a less expensive alternative treatment that is just as effective. (Why would a doctor ever recommend a drug or treatment if there is an equally effective and less expensive alternative?)
2. Some patients may be “willling to trade off some chance of medical benefit” in exchange for lower cost. (This possibility, which the authors refer to as “complex and ethically charged,” gets to the heart of the matter. Some patients may choose to forego treatment rather than leave themselves or their families bankrupt. It is implied that knowing the full cost of treatment may persuade some folks to commit passive suicide.)
3. Patients could attempt to obtain financial assistance in advance of the treatment. (An example is given of someone who was able to obtain help from a charity—a rare event, at best.)
4. “A growing body of evidence” suggests that if patients take cost into account, it “might reduce costs for patients and society in the long term.” (However, there is no citation to this body of evidence and the authors do not elaborate. They may mean that if everyone became more cost-conscious, prices might come down, but does the health care industry operate the same way as other more competitive markets?)

It seems so obvious that doctors should discuss costs with patients that it hardly seems necessary for NEJM to publish an editorial suggesting that they do so. But the most revealing thing about this article is the issues Ubel and his colleagues don't even mention.

First of all, they don't ask why the costs of drugs and medical treatment are so much higher in this country than in other industrialized countries. Medical costs are treated as if they were merely an uncontroversial feature of the natural environment, and no mention is made of how they might be reduced.

My colleague Paul Ricci has blogged frequently—for example, here—about how we're spending much more per person on health care than other countries, and getting mediocre results. Ezra Klein has posted 21 graphs with comparative data on the costs of specific drugs and medical treatments. Medical bills account for over 60% of U. S., bankruptcies, and 75% of people with medically-related bankruptcies had health insurance.  A 2013 survey of 11 countries by the Commonwealth Fund found that Americans were more likely than residents of the other ten countries to forego health care because of cost and to have difficult paying for care even when they were insured.

There is some objective data comparing the causes of our higher prices. A 2012 study by the Institute of Medicine, a division of the National Academy of Sciences, estimated that the U. S. health care system wastes $750 billion a year, roughly 30% of the money spent. The report identified six major areas of waste: unnecessary services ($210 billion annually), inefficient delivery of care ($130 billion), excess administrative costs ($190 billion), inflated prices ($105 billion), prevention failures ($55 billion), and fraud ($75 billion). Our doctors are more highly compensated than doctors in the rest of the world. Our hospitals attempt to maximize their profits, regardless of whether they are legally registered as for-profit or nonprofit corporations. Part of the problem is political corruption. For example, when Congress expanded Medicare to include prescription drug coverage, Medicare was forbidden to use its purchasing power to negotiate for lower drug prices.

More importantly, the authors don't even question why it is necessary for so many Americans to choose between financial ruin and illness or death when they suffer from common medical conditions. They fail to mention that the rest of the world's developed countries have largely solved this dilemma by establishing government run single payer health care systems. If this were merely a matter of money, we could talk about the vast sums this country wastes on overseas military misadventures, or the way our billionaires grow increasingly rich while paying lower tax rates than their secretaries. But these outrages are irrelevant, since a single payer system will save money. All the countries with single payer spend less per capita on health care than we do.

To be fair, Ubel does say, “No one should have to suffer unnecessarily from the cost of medical care.” But he fails to pursue any of the implications of this remark. The authors never make the point that single payer would almost certainly solve many of the financial problems they agonize over in these articles. I suppose it's possible Ubel and his colleagues are secretly hoping to build momentum for single payer by encouraging doctors to empathize more with their patients, but there's nothing in the article to support this speculation.

To paraphrase a point frequently made by Noam Chomsky, no one becomes a tenured professor at an elite university, or is invited to write an editorial for The New York Times, unless he or she has completely internalized the world view of the ruling class, and in the process learned to ignore all the really important issues facing our society.

You may also be interested in reading:

Why Are American Health Care Costs So High?

New Time Magazine Article on Health Care Costs

Protecting the Parasites:  The Irony of Obamacare

Conceptualizing Health Care Policy

Mike Konczal has written an important article in which he asks: (1) What parts the Affordable Care Act (ACA) are not working well, and why?, and (2) What does this imply about future developments in health care policy? Will government abandon the effort to provide health care for all, or will we move toward a single-payer system?

Paul Krugman has described the ACA as a “kludge.” It is too complicated, and those complications are making the system inefficient and expensive, while depriving many Americans of health insurance. Konczal notes four specific problems:

1. The process of signing up for health insurance in the federal exchange (HealthCare.gov) is complicated because everyone must be means tested. The government must be able to confirm virtually every datum the applicants enter: their identity, their citizenship, their income, their eligibility for coverage through other federal or state programs, etc. All this is necessary to determine whether each applicant is entitled to a subsidy, and if so, the amount.
2. A further complication is that each applicant must be matched to a private insurer. The government must check that all of the thousands of insurance plans meet their minimum standards. They must clearly communicate the important characteristics of each policy to consumers, even though the insurance companies deliberately try to confuse them. They must contend with insurance company sabotage such as canceling plans abruptly and arbitrarily raising rates.
3. The ACA faces the threat of adverse selection—the possibility that the oldest and sickest among us will patiently navigate the exchange and eventually purchase a policy, while the youngest and healthiest will ignore the law and hope the penalty for not buying insurance is unenforceable. If Americans in poor health are more likely to buy insurance, the costs go up and there is a very real possibility that the system will collapse.
4. Finally, the federal government has to deal with attempted sabotage by states controlled by Republican governors and legislatures, exemplified by their refusal to set up state exchanges and to participate in Medicaid expansion, which is denying coverage to over 5 million low income Americans.

Summarizing these problems, Konczal describes two approaches to social insurance, which he calls Category A and Category B.

Konczal describes Category A as the “neoliberal” approach to public policy. Neoliberalism has, in recent years, become a synonym for conservatism. It refers to policies that reduce the role of government in public life through strategies such as privatization and deregulation. Category A social insurance sees the government as “an enabler to market activities, with perhaps some coordinated charity to individuals most in need.”

Category B, on the other hand, encompasses progressive programs such as the New Deal and the Great Society. It sees certain goods and services, such as food, shelter and health care, as basic human rights, and attempts to remove them from the marketplace by providing them to everyone.

There are very few pure examples of Categories A and B; most policies fall somewhere along a continuum between these extremes. However, the ACA falls clearly into Category A. This is not surprising because it is a plan devised by a conservative think tank which was promoted for decades by the Republican party. Social Security and Medicare, on the other hand, fall into Category B. Medicaid is a hybrid, since it is means tested and administered (and regularly sabotaged) by the states.

In the last three decades, we have seen a gradual rollback of Category B programs. This is not surprising, given the extent to which the political system is controlled by corporations and wealthy individuals. In the old days, the Republicans favored Category A and the Democrats Category B. As both parties have shifted to the right, the Democrats have shifted their allegiance to the Category A policies favored by their corporate donors, while many Republicans advocate eliminating social insurance entirely.

Whenever a public service is privatized, it moves from Category B to A. This is what happens, for example, when you turn over tax dollars to charter schools, so that corporations can make profits by educating children as cheaply as possible. Of course, the ultimate disaster for the country would be the Republican plan to privatize Social Security, since another Great Recession—a virtual certainty in the absence of financial reregulation—would have the potential to impoverish our elderly population.

PA Governor Tom Corbett's proposal to expand Medicaid would move this program further toward Category A through a combination of stricter means testing and turning the program over to private insurance companies. Dave Steil, President of Healthcare 4 All--PA, has written an op-ed critizing the Corbett plan. He rightly notes the waste of money that would result from turning Medicaid over to private insurance companies. However, he overlooks the hardship that increased means testing, premiums and copayments will impose on working class Pennsylvanians.

Advocates of single payer health insurance—obviously a Category B program—are going to be urinating into a stiff wind for the foreseeable future. However, there is some hope. It is the four Category A characteristics noted above that are turning the ACA into a “kludge.” While Republicans will argue for repeal, pragmatists are likely to notice that if you drop some of these characteristics, you can improve health outcomes while saving money. And if you drop all four, you have single payer.

You may also be interested in reading:

The Coverage Gap:  The Real Failure of Obamacare

A Clouded Vision, Part 1:  The Stick

A Clouded Vision, Part 2:  The Carrot

Why Are American Health Care Costs So High?

Here's a 8-minute video by author John Green that repeats some arguments that are familiar to single-payer advocates, but in a very clear and concise way.

The Friday Morning Quarterback

So much is being written about yesterday's Supreme Court decision “upholding” the Affordable Care Act (ACA) that it's hard to gain a clear perspective on the consequences of the decision. One week for now, I may regret most of what I've written here.

Here's the Court's decision. For those interested in just the basics, check out The New York Times' annotated summary. However, I recommend that everyone read Justice Ruth Ginsberg's dissent (which starts after p. 59) in its entirety. It's a masterpiece of clarity and common sense.

In reacting to the decision, I think President Obama hit the right note by refusing to discuss its political implications and focusing on the millions of Americans who are or will become seriously ill who will benefit from the decision. Paul Krugman had a similar reaction.

Let's face it. Regardless of Chief Justice John Roberts' motives, we dodged a bullet here. Just look at the decisions—both good and bad—that were announced this week: the reaffirmation of Citizens' United by striking down Montana's campaign finance reform law, the rejection of mandatory life sentences for juveniles, the upholding of Arizona's right to stop and detain people merely because they appeared to be Hispanic. A conservative, activist Supreme Court has inserted itself into the history of the country with consequences that will be difficult or impossible to reverse. The most important issue in November's presidential election may be its implications for future Supreme Court appointments.

Roberts' denial that the ACA constituted the “regulation of interstate commerce,” when health care accounts for 18% of GDP, is not just absurd. The implications of ruling that people who refuse to buy health insurance are not engaged in interstate commerce because they haven't bought it yet are difficult to foresee. In the past, the commerce clause has been used to justify a variety of labor, public health and safety, and civil rights laws that protect people who are not directly engaged in interstate commerce, but who are indirectly affected by its consequences, i.e., people who live downwind from a source of industrial pollution. These reforms now appear endangered by this decision. Does this mean that corporations may refuse to hire or serve minority applicants because, after all, if they are excluded from participation, they are not engaged in interstate commerce? How will this decision impact Congress's ability to implement a national energy strategy by, for example, requiring people to purchase some of their energy from renewable rather than nonrenewable sources?

One important provision of the ACA that the Supremes failed to uphold was the expansion of Medicaid. Under the ACA, Medicaid was expanded to cover all folks under 65 whose incomes are 133% of the federal poverty level or less. This amounts to about half of the 30 million people who are not now insured, but would be under the ACA. Medicaid is administered by the states, but the federal government agreed to provide 100% of the money for the Medicaid expansion in 2014. This was to be gradually reduced to 90% in 2020. The incentive for states to comply was that, if they refused, the federal government would withhold all their Medicaid funds.

Chief Justice Roberts thought this was too coercive, a “gun to the head” of the states. This is the first time in our history that a state spending requirement has been rejected as too coercive. What other federal requirements will states object to? In 1987, the states were told that all federal highway funds would be withheld unless they agreed to raise the drinking age to 21. Presumably the Roberts court would consider this too coercive. Federal funds for public education are contingent on the states' meeting federal standards. Is that too coercive?  

Will the states implement the Medicaid expansion even though there is no penalty for refusing to do so? The Democrats are optimistic. How can the states justify withholding benefits from poor people that are paid for entirely by the federal government? That's like turning down free money, right? However, just within the last three years, some states have turned down federal stimulus money and even unemployment benefits for their citizens. The Jackasses may have underestimated the extent of some Americans' hostility toward the poor, especially those Americans who mistakenly think that most Medicaid recipients are African-Americans.

If not all states implement the Medicaid expansion, the states in which this coverage is most likely to be denied are those whose citizens have the greatest need for it—states like Alabama, Mississippi, Louisiana and Texas. Although experts are still working out the detailed implications of yesterday's decision, it appears that, because the ACA assumes that the states will implement the Medicaid expansion, most of the people below 133% of the poverty level in any states that refuse to expand Medicaid will also be ineligible for low income subsidies to help them purchase health insurance. What a mess! Health care is far too important to be left to the states.

Finally, let's remember that the ACA is no substitute for a single payer health care system. Even if it is completely implemented, it still leaves 27 million people living in this country uninsured. As presently written, it does little to control either the cost or the quality of our health care. Needless to say, there is still a lot more work to be done.

Unrealistic Optimism

Yesterday, I received an email that linked to 29 different op-ed articles, some by politically astute folks like E. J. Dionne, Robert Reich and Eugene Robinson. All of them suggested that if the Supremes rule the Affordable Care Act (ACA) unconstitutional, this opens up an opportunity to pass single payer health care legislation, since it is a better solution to many of the problems the ACA was intended to address, and it is clearly constitutional. Some of them referred to passage of single payer as “inevitable,” although, to be fair, some of them also called it a “long-term” solution to the health care crisis.

If you read my post on this week's events at the Supreme Court, you know that I'm seriously out of step with these political heavy hitters. We all enjoy reading optimistic articles, but as much as I hope they're right, I'm afraid these authors are more engaged in wishful thinking than the realistic prediction of future events.

Apparently MSNBC commentator Chris Hayes read some of these same op-eds. This morning, on Up with Chris Hayes, he asked Senator Sheldon Whitehouse, Jackass from Rhode Island, if he could foresee any “plausible scenario” by which rejection of the ACA might lead to the passage of single payer. Whitehouse's answer was an unequivocal no. He pointed out that this week the House refused to pass even a seemingly non-controversial highway transportation bill that he said would have created three million jobs.

These optimistic-eds seem to overlook the campaign financing, lobbying and advertising power of the “corporate persons” that us sell health insurance. Not only is single payer rejected by 100% of the Elephants, it is opposed by President Obama and a majority of the Jackasses as well.

When a major health care reform initiative has failed in this country, it has taken a long time for someone to try again. It was almost 20 years between the failure of the Clintons' reform proposal and the passage of the ACA. As we're all learning, just because we have a serious problem in this country, that doesn't mean our government will try to solve it. Every year, 45,000 Americans lose their lives due to lack of or inadequate health insurance. Very few of these people contribute to political campaigns.  As Ezra Klein, one of those "optimists" who sees single-payer only as a distant possibility, states:

The key word here is “eventually.” This is a long, ugly process that ensures a very large uninsured population for decades. . . [I]n the decades between here and there, there will be a lot of unnecessary suffering and deaths among the uninsured. That's the real cost of losing this opportunity to insure 30 million people.  

If you're hoping the Supremes strike down the ACA, be careful what you wish for.

Protecting the Parasites: The Irony of Obamacare

Earlier this month, the Green Party called on the Supremes to strike down the individual mandate and put an end to the Affordable Care Act (ACA). Their argument is that the ACA is merely a multibillion dollar public subsidy for the insurance, pharmaceutical and medical industries. This is certainly true. But they go on to predict that if the ACA were declared unconstitutional, this would hasten the passage of a single payer, or Medicare for All (as they call it), health care system. (The usually astute economist Robert Reich has made a similar argument.)

As much as I sympathize with their goals, I find that hard to believe that a single payer health care system will make its way through Congress in the near future, even in the unlikely event that a re-elected President Obama were to support it. If he didn't have the votes to support even a public option in early 2010, when the Jackasses controlled the House and had a veto-proof majority in the Senate, what are his chances of passing an all public system in 2013? And how will an overturning of the act by the Supremes affect Obama's chances of re-election? Are you ready for the endless barrage of super PAC-financed TV ads reminding voters that Obama's “signature accomplishment” has been rejected by the courts?

The public also wants the ACA to be overturned. According to a New York Times poll, 29% want the Supremes to overturn the individual mandate, which requires all Americans to purchase health insurance, and another 38% want them to overturn the entire law. After three days of debate, it looks as though they will get their wish. This morning's Washington Post reports that the Supremes “may be on the brink of a major redefinition of the federal government's power.”

Justices on the right of the deeply divided court appear at least open to declaring the heart of the overhaul unconstitutional, voiding the rest of the 2,700-page law and even scrapping the underpinnings of Medicaid, a federal-state partnership that has existed for nearly 50 years.

Of course, you can never predict the Supremes' decision solely on the basis of oral arguments. But if you doubt that they are seriously considering it, remember that they spent 1.5 hours Wednesday discussing what should happen to the rest of the ACA if—or is it when?—the individual mandate is overturned.

This is not a game. With all its flaws, the ACA extends health insurance to 32 million people not previously covered. Without that coverage, we return to a status quo in which 45,000 Americans die every year from lack of health insurance. The Elephants don't have an alternative plan. Their plan B is to “let them die.”

I can point you to a serious article giving at least three constitutional bases for the ACA, but in fact, it's a no-brainer. John Cassidy has referred to this legal case as a “bad joke.” Robert Parry refers to the justices as “clowns.” Who could possibly believe that Congress has no right under the Commerce Clause to regulate the health care, an industry which accounts for 17.6% of GDP? In 2005, Justice Scalia wrote a concurring opinion in Gonzales v. Raich, in which argued he that the Commerce Clause gave government the right to prohibit the sale of medical marijuana. I don't know what percentage of the nation's health care dollars are spent on medical marijuana. Let's say it's about one-tenth of 1%. Are the conservative justices saying that the sale of medical marijuana is important enough to affect interstate commerce, but the entire health care industry is not? Seriously?!?  It's hard to see this as anything but a farce.

In my opinion, all the verbal jousting going on this week is intended to mystify the public and give judicial cover to the five conservative justices, so they can do what they intended all along: Help the Elephant Party to ensure that Barack Obama will be a one-term president whose four years in office are remembered as a failure. This should not be unexpected. Previous lineups of the Supremes have already allowed politics to trump both the Constitution and legal precedent.

This brings us to the Supreme irony of Obamacare. It appears that the ACA will be destroyed by the individual mandate—an Elephant proposal that Obama was initially reluctant to accept, and that he agreed to in order to save our privatized health care system from the threat of single payer.

During the 2008 campaign, Obama opposed the individual mandate, which Hilary Clinton supported, because he knew it would be perceived as a restriction of individual freedom and there would be a backlash. Why did Obama eventually agree to include something as unpopular as the individual mandate? Basically, it was to save the private health insurance companies.

Insurance companies make money by covering healthy people and denying coverage to those who are sick—or refusing to pay the medical bills of their clients who get sick. That means that in this country, if you develop a serious illness, you are for all practical purposes uninsurable. Americans in this unfortunate situation either become dependent on some sort of public program, die sooner than they otherwise would, or both.

To avoid this, you could require the insurance companies to insure everyone (called guaranteed issue). But if they are forced to cover sick people, they will charge them an amount that most of them can't afford. To avoid this, you could require the insurance companies to charge everyone the same amount regardless of their prior medical history (called community rating). But if you have both guaranteed issue and community rating, there is no logical reason for healthy people to purchase insurance. They can simply wait until they get sick, confident that the insurance companies will have to cover them at an affordable rate. This is known as adverse selection—the tendency for people who buy health insurance voluntarily to be less healthy than the general population. This causes insurance company profits to go down, rates to go up for everyone, and eventually the entire system descends into chaos. To avoid this, you have to require everyone to buy insurance—the individual mandate. This ensures that there are enough healthy people in the system to spread the risk and make insurance affordable for all.

But there's another way. You could simply bypass the insurance companies. Collect the money that people would otherwise pay for insurance premiums up front as taxes and use it to insure everyone. In other words, you could establish a single payer system. This is how social security and Medicare are financed. It would be politically difficult to argue that they are unconstitutional (although some of the arguments currently being advanced against the individual mandate imply that they are).

This irony at the heart of Obama's dilemma was not lost on at least one of the Supremes, Justice Ruth Ginsberg, who noted on Tuesday that:

There's something very odd about that, that the government can take over the whole thing and we all say, oh, yes, that's fine, but if the government wants to preserve private insurance, it can't do that.

Of course, single payer would eliminate the health insurance business. But that's exactly what we should do! Health insurance consumes about 20% of medical spending and provides no useful service in return. It's a giant parasite that sucks up our resources, even as it adds additional misery to the lives of some of our sickest citizens. Eliminating that 20% surcharge virtually guarantees that the extra amount people pay in taxes for single payer will be less than they are currently paying for health insurance.

(That's not the only way single payer will save money. Single payer will give the government the bargaining power to negotiate lower prices for prescription drugs and to rein in the exhorbitant fees paid to doctors and hospitals. Needless to say, big pharma and the for-profit hospitals oppose it too.)

So why couldn't Obama propose a single payer health care system? As the media put it, single payer was “not politically feasible.” That's media-speak for a proposal that is favored by the majority of the American people, but opposed by the “corporate persons” who finance our political campaigns. And in a political system that's basically just legalized bribery, those who finance the campaigns are the only ones who really matter. The richest 1% not only bought and paid for Obama, but most of Congress as well. Had he proposed single payer, he would have faced opposition not only from the Elephants but also from the majority of his fellow Jackasses.

Or as E. J. Dionne put it:

The individual mandate was a conservative idea that President Barack Obama adopted to preserve the private market in health insurance rather than move toward a government-financed single-payer system. What he got back from conservatives was not gratitude but charges of socialism—for adopting their own proposal.

No matter how often he kisses their behinds, the 1% will never accept the legitimacy of Obama's presidency.

Give some credit to the conservative propaganda apparatus. They have successfully framed the individual mandate, the central issue of the debate, as an attack on personal freedom. “The government is trying to force you to buy health insurance.” This is reinforced by a series of wildly implausible slippery slope arguments. “If the government can force you to buy health insurance, then it can also force you to buy broccoli, or a cell phone, or gay pornography!” (Naturally, such proposals are likely to sail through Congress with little dissent.) An American public that lacks the ability or motivation to think critically appears to be buying into this fallacy.

I think Slate's Dahlia Lithwick nailed it when she pointed out that, “This case isn't so much about freedom from government-mandated broccoli or gyms. It's about freedom from our obligations to one another. . . It's about freedom to ignore the injured, walk away from those in peril. . . It's about the freedom to be left alone.”

During Tuesday's oral argument, Solicitor General Donald Verilli argued that health care is different from other markets because we don't just let sick people die. “(G)etting health care service,” he said, “[is] a result of the social norms to which we have obligated ourselves so that people get health care.”

To which Justice Scalia replied, “Well, don't obligate yourself to that.”

Accountable to Whom?

An article by Ezekiel Emanuel and Jeffrey Liebman promises “the end of health insurance companies.” According to these former Obama administration advisors, they will be made obsolete by accountable care organizations (ACOs).

The Affordable Care Act provides for the establishment of ACOs to serve Medicare and Medicaid patients. Essentially, a group of health care providers (doctors and/or hospitals) form an ACO and sign a contract with the government to provide care for a large group of patients. They receive a bundled payment based only partially on services provided. Some part of the payment is based on the quality of the health care they provide and their ability to control costs.

In theory, cost control can be done by better coordination of patient care, for example, with the help of computerized records. Since so much of medical care is unnecessary or harmful, a lot of money could be saved, provided the incentives were greater than the profit to be made through overtreatment. It should at least be possible to measure whether money is being saved in comparison to the current fee-for-service system.

Measuring quality of care is more difficult. But it is crucial, since without it, the incentive structure of ACOs might encourage them to withhold necessary care from their patients. But what are the criteria of good health, and how could they be measured without incurring additional expense? Health care research focuses on hospital admissions and readmissions as an indicator that the patient is not healthy, but this is an imprecise measure of health which only becomes apparent after the patient's situation has deteriorated. Like other health indicators, it can be manipulated by denying treatment.

It is possible to imagine ACOs working well under Medicare with proper oversight from government. Nevertheless, there are problems. If an ACO is to be responsible for prevention as well as treatment, subscribers must remain in the system long enough for the ACO to reap the savings that come with prevention. This is possible in a single payer system, but not in this country where there is a lot of client turnover. Also, to be accountable for all their clients' health care needs, an ACO must include specialists in all health problems, which means it must be quite large. But large organizations have greater market share, which discourages competition and leads to higher prices—just the opposite of what ACOs are supposed to do.

However, Emanuel and Liebman are suggesting that ACOs will dominate the private health care market as well. In fact, hospitals are already buying out competitors and hiring more doctors, and insurance companies are merging with hospitals in anticipation of forming ACOs. This trend is evident in the Pittsburgh area. The University of Pittsburgh Medical Center (UPMC), the largest hospital chain, has bought out competitors and has gone into the health insurance business as well. Meanwhile Highmark, the region's largest health insurer, has purchased West Penn Allegheny, the only major hospital chain not owned by UPMC. Not surprisingly, this morning's paper reports that Pittsburgh has the highest hospital care costs of any city in the U. S.

Apparently we can look forward to a brave new world in which, when we purchase health insurance, either alone or through our employer, we affiliate with an ACO which promises to keep us in good health. But Austin Frakt, a health care policy expert who is sympathetic to ACOs, suggests that they “are fine and good for Medicare, but somebody needs to think through the consequences for the private side of the market.”

The dominant characteristic of today's corporations is that they are not accountable to anyone except perhaps their stockholders. A combined health insurance-medical care corporation will have strong financial incentives to charge as much as possible for health insurance while providing as little health care as possible in return. At least under the current system, the patient is caught between two corporations pushing in different directions. If their insurance company is trying to deny them care, there is a good chance that their doctor will come to their defense and insist that they receive medically necessary treatment. If the insurance company and the doctors are all part of the same corporation, who will defend the patient's interests? Without third party oversight, what is to keep the patients from being harmed when their very lives may be at stake?

It is possible that a conscientious employer might provide oversight of an ACO with which it affiliates, since companies may want to keep their employees healthy. However, this is certainly problematic, and, in any case, individual health care subscribers are on their own under this system. I don't see how the entire country can shift to ACOs without substantial government oversight. This, of course, will be strongly resisted by hospitals and insurance companies, in part because it would start to take on the characteristics of a single payer system.

Many countries—Germany, Japan and Switzerland are examples—have systems in which both health care providers and insurers are private entities. But these countries have tight government regulation of medical services and fees. These private entities are required to cover everyone and they are permitted to make only modest profits, if any. And why should they make large profits? Under a single payer system, insurance companies are completely unnecessary, while doctors and hospitals can be limited to a “reasonable” fee for their services. If they want to increase their income, maybe they should be allowed to compete for higher wages by demonstrating that they can keep their patients healthy and, as a consequence, control costs.

Although I have serious doubts as to whether ACOs will work in our private health care system, they may be a good idea when embedded within a single payer system.

It Ain't Over 'Til It's Over

UPMC and Highmark have agreed to extend their contract until June 30, 2013. Until then, people who have Highmark health insurance will not have to pay out-of-network fees. Certainly, this is good news. Credit goes to Jay Costa, Dan Frankel, Randy Vulakovich, Don White and all those state legislators who put pressure on UPMC to negotiate, and to Governor Corbett, whose unnamed mediator is said to have brokered the deal.

However, Highmark customers may want to hold their applause. News reports don't say whether there have been any changes in the financial terms of the contract for the period between June 2012 and June 2013. It's still possible that Highmark policy holders face an unpleasant surprise the next time new rates are announced. More importantly, this is not a permanent solution to the problem. A UPMC spokesperson pissed on everyone's parade by stating, “This date provides 18 months for UPMC patients to review the multiple competitive health insurance options now available to assure that their care will continue uninterrupted with UPMC physicians and hospitals.” In other words, UPMC's refusal to negotiate with Highmark will continue. Highmark customers with pre-existing conditions have been given a stay of execution rather than a pardon.

On November 29, Ed Grystar, Chuck Pennaccio and Tony Buba published an op-ed in the Pittsburgh Post-Gazette pointing out how the ongoing conflict between these two corporate psychopaths shows how much we need a health care system administered by people who are accountable to the public—a single payer or Medicare-for-all system. This new agreement gives single payer advocates another 18 months to keep repeating this argument to anyone who will listen.

Moving Backward

If you are a supporter of single payer who believes that change in the U. S. health care system will be gradual and incremental, you probably support the Affordable Care Act, and you probably think any policy changes that move us in the direction of single payer are progress, while you oppose any changes that move us toward privatization. Medicare is the largest single payer system we have in this country. The members of the Elephant Party are nearly unanimous in their support of Rep. Paul Ryan of Wisconsin's plan to privatize Medicare. Up until now, they have been unsuccessful in getting any Jackasses to sign onto the Ryan plan. That has all changed. Sen. Ron Wyden of Oregon, a member of the Jackass Party, has joined with Ryan to propose a “compromise” plan to “save” Medicare. While it stops short of privatizing Medicare, it is a major step in that direction.

When the Affordable Care Act was being debated, supporters of single payer favored a public option to compete with private health insurance plans. Our thinking was that if the public option proved more attractive to subscribers, it would move the country in the direction of single payer. The Ryan/Wyden plan offers seniors a “private option” as an alternative to the single-payer Medicare, possibly in the hope that competition from the private sector will eliminate Medicare from the U. S. health care system (although they deny that intention).

The Ryan/Wyden plan is a premium support program, similar to school vouchers. Seniors will be given a certain amount of money to spend on health care. They will choose among several alternatives, including traditional Medicare and various private health care plans, most of which will cost more than the amount they have been given.

Here is a simplified version of Austin Frakt's summary of the plan:

• Private medicare plans will compete with traditional Medicare in an exchange. Private plans must offer the “actuarial equivalent” of what is available from Medicare. In other words, the private plans don't have to offer the same coverage as Medicare, but the coverage they offer must be of equal value.
• The premium support citizens receive is equal to the cost of either the second cheapest private plan in the exchange or Medicare, whichever is lower. If you choose a more expensive plan, you pay the difference. If you choose the cheapest plan, you get a rebate.
• Private plans may not reject an applicant for any reason; that is, discrimination on the basis of pre-existing conditions is not permitted.
• If this price competition doesn't work to contain the cost of Medicare, the cost will be capped at a growth rate equal to the growth rate of the GDP, plus 1%. This will be done by reducing support for the sector or sectors (hospitals, drug companies, etc.) most responsible for the cost increase.
• Anyone now over 55 will not participate in the new plan, which will not be implemented before 2022.

There are several potentially serious problems with the Ryan/Wyden plan. Again, I am indebted to Frakt for his thoughtful posts about premium support programs (which he favors, by the way).

• Although private insurance companies will be forbidden to turn away people with pre-existing conditions, they will find all kinds of ways to enroll only the healthiest people, i.e., by directing their advertising at affluent citizens. Traditional Medicare will be left with the sickest people, who will pay the highest fees. A process called “risk adjustment” is supposed to deal with this problem by increasing the rebate to plans that cover less healthy people, but this is after-the-fact and it's not clear how it will work.
• Private insurance companies often treat their customers badly. The deny necessary care and provide poor customer service. This can also be used to drive away the least healthy people.
• When it comes time to design the plan, Medicare will have no money to spend on lobbying and campaign contributions, while the insurance companies will be stuffing Congress-critters' pockets with cash. This virtually guarantees that the playing field will be tilted in favor of the private plans.
• Since private plans don't have to offer the same coverage as Medicare, but only the actuarial equivalent, it will be hard for seniors to compare the plans. The insurance companies have almost unlimited advertising budgets with which to confuse and mislead consumers. Most seniors citizens do not have a friend with a Ph.D. to help them pick the best plan, so many of them will make bad choices.

The combined effect of these problems will be to leave Medicare with fewer and less healthy customers. This will increase Medicare's costs, while weakening its bargaining power when negotiating with hospitals or drug companies over the prices of goods and services. This could eventually lead to the demise of Medicare.

When Walmart goes into a new community, they offer consumers heavily advertised “sales” for the first couple of years. (Since they have thousands of outlets, they can afford to run some of them at a loss for a short time.) The purpose is to drive other local retail stores out of business. Once they have eliminated the competition, they quietly raise their prices. It's possible that the insurance companies will begin by setting their prices unrealistically low, in the hope of sending Medicare into a death spiral.

It's going to be difficult to oppose a premium support plan. Critics will ask: "What can be wrong with offering people more choices? If you are really confident that single payer is more cost effective, why do you worry that people will switch to private health insurance?"  Some of our objections will sound as if we oppose giving people more choices because we are afraid they will choose unwisely. This seems paternalistic, and conflicts with most Americans' mistaken view that they are too smart to be influenced by advertising.

I apologize for the length of this post, but I believe that premium support programs are a serious threat to move our health care system in the wrong direction. The New York Times has come out in favor of premium support. The insurance companies have almost unlimited funds with which to bribe Congress and the President to pass such a program. In fact, I'm afraid that dismantling Medicare is almost inevitable. If that happens, it will be nearly impossible to pass single-payer health care in this country. How can you demand Medicare for all when there is no Medicare?

Early news reports have suggested that Senator Wyden is seen by his fellow Jackasses as a traitor for breaking ranks and suggesting major changes to Medicare. (Paul Krugman refers to him as a "useful idiot.") My guess is that the reality is quite different. They are probably grateful to him for offering them cover while they quietly line up to follow his lead. The insurance companies have millions of dollars to pass out. Right now, the Elephant Party is getting most of that money. But the Jackasses want it, and if they signal a willingness to pass premium support, they are likely to get a lot more of it. The results will be disastrous for single payer, and possibly for the country.