Repeal Failed but the GOP’s ACA Attack Continues; And Who is to Blame?

16831845_1116900401772951_1540332812797294563_nAs the midterm elections get closer and closer one wonders what the real effect of the GOP’s attack on Obamacare is and will be. Having failed in their effort to repeal the Affordable Care Act outright, the Trump administration and the Republican Congress are now waging a piecemeal assault on Barack Obama’s most significant domestic accomplishment. They have, of course, proclaimed its demise time and time again. But all that 2017 talk about how the law had failed or was starting to fail was just so much blather designed to justify their repeal efforts. However, the GOP’s multi-front assault on the ACA now appears to be having some effect. Last fall, the Trump administration ended the cost-sharing-reduction payments designed to help offset copayments and deductibles for low-to-moderate earners. That roiled the insurance markets. The administration also slashed the advertising and outreach efforts that encourage people to sign up for plans during the ACA enrollment period. The result is obvious and we are seeing presently, the fewer healthy enrollees, the higher the plan premiums.

Then, as part of its tax cut legislation passed on a party-line vote, the Republican Congress nixed the penalty for individuals who fail to buy health coverage, starting in 2019. Without a penalty, the requirement is toothless. (The mandate is hardly the only, or even principal, reason that people bought health care under the ACA; 90 percent of those polled earlier this spring by the Kaiser Family Foundation said they planned to buy insurance next year despite its de facto repeal.)

Meanwhile, the administration is finalizing regulations for short-term health insurance plans; because they needn’t meet ACA coverage requirements, those skimpier plans will be cheaper and thus may lure younger and healthier people from broader but more expensive ACA-compliant plans. And when it comes to having a sufficiently large risk pool to spread costs widely enough to keep premiums affordable, relatively small percentages can matter.

According to the Commonwealth Fund, another nonprofit that specializes in health care policy, the rate of working-age people without insurance has gone from 12.7 percent in 2016 to 15.5 percent today. That means about 4 million fewer people are covered. The Fund also found that 9 percent of those currently covered in the individual insurance markets say they won’t buy coverage next year. Larry Levitt, senior vice president for health reform at the Kaiser Family Foundation, notes that insurers are already citing the pool-depleting effects of impending short-term plans in order to justify price hikes for next year’s ACA-compliant coverage.

Meanwhile, congressional efforts to stabilize the insurance pools, either by re-establishing cost-sharing subsidies or helping states set up reinsurance plans to offset costs of the most expensive patients, have gone nowhere. Given the reflexive hostility Trump and congressional Republicans have for all things Obama, it’s hard to see these issues get worked out while Republicans retain control of both houses of Congress and the presidency.

But rising insurance premiums are likely to be an issue in the fall congressional campaigns. Voters who support the ACA need to hold the proper party responsible for the intentional slow-motion, beneath-the-radar screen effort to gum up the law’s works. And make no mistake, that’s the GOP.

Fact Check: ObamaCare, Not Trump, Is To Blame For the Rise In Uninsured In 2017

As some insurers angle for hefty premium hikes and concerns grow that more Americans will wind up uninsured, the federal health law is likely — once again — to play big in both parties’ strategies for the contentious 2018 election. Candidates are already honing talking points: Is the current dysfunction the result of the law or of GOP attempts to dismantle it?                                                                                                                The impact of changes to the law made by Republicans over the past year — modifications short of the “repeal and replace” they promised — is becoming clear. Initial announcements show health insurers in several states are seeking big increases in premiums for next year for people who buy their own insurance. That is renewing concerns about the potential for “bare” counties that will have no insurer selling coverage and hints that the number of uninsured Americans could again be on the rise.                                                                                                                                      “It’s sort of Insurance 101,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. Insurers “are facing a smaller and sicker risk pool as a result of both Trump administration and congressional action, and that means higher premiums,” she said.                                                                                                                           “A number of policy changes definitely impacted rates,” said Jeanette Thornton, a senior vice president for the trade group America’s Health Insurance Plans.

Among those changes is the elimination of the tax penalty for those who forgo insurance, included in December’s tax overhaul, and President Donald Trump’s cancellation of federal payments to insurers who provide discounts to some low-income customers.

Democrats say they will make sure voters know that Republicans deserve the blame. “Senate Democrats will be on the floor of the U.S. Senate every week talking to the American public about these rate increases and make sure they know about this campaign of sabotage,” said Sen. Chris Murphy (D-Conn.).

Republicans, however, say Democrats are at fault for blocking bipartisan legislation, which might not even have had enough GOP votes to pass. The effort sought to stabilize the Affordable Care Act’s marketplace through measures such as setting up reinsurance funding to help keep an individual insurer from facing devastating losses and guarantees for insurers to help pay their share of the out-of-pocket expenses for low-income customers.

“Democrats could have worked with us to lower premiums by as much as 40 percent but instead choose to cling to an unworkable law,” Sen. Lamar Alexander (R-Tenn.), chairman of the Health, Education, Labor, and Pensions Committee, said on the Senate floor Tuesday. “So if you have an insurance premium that is going up 40 percent next year, on top of an over 105 percent increase since 2013, you can thank a Democrat.”

The heightened political rhetoric comes after the first two states unveiled insurance company premium requests for policies on the individual market for 2019. These are not final rates, but they give an idea of what premiums for next year might be for people who don’t get insurance through their job or the government and buy their own coverage on the individual market.

That market included about 15.6 million people, both inside and outside the ACA insurance marketplaces, in the final quarter of 2017, according to the consulting firm Mark Farrah Associates.

State deadlines for filing next year’s rates run from May through July. Once insurers have made their initial premium requests, state regulators negotiate final rates before open enrollment begins in the fall. In Virginia and Maryland, insurers are seeking a wide range of significant increases, from about 15 percent for some plans up to more than 91 percent for one Maryland PPO.

Analysts are not surprised by the requested rate hikes and predict more to come. The first requests in past years have often moderated before being finalized, but this year’s political uncertainties could play a bigger role.

The Congressional Budget Office estimated that the elimination of the tax penalty for people without health insurance, which was included in last December’s tax law, by itself, would result in premium increases of around 10 percent per year. That’s because, without the prospect of a fine, healthier people would be more likely to forgo coverage, making the pool of people who continue to buy insurance sicker and more expensive for insurers.

Separately, Trump roiled the individual insurance market by canceling federal “cost-sharing reduction” payments for moderate-income insurance buyers.

The administration is also trying to extend the availability of short-term insurance plans, which frequently offer only bare-bones coverage, and “association health plans,” which can provide cheaper alternatives for those who are considered healthy. But such plans don’t include all the benefits of ACA plans. Analysts say both types of options would draw even more healthy people out of ACA plans..

The insurance industry acknowledges the actions have boosted next year’s rates. Chet Burrell, the CEO of CareFirst Blue Cross Blue Shield, which serves both Maryland and Virginia markets, told The Washington Post that “continuing actions on the part of the administration to systematically undermine the market … make it almost impossible to carry out the mission.”

AHIP’s Thornton cautioned that it is still early in the process and many things could change. Maryland, for example, has passed legislation to create a “reinsurance” pool that could substantially lower premiums for next year. It still requires formal permission from the Trump administration, however.

And while Congress could still help ameliorate next year’s increases, that appears increasingly unlikely. In a sign that the bipartisanship that characterized the effort last fall has broken down, Alexander said in his Senate speech that he plans to move on to other health issues, including ways to address the opioid crisis.

“Given Democrats’ attitude, I know of nothing the Republicans and Democrats can agree on to stabilize the individual health insurance market,” he said. Sen. Susan Collins (R-Maine), who was promised a vote on her bipartisan bill by Senate Majority Leader Mitch McConnell (R-Ky.) that never materialized, now blames Democrats. In a column she wrote for her home-state Portland Press-Herald late last month, Collins said Democrats refused to accept additional restrictions on abortion funding. “Although federal funding has not been used to pay for elective abortions for decades, some Democrats reopened the long-settled debate on the Hyde Amendment in order to block these much-needed insurance reforms,” she wrote.

Democrats, however, say it was Republicans who reopened the abortion debate by demanding language to create new, permanent restrictions that could eliminate abortion even in private insurance plans. Even so, some say they still hope consensus may be reached.

“Patients and families deserve better than the higher costs and dysfunction they are getting under Trumpcare by sabotage,” Sen. Patty Murray (D-Wash.) told reporters Tuesday. “And as soon as Republicans are ready to work again in a bipartisan way and act actually to lower families’ costs, Democrats will be at the table.”

Health Care: The ranks of the uninsured climbed last year. So, naturally, President Trump is taking the blame because of his attempts to repeal ObamaCare. The fault, however, lies not with Trump, but with ObamaCare itself.

A new Gallup report shows that the ranks of the uninsured climbed from 10.9% in Q4 2016 to 12.2% by Q4 2017. At first blush, it makes sense to point to Trump, given that this increase came during his first year in office.

As Huffington Post put it: “Trump’s sabotage of the Affordable Care Act appears to be working.”

But a closer look at the data and a review of recent history shows that Trump had nothing to do with the increase in the uninsured last year. The factors that did were baked in the cake in the summer of 2016 — when President Obama was sitting in the White House and Hillary Clinton was busy measuring the Oval Office drapes.

Let’s review the facts.

Insurers had to announce their proposed 2017 premiums in mid-2016, which then got reviewed by state regulators. The result was a massive 25% increase in average ObamaCare premiums nationwide. In Pennsylvania, premiums shot up 33%. In Illinois, they climbed 44% and in Oklahoma premiums climbed by 76%!

That was after two previous years of historic rate hikes. And insurance companies fleeing ObamaCare markets marked each year.

At the time, Democrats and the press dismissed skyrocketing ObamaCare premiums, saying that they really didn’t matter since most people enroll in an ObamaCare exchange get generous subsidies, which means their actual premiums would remain unchanged.

But that overlooked the millions who buy coverage in the individual market but who aren’t eligible for any ObamaCare subsidies. Thanks to ObamaCare’s mandates and regulations, basic insurance was fast becoming unaffordable.

Trump and the GOP had nothing to do with these failures. The changes they did enact had only a modest impact on 2018 premiums.

What’s more, open enrollment in the exchange for 2017 closed on January 31, 2017 — one week after Trump took the oath of office. So the fact that enrollment in the exchanges dropped in 2017 also had nothing to do with Trump. Enrollment in the ObamaCare exchanges came in well below forecasts every year since they opened in 2014.

The combination of declining ObamaCare enrollment and skyrocketing premiums ended up pushing more people out of the insurance market in 2017.

What’s more, Gallup’s survey found that the uninsured rate had essentially bottomed out in early 2015, when it hit 11.4%. By the end of that year, it was back up to 11.9%. It dipped down to 10.9% during the last half of 2016, before resuming its upward trend in 2017.

Even if Hillary Clinton had been president, the ranks of the uninsured would have started climbing again last year as ObamaCare’s years of massive rate hikes priced more and more people out of the insurance market.

In fact, Seema Verma, the administrator of the Centers for Medicare & Medicaid Services, lashed out during a recent meeting at critics of the Trump administration’s changes to the Medicaid program and the Affordable Care Act (ACA), also known as Obamacare.

“I take exception to those out there who have made claims that we have tried to sabotage the healthcare of the American people, particularly when it comes to the healthcare exchanges,” she said here at the World Health Care Congress. “Obamacare was failing long before Donald Trump became president and I became CMS administrator.”

The reality, said Verma, is that health insurers have fled the exchange markets “after losing millions of dollars,” adding that with only one insurer offering policies, “half the counties in America, and 10 states in our country, don’t even have a choice of a health insurer.”

Verma went on to detail some of the problems with the ACA’s insurance marketplaces. “We were promised that Obamacare would lower premiums by up to $2,500 for a typical family, but the reality is that premiums more than doubled since its inception,” she said, noting that in states such as Arizona, premiums rose by an average of 190%, and in Oklahoma, they rose 201%.

“These are plain, clear facts,” said Verma. “The stark reality was that when we came into the market, we were faced with health exchanges that were pricing Americans out of the system … and punishing them with penalties for being unable to afford government-mandated coverage.” In December, Congress repealed the individual mandate, which required all Americans to acquire health insurance or pay a penalty.

Supporters of the ACA have blamed Republicans in Congress for the exchanges’ increasing premiums, citing Congress’s failure to continue funding the “risk corridors” that would have helped health insurers pay for higher-cost patients; providing that funding, they say, would have encouraged more insurers to offer policies on the exchanges and made the marketplaces more competitive. They also are critical of the Trump administration’s canceling of the cost-sharing reduction payments the federal government had been making to help lower-income enrollees with their copays and deductibles.

Verma said the administration would “refuse to stand idly by while Americans are suffering,” so officials are “cleaning up regulations to provide states with more flexibility … to create more choice and competition to help drive down costs.”

“We have also proposed to expand the use of short-term insurance to now be used as an affordable option for people caught between individual market premiums they can’t afford and no coverage at all,” she said. These short-term plans are not required to include all of the benefits mandated by the ACA and can, therefore, be sold more cheaply than plans on the exchanges.

In addition, “it’s impossible to address Obamacare without addressing the strain it put on the Medicaid program,” Verma said. For patients who are severely disabled, and for their families, “Medicaid is more than a safety net — it’s a lifeline, one that needs to be preserved and protected for those who truly need it.”

However, the ACA’s Medicaid expansion has resulted in the addition of able-bodied adults to the Medicaid rolls, and with increased reimbursement rates for this population. “That stretches the safety net for fragile populations who are still on the waiting lists for [services like] home care,” argued Verma, and puts millions of people “into a program that wasn’t designed to meet their needs.”

The Obama administration was resistant to efforts aimed at allowing states to tailor their programs to better serve this population, said Verma. The Trump administration is remedying this problem by allowing states to require able-bodied Medicaid recipients to either work, take classes, or volunteer — a mandate known as “community engagement.” Three waivers for community engagement have already been approved, she said, “and we have 11 more we should be making decisions on pretty soon.”

Currently, eight in 10 adults who are receiving Medicaid are in families in which at least one family member is working, according to a report from the Kaiser Family Foundation. In total, 60% of Medicaid recipients are working themselves; of those who aren’t working, most cite impediments such as a disability, illness, or caregiving responsibilities as the reason, the report found.

“I hope it’s clear to everyone in this room that through all our actions we start with the goal of putting patients first,” Verma concluded. “We need to work together to create a healthcare system that pays for value, not merely volume.”

Do I think that the Democrats and the GOP will work together? Not a chance. We are dealing with politicians who are still confused and angered. Bernie and most of the Democrats are looking at some type of single-payer health care system and point to the Europeans and Canada as the models for a health care system. I have already pointed some of the frustrations in the European systems and the way that they pay for their system and some of the limitations. So, what would our model look like and will it work in a free-market society?

I promise that next week I will start putting together the single-payer option; what it is, what it looks like and will it work?

And most important-Happy Mother’s Day to all the Most Important People out there! Thank you for all that you have done for all of us and thank you for your continuous support and love!

Also, remember to check out our new book The Search for Excellence in Clinical Practice: A Handbook on Clinical Process Improvement for Providers, Sentia Publishing Company.

New Disease Treatments! Consideration of Cost and Will We be Able to Afford It?

13077059_884816618314665_778767240526006929_nAs a continuation regarding my experience in a discussion of a single-payer healthcare system in other countries that I visited the CBS 60 minutes story last Sunday discussing the CRISPR discovery struck me. Why do I mention this? Because in speaking with various of my sailing “buddies” from Europe I found out that many don’t have choices of some of the newer more effective treatment therapies including chemotherapy drugs and immunotherapy due to the cost. It is difficult to understand, especially when one listens to the CBS 60 Minute’s episode narrated by commentator Bill Whitaker.

He reviewed a new tool could be the key to treating genetic diseases and may be the most consequential discovery in biomedicine this century

It’s challenging to tell a story about something that’s invisible to the naked eye and tricky to explain. But it’s one we undertook because rarely does a discovery come along that could revolutionize medicine.  It’s called CRISPR and it stands for Clustered Regularly Interspaced Short Palindromic Repeats. CRISPR sounds more like a refrigerator compartment than a gene-editing tool, but it’s giving scientists power they could only imagine before – to easily edit DNA – allowing them to reprogram the genetic code of living things. That’s opening up the possibility of curing genetic diseases. Some researchers are even using it to try to prevent disease entirely by correcting defective genes in human embryos. We wanted to see for ourselves, so we went to meet a scientist at the center of the CRISPR craze.

Bill interviewed Dr. Feng Zhang a young tenured professor at MIT and one of the brains behind CRISPR, he figured out a way to override human genetic instructions using CRISPR.

For the last seven years, Zhang has been working on CRISPR at the Broad Institute in Cambridge, Massachusetts. It’s a research mecca brimming with some of the brightest scientific minds from Harvard and MIT on a mission to fight disease. CRISPR is making medical research faster, cheaper, and easier. Zhang’s colleagues predict it will help them tackle diseases like cancer and Alzheimer’s.  

Bill Whitaker asked how many diseases are we talking about that this could be used to treat?

Feng Zhang stated that there are about 6,000 or more diseases that are caused by faulty genes. The hope is that we will be able to address most if not all of them.

Eric Lander, Director of the Broad Institute, commented that he thought that CRISPR, it’s fair to say, is perhaps the most surprising discovery and maybe most consequential discovery in this century so far.

To understand exactly what CRISPR is, we went to Eric Lander for a quick science lesson. He’s director of the Broad and Zhang’s mentor. He is best known for being a leader of the Human Genome Project that mapped out our entire DNA, which is like a recurring sequence of letters.

Eric Lander stated that during the Human Genome Project, we could read out the entire human DNA, and then, in the years afterward, find the misspellings that caused human diseases. But we had no way to think about how to fix ’em. And then, pretty much on schedule, this mind-blowing discovery that bacteria have a way to fix those misspellings, appears.

Eric Lander went on to clarify that this comes from bacteria.  Bacteria, you know, they have a problem. And they came up with a really clever solution. When they get infected by viruses, they keep a little bit of DNA, and they use it as a reminder. And they have this system called CRISPR that grabs those reminders and searches around and says, “If I ever see that again, I am gonna cut it.”

Zhang used that same bacterial system to edit DNA in human cells. Our DNA is made up of chemical bases abbreviated by the letters A, T, C, and G. As you can see in this animation from Zhang’s lab at MIT, a mutation that causes disease reads like a typo in those genetic instructions. If scientists can identify the typo, they can program CRISPR to find it and try to correct it. Dr. Zhang went on to further describe how the CRISPR will go in, and out of billions and billions of letters on your DNA, find the exact ones that have been programmed and cut it to edit it, snip out the bad part and add something to give the cell a new piece of DNA that carries the sequence you want to be incorporated into the genome.

More was discussed such as the multiple uses and studies and the potential for curing diseases and preventing disease. Mr. Lander states that he didn’t think that we’re close to ready to use it to go edit the human population. He thought that we’ve gotta use it for medicine for a while. I think those are the urgent questions. That’s what people want right now, is they want cures for disease.

Urgent questions are being answered as we speak with small clinical trials, the first in the U.S. using CRISPR to target certain types of cancer, which is now enrolling patients. We all believe that this is gonna have a real effect over the course of the next decade and couple of decades. And for the next generation, others and I believe that it’ll be transformative. Consider these other reports.

Last year, the Food and Drug Administration approved the first cellular immunotherapies to treat cancer and that CRISPR can enhance cancer immunotherapy. These therapies involve collecting a patient’s own immune cells — called T cells — and supercharging them to home in on and attack specific blood cancers, such as hard-to-treat acute lymphoblastic leukemia and non-Hodgkin lymphoma.

But so far, these T cell immunotherapies — called CAR-T cells — can’t be used if the T cells themselves are cancerous. Even though supercharged T cells can kill cancerous T cells, they also can kill each other because they resemble one another so closely.

Scientists at Washington University School of Medicine in St. Louis now have used the gene-editing technology CRISPR to engineer human T cells that can attack human T cell cancers without succumbing to friendly fire.

The study evaluating the approach in mice appears online in the journal Leukemia. The researchers also engineered the T cells so any donor’s T cells could be used. A “matched” donor with similar immunity is not required and neither is the patient’s own T cells, which is important for the obvious reason: Many of the patient’s own T cells are cancerous.

“Cancerous T cells and healthy T cells have exactly the same protein — CD7 — on their surfaces,” said senior author John F. DiPersio, MD, Ph.D., the Virginia E. and Sam J. Golman Professor of Medicine in Oncology.

DiPersio’s team first generated a novel CAR-T strategy targeting CD7, allowing for the targeting and killing of all cells with CD7 on the surface.

“But if we program T cells to target CD7, they would attack the cancerous cells and each other, thus undermining this approach,” DiPersio said. “To prevent this T cell fratricide, we used CRISPR/Cas9 gene editing to remove CD7 from healthy T cells, so they no longer carry the target.”

DiPersio, who treats patients at Siteman Cancer Center at Washington University School of Medicine and Barnes-Jewish Hospital, and his colleagues also used CRISPR gene editing to simultaneously eliminate the therapeutic T cells’ ability to see healthy tissues as foreign.

To do this, they genetically deleted the T cell receptor alpha (TCRa) subunit. This way, T cells from any normal donor can be used without risk of life-threatening toxicities such as graft-versus-host disease, in which T cells attack the organs of the recipient, sometimes resulting in death. This new approach also may have broad implications for the CAR-T field, allowing for use of therapeutic T cells from any healthy donor. Healthy T cells could be collected in advance and stored for any patient with a relapsed T cell malignancy.

“We have genetically modified these T cells so they are unable to cause graft-versus-host disease but can still kill cancerous cells,” said first author Matthew L. Cooper, Ph.D., an instructor in medicine. “One additional benefit of this approach is that a patient could receive this therapy much more quickly after diagnosis. We wouldn’t need to harvest the patient’s own T cells and then modify them, which takes time. We also wouldn’t have to find a matched donor. We could collect T cells from any healthy donor and have the gene-edited T cells ready in advance, a strategy termed ‘off-the-shelf’ CAR-T cell therapy.”

The researchers demonstrated that this approach is effective in mice with T cell acute lymphoblastic leukemia (T-ALL) taken from patients. Mice treated with the gene-edited T cells targeted to CD7 survived 65 days, compared with 31 days in a comparison group that received engineered T cells targeting a different protein. The researchers also found no evidence of graft-versus-host disease in mice that received T cells lacking the molecular machinery that sees healthy tissues as foreign. They also found that the therapeutic T cells remained in the blood for at least six weeks after the initial injection, suggesting it could ramp up again to kill cancerous T cells if they return.

“T cell malignancies represent a class of devastating blood cancers with high rates of relapse and death in children and adults with the disease,” Cooper said. “In an effort to develop the first clinically viable targeted therapy for this type of cancer, we are scaling up the manufacturing of our gene-edited CAR-T cells for clinical trials, which we hope to complete at Siteman Cancer Center.”

And another announcement about a new application of CRISPR in the report that researchers from the Wellcome Trust Sanger Institute have reported that a new target for the treatment of leukemia has been found. 

A new drug target for acute myeloid leukemia (AML) has been identified that could open new avenues for the development of new treatments against the deadly disease. Researchers from the Wellcome Trust Sanger Institute have published research in Nature that shows the inhibition of the METTL3 gene specifically kills human and mouse leukemia cells. The gene is responsible for the survival of cancer cells but not healthy cells, meaning it could be targeted safely.

AML is an aggressive blood cancer that can affect people of all ages. It develops in the bone marrow, overwhelming the healthy cells that reside there, which impairs the immune system leading to serious infections and bleeding. The disease is rare, with just 3,100 cases per year in the UK, but it develops quickly making it difficult to catch. Current treatments used for AML include chemotherapy and bone marrow transplants, but these save fewer than one in three patients.

The researchers used CRISPR-Cas9 gene-editing technology to screen cancer cells for potential therapeutic targets. They created a leukemia mouse model containing mutations that could be targeted in human AML cells. Each gene was tested to decipher its role in the disease. Forty-six genes were identified that could modify RNA, including METTL3, which had a particularly strong effect.

The group found that the METTL3 protein binds 126 genes, many of which support AML cell survival, and then modifies the RNA that is subsequently produced, increasing their translation. When this modification was blocked, essential proteins for the survival of the leukemia were no longer produced.

George Vassiliou, the joint project leader and consultant hematologist at Cambridge University Hospitals NHS Trust, commented on the implications of the study’s findings: “Our treatments have changed little for decades and outcomes remain poor… We believed that we had to think differently and look in new places for ways to treat the disease… We hope that this discovery will lead to more effective treatments that will improve the survival and the quality of life of patients with AML.”

One way to boost survival could be to improve the treatments that we already have. This is what Italian biotech, MolMed, has done, developing Zalmoxis, which ups the safety of bone marrow transplants. A major area of hype in the blood cancers field is CAR-T, and Novartis’Kymriah was the first to be approved by the FDA after demonstrating efficacy against B cell leukemia, while Celyad has developed a Natural Killer Receptor T cell platform, which cleared a patient of cancer during the early stages of a clinical trial.

Consider the announcement that the F.D.A. Panel Recommended the Approval for a Gene-Altering Leukemia Treatment.

Denise Grady last year reported on a set of cases that started me on my investigation into CRISPR where a Food and Drug Administration panel opened a new era in medicine on Wednesday, unanimously recommending that the agency approve the first-ever treatment that genetically alters a patient’s own cells to fight cancer, transforming them into what scientists call “a living drug” that powerfully bolsters the immune system to shut down the disease.

If the F.D.A. accepts the recommendation, which is likely, the treatment will be the first gene therapy ever to reach the market in the United States. Others are expected: Researchers and drug companies have been engaged in intense competition for decades to reach this milestone. Novartis is now poised to be the first. Its treatment is for a type of leukemia, and it is working on similar types of treatments in hundreds of patients for another form of the disease, as well as multiple myeloma and an aggressive brain tumor.

To use the technique, a separate treatment must be created for each patient — their cells removed at an approved medical center, frozen, shipped to a Novartis plant for thawing and processing, frozen again and shipped back to the treatment center.

A single dose of the resulting product has brought long remissions, and possibly cures, to scores of patients in studies who were facing death because every other treatment had failed. The panel recommended approving the treatment for B-cell acute lymphoblastic leukemia that has resisted treatment or relapsed, in children and young adults aged 3 to 25.

One of those patients, Emily Whitehead, now 12 and the first child is ever given the altered cells, was at the meeting of the panel with her parents to advocate for approval of the drug that saved her life. In 2012, as a 6-year-old, she was treated in a study at the Children’s Hospital of Philadelphia. Severe side effects — raging fever, crashing blood pressure, and lung congestion — nearly killed her. But she emerged cancer free and has remained so.

“We believe that when this treatment is approved it will save thousands of children’s lives around the world,” Emily’s father, Tom Whitehead, told the panel. “I hope that someday all of you on the advisory committee can tell your families for generations that you were part of the process that ended the use of toxic treatments like chemotherapy and radiation as standard treatment, and turned blood cancers into a treatable disease that even after relapse most people survive.”

The main evidence that Novartis presented to the F.D.A. came from a study of 63 patients who received the treatment from April 2015 to August 2016. Fifty-two of them, or 82.5 percent, went into remission — a high rate for such a severe disease. Eleven others died.

“It’s a new world, an exciting therapy,” said Dr. Gwen Nichols, the chief medical officer of the Leukemia and Lymphoma Society, which paid for some of the research that led to the treatment.

The next step, she said, will be to determine “what we can combine it with and is there a way to use it in the future to treat patients with less disease so that the immune system is in better shape and really able to fight.” She added, “This is the beginning of something big.”

At the meeting, the panel of experts did not question the lifesaving potential of the treatment in hopeless cases. But they raised concerns about potentially life-threatening side effects — short-term worries about acute reactions like those Emily experienced, and longer-term worries about whether the infused cells could, years later, cause secondary cancers or other problems.

Oncologists have learned how to treat the acute reactions, and so far, no long-term problems have been detected, but not enough time has passed to rule them out. Patients who receive the treatment will be entered in a registry and tracked for 15 years.

Treatments involving live cells, known as “biologics” are generally far more difficult to manufacture than standard drugs, and the panelists also expressed concerns about whether Novartis would be able to produce consistent treatments and maintain quality control as it scaled up its operation.

Another parent at the meeting, Don McMahon, described his son Connor’s grueling 12 years with severe and relapsing leukemia, which started when he was 3. Mr. McMahon displayed painful photographs of Connor, bald and intubated during treatment. And he added that chemotherapy had left his son infertile.

A year ago, the family was preparing for a bone marrow transplant when they learned about the cell treatment, which Connor then underwent at Duke University. He has since returned to playing hockey. Compared with standard treatment, which required dozens of spinal taps and painful bone marrow tests, the T-cell treatment was far easier to tolerate, Mr. McMahon said, and he urged the panel to vote for approval.

A third parent, Amy Kappen, also recommended approval, even though her daughter, Sophia, 5, had died despite receiving the cell treatment. But it did relieve her symptoms and give her a few extra months. Sophia’s disease was far advanced, and Ms. Kappen thought that if the treatment could have been given sooner, Sophia might have survived.

The treatment was developed by researchers at the University of Pennsylvania Children’s Hospital and licensed to Novartis. The use will not be widespread at first because the disease is not common. It affects only 5,000 people a year, about 60 percent of them children and young adults. Most children are cured with standard treatments, but in 15 percent of cases — like Emily and Connor’s — the disease does not respond, or it relapses.

Although the figure may seem high, people with cancer often endure years of expensive treatment and repeat hospital stays that can ultimately cost even more.

Because the treatment is complex and patients need expert care to manage the side effects, Novartis will initially limit its use to 30 or 35 medical centers where employees will be trained and approved to administer it, the company said.

As to whether the treatment, known as CTL019 or tisagenlecleucel (pronounced tis-a-gen-LEK-loo-sell), will be available in other countries, Ms. Masow said by email: “Should CTL019 receive approval in the U.S., it will be the decision of the centers whether to receive international patients. We are working on bringing CTL019 to other countries around the world.” She added that the company would file for approvals in the European Union later this year.

By late November 2016, 11 of the 52 patients in the study who went into remission relapsed. Twenty-nine were still in remission. Eleven others had further treatments, like bone marrow transplants. One patient was not available for assessment. Three who had relapses died, and one who did not relapse died from a new treatment given during remission. The median duration of remission is not known because it has not been reached: Some patients were still well when last checked.

Researchers are still debating about which patients can safely forgo further treatment, and which might need a bone marrow treatment to give the best chance of a cure.

The treatment requires removing millions of a patient’s T-cells — a type of white blood cell often called soldiers of the immune system — and genetically engineering them to kill cancer cells. The technique employs a disabled form of H.I.V., the virus that causes AIDS, to carry new genetic material into the T-cells to reprogram them. The process turbocharges the T-cells to attack B-cells, a normal part of the immune system that turns malignant in leukemia. The T-cells home in on a protein called CD-19 that is found on the surface of most B-cells.

The altered T-cells are then dripped back into the patient’s veins, where they multiply and start fighting cancer.

Dr. Carl H. June, a leader of the University of Pennsylvania team that developed the treatment, calls the turbocharged cells “serial killers.” A single one can destroy up to 100,000 cancer cells.

Because the treatment destroys not only leukemic B-cells but also healthy ones, which help fight germs, patients need treatment to protect them from infection. So every few months they receive infusions of immune globulins.

In studies, the process of re-engineering T-cells for treatment sometimes took four months, and some patients were so sick that they died before their cells came back. At the meeting, Novartis said the turnaround time was now down to 22 days. The company also described bar-coding and other procedures used to keep from mixing up samples once the treatment is conducted on a bigger scale.

The Food and Drug Administration, ushering in a new era of cancer treatment, has approved the revolutionary cancer therapy that uses genetically engineered immune cells. The FDA calls the treatment, made by Novartis, the “first gene therapy” in the U.S. The therapy is designed to treat an often-lethal type of blood and bone marrow cancer that affects children and young adults. Known as a CAR-T therapy, the approach has shown remarkable results in patients. The one-time treatment will cost $475,000, but Novartis says there will be no charge if a patient doesn’t respond to the therapy within a month.

Michael Werner, a lawyer and expert on gene and cell technologies and regulation, and a partner at Holland and Knight in Washington said that results so far proved that T-cell treatment works. “The fact that it can be done means more people will go into the field and more companies will start developing these products.” He added, “I think we’re in for really exciting times.”

The FDA defines gene therapy as a medicine that “introduces genetic material into a person’s DNA to replace faulty or missing genetic material” to treat a disease or medical condition. This is the first such therapy to be available in the U.S., according to the FDA. Two gene therapies for rare, inherited diseases have already been approved in Europe.

This is the future! But will a new single-payer health care system allow the newer techniques to be used to treat patients? Consider the European experience and wait to see what is on the horizon for the CRISPR technology. I for one am excited!!


Why Single-Payer Health Care Denies Care To Sick Children Like Alfie Evans and the Idea of a Guaranteed Income System


Single-payer advocates ask what the difference is between Alfie and an American who dies because he is too poor to afford care. It’s not an unfair question, and it deserves an answer.

Alfie Evans, a terminally ill British toddler whose case drew attention from Pope Francis and others around the world, has died, his parents announced Saturday morning.

23-month-old Alfie Evans has died after his parents lost their legal fight to continue his life support

Parents Kate James, 20, and Tom Evans, 21, wrote on Facebook that they were “absolutely heartbroken” that they had lost their son.

and mileage in the most fuel-efficient Wrangler ever.

Alfie was born in May 2016. Later that year he suffered a series of seizures and was admitted to a hospital in Liverpool where he has been since BBC reported.

Alfie developed an incurable degenerative brain condition and was at the center of a legal battle over his treatment.

Medics struggled to precisely identify Alfie’s condition.

Doctors said the further treatment was futile and recommended that Alfie be allowed to die, but his parents — backed by the pope and Christian groups — fought for months to take him to a hospital in Italy so he could be kept on life support.

Alfie’s father, Tom Evans, speaks to the media outside Alder Hey Children’s Hospital in Liverpool, England.  (Associated Press)

The hospital withdrew Alfie’s life support Monday after a series of court rulings sided with doctors who said continuing Alfie’s treatment was “not in Alfie’s best interests.”

Justice Anthony Hayden, a U.K. judge, said the ruling represented “the final chapter in the life of this extraordinary boy.”

Under British law, courts often intervene when parents and doctors disagree over the treatment of a child, who’s rights often take precedence over the parent’s right to decide what’s best.

RIP Alfie Evans. Heartbreaking news to hear this morning, My thoughts & prayers are with his parents, they did everything they could for this little man God rest his soul

RIP Alfie Evans.

My deepest condolences to his parents, who fought so hard for their brave little boy.

Heaven has its newest angel. Alfie Evans

News of Alfie’s death has brought an outpouring of messages from people sending their condolences.

Thomas Wheatley wrote recently that once again, a single-payer health-care system has attracted international attention for its moral depravity. The case concerns Alfie Evans, a British toddler who, by virtue of his slim chance at survival, is barred from seeking treatment elsewhere that might well save his life.

Appropriately, opponents of single-payer health-care have seized on Alfie’s case as an example of taxpayer-funded medicine’s evil nature. In response, single-payer advocates have asked what the difference is between Alfie and an American who dies because he is too poor to afford the health care he needs.

It’s not an unfair question, and it deserves an answer. To do that, however, it’s important to revisit how a situation like Alfie’s came to be.

Single-Payer Is Limited by Tax Revenue.

When a nation enacts universal, taxpayer-funded health care, it effectively builds a wall around its health-care system. Within this wall, resources are finite, which effectively creates a zero-sum game where one person’s gain is necessarily another person’s loss (only so much medication may be dispensed; only for so many hours of the day can a doctor spend seeing patients; only so many hospital beds can be vacant).

Where in a free market health system a patient has the entire global health industry at his or her disposal and is limited only by individual wealth, in a public system, a patient has access only to resources the government has acquisition and made available for use.

The extent of these initial constraints varies on the type of the system (a single-payer system, for example, will have tighter controls than a government health insurance option), but the underlying forces at work remain the same—namely that people prefer quality in health care for themselves over quantity in health care for the masses.

But preferring oneself in a collectivist health care system is problematic. For example, in a public health insurance model, in which the federal government offers an insurance plan that competes with private plans, doctors will generally prefer the payout of private insurance over that of public insurance. This is hardly a theory. According to a 2017 study, in the United States, the average Medicaid acceptance rate among physicians in major metro markets is only 53 percent.

To solve this problem, the government will force doctors to accept a certain quota of publicly funded insurance-holders or restrict access to private insurance altogether. Both options create a de facto single-payer system. The former destroys the incentive to pay extra for private health insurance (chiefly, faster and better care) while the latter simply destroys private health insurance itself.

Offering Unlimited Care Causes People to Use Much More.

Regardless of execution, once a government has secured total control over a nation’s health system, it will immediately run into a cost problem. Realizing the enormous fiscal burden that accompanies shouldering an entire nation’s health needs (a nation, mind you, in which individual consumers have no motivation to limit their costs), governments will turn to a mixture of three solutions to reduce spending or increase revenues.

The most obvious of these is to increase taxes. But this alleviates the government’s financial shortcomings only temporarily. A tax plan is only as good as the economy that supports it, and a tax-and-spend plan that excessively saddles a country’s economic engine will ultimately fail. Nowhere is this clearer than in Greece, where public health-care providers have turned to soliciting donations to meet their needs. Even taxing the contemptible “millionaires and billionaires” will provide only short-term relief, if any. There’s simply not enough money there for everyone.

When tax increases inevitably fail to cover costs, the government will adopt a more draconian approach to control spending. Laws will be introduced—like those in Britain—that force doctors to work in the public sector for lower wages. Doctors may be forced to work for free, and despite having obtained years of advanced and highly technical education, will find themselves in wage wars similar to those involving public school teachers.

Understandably, this decline in wages will force some doctors to cease practicing medicine, at least in their home country (see Greece’s “exodus of doctors and nurses”). To be sure, not all doctors will close their doors, but many will—likely enough to exacerbate the already-short supply of doctors, leading to the infamously long wait lines common to all taxpayer-funded systems. A tighter supply of doctors will, by default, increase their demand. Unable to pay doctors their true worth, the government will make a ham-fisted attempt to “reduce” demand—by rationing health care.

Enter Alfie Evans: a toddler destined to die so the government can pay the entire nation’s health bills. It doesn’t matter that Alfie can get treatment elsewhere. It doesn’t matter that Alfie’s parents object. It doesn’t matter that all human decency in the world is screaming in outrage at the barbaric injustice perpetrated by Britain’s single-payer death squads. The sacrificial lamb must be slaughtered in the name of progress.

What, then, is the difference between little Alfie’s case and the case of the poor American who cannot afford the healthcare he needs? Simple: The American’s life was lost. Alfie’s life was stolen.

Warning, could this happen in the United States? Under a government run single-payer health care system my fear is that it is a very real possibility.

Finland to end its universal basic income program by year’s end!

Edmund DeMarche from Fox News recently reported that the Finnish government reportedly announced Tuesday that it will end the country’s universal basic income program by year’s end — and appears to be taking on new measures to cut benefits to those who do not actively seek employment.

In January 2017 Finland became the first country in Europe to pay free basic income in a pilot, which evoked enthusiasm around the world.  (Reuters)

Basically what we are talking about when we consider the European healthcare system is the extension of a socialized system. One of the other benefits that many countries are touting is the guaranteed income for all. I included this article because Canada is considering the same guaranteed income system. A recent article noted that something is happening in the postindustrial pocket of Hamilton, Ontario, a 45-minute drive from Toronto’s gleaming skyscrapers. In its squat downtown, where payday loan services with names like Money Mart and Cash 4 U compete across the street from each other and a beware of dog sign hangs from a church gate, a potentially transformational future is on trial.

Hamilton (population: roughly 500,000 people) was built with steel and smoke, and recent downturns in manufacturing have hit the once-booming steel town hard. A study by the city’s social planning office last year found that in 2014 one in five children there were living in poverty. What’s more, dropping housing prices have made Hamilton something of a destination for would-be Toronto property owners looking for a deal, arguably driving up rental prices in the city even as vacancies increase.

So there was a sense of relief—excitement, even—when the Ontario government announced in mid-2017 that Hamilton had been chosen as one of three cities in the province for a pilot study on the effects of a basic income. A basic income is an essentially social support in the form of lump-sum payments with no strings attached, just like income from waged labor minus the work.

As of January 2018, more than 2,000 people in Ontario were getting basic income checks. All of them have applied of their own volition, though some people who met the criteria were sent application packages by the government as an incentive to check out the program. Ultimately, the government wants 4,000 people to participate in the pilot, which has the potential to be rolled out across the province as real policy after the trial runs its three-year course.

Yet the Ontario government has had substantial difficulties onboarding people for the pilot, which is why it enlisted the help of community groups like the Hamilton Roundtable for Poverty Reduction. At the Roundtable’s office in downtown Hamilton, I met a pilot participant, Dave Cherkewski, who chalked up the slow uptake to people’s fear of losing the benefits they already receive or getting caught in bureaucratic quagmires. This, he said, is the attitude created by living under existing social programs.

In Ontario, the basic income trial is open to anybody in the trial areas aged 18 to 64. Single people making under $34,000 annually receive up to $17,000, and couples earning under $48,000 will get up to $24,000 (as a whole sum or as a top-up), minus 50 percent of any earned income. People with disabilities receive up to $6,000 more per year, although they must stop receiving disability supports for the duration of the trial (“basic needs” disability payments in Ontario max out at roughly $8,000 per year for singles with no dependents and $12,000 for couples), which will run for three years.

By contrast, Ontario’s current last-resort social support program, Ontario Works, gives single people roughly $4,000 annually to live on, treating them as “clients” to be managed with caseworkers and regular check-ins.

Still, this isn’t Canada’s first experience with a basic income. The province of Manitoba first tested the idea in the 1970s, and the results suggested that people don’t become lazy slobs when freed from the struggle for survival. Instead, they go to school, get jobs, care for their families, and engage in their community. And while a basic income does cost more than many existing social programs, the cost of persistent poverty to provinces—reinforced, some argue, by services that seek to reduce poverty rather than eliminate it—amounts to tens of billions of dollars annually, through healthcare costs and lost productivity.

That a basic income lets people rethink their relationships with work, and one another, gives it a revolutionary aura for those who want society to move beyond capitalism to something more egalitarian. In a recent book called Postcapitalism and a World Without Work, authors Nick Srnicek and Alex Williams argue that we should automate as much work as possible and distribute the proceeds from robot labor to everyone as a basic income.

It’s these kinds of ideas that proponents say a basic income unlocks—that life freed from waged labor engenders more, fuller life. What new kinds of social cooperation, recreation, or work might emerge?

“A basic income makes people’s lives easier now, and I don’t think capitalism is going to end imminently,” said Evelyn Forget, an economist at the University of Manitoba who studies basic income and is consulting on the Ontario pilot. “But I also think it lets us have these wider conversations.”

But other countries have tried the same and it seems to work if you have the finances and the restrictions are realized. Here is an example of the turning tide and may be indicative of the other socialized delivery systems including healthcare.

Finland was considered the first European country to pay a monthly check of $685 to its unemployed between ages 25 and 58. It was considered a pilot program — serving 2,000 randomly selected jobless people — that its founders hoped to expand.

It may seem premature to establish a long-term plan at the beginning of your executive career. But the failure to act now could have serious consequences.

“It’s a pity that it will end like this,” Olli Kangas, who oversees the Finnish government agency that focuses on social welfare and helped design the program, told the New York Times. “The government has chosen to try a totally different path,” Kangas said. “Basic income is unconditional. Now, they are pursuing conditionality.”

“The government has chosen to try a totally different path. Basic income is unconditional. Now, they are pursuing conditionality.” – Olli Kangas, designer of Finland’s basic income program David Whitley summed up Finland’s decision in the Orlando Sentinel.

“Proponents said the program wasn’t comprehensive enough to gauge its merits,” Whitley wrote. “Critics say it would have required a 30 percent tax increase on an already over-taxed population to be viable.”

But some cities, including San Francisco, continue to look into the basic income theory, the Times wrote. Facebook CEO Mark Zuckerberg in 2017 said that basic income should be explored “to make sure that everyone has a cushion to try new ideas.”

That was essentially Finland’s theory when announcing the pilot program. The initial move was met with skepticism from citizens who questioned whether an unemployed young person would be motivated to find a job if they were making a steady income, albeit small.

“There is a fear that with the basic income they would just stay at home and play computer games,” Heikki Hiilamo, a professor at the University of Helsinki, told the paper.

Also, as I traveled the Danube River and questioned many Europeans that the guaranteed income system was a great idea as long as everyone was contributing to the economy as working constituents or at least the majority of the country’s citizens. I believe the same should be considered for a socialized universal health care system. There has to be a way to financially sustain the system chosen!

Explaining U.S. Healthcare to Foreigners and Some Interesting Facts About the European System


diy313This post is going to be a fairly short discussion but I thought that I would include it even though I am on vacation. I know, this will not be my normal 6-9 pages of long-winded discussions, but I think that it is worth the read. I couldn’t post this last night due to many Internet problems as we were sailing up the Danube River, but here it is!
As I traveled through Hungary, Austria, and Germany I was asked by a number of my European shipmates to explain this healthcare system called Obamacare. They wanted to truly understand how Obamacare could be controversial to anyone with an ounce of human empathy. It seems that they thought that the U.S. had hospitals for poor people and hospitals for rich people. Show up at the wrong hospital and you will be shown the door, or if you are lucky, you get a ride to the correct place. No money, no care. The idea of EMTALA was a true surprise to them. What is EMTALA, I pointed out that this is the Emergency Medical Treatment and Labor Act, which was passed in 1986 and this federal law requires that anyone coming to an emergency department must be stabilized and treated, regardless of their insurance status or ability to pay and has remained as an unfunded mandate. They asked me to provide references. Mostly because their family is leftist and no one would believe them and anything that I provided as evidence needed proof. I pointed them to the many references on the Internet, but I also invited them to visit any Emergency Department and just look on the wall of the hospitals and clinics. The law is not secret.
I went on to tell them that to give away free care to Medicare patients is considered fraud and punishable with substantial fines. They had never heard of Medicare and Medicaid. That the poorest and the oldest are cared for already absolutely shocked them. They were well aware that the middle class of the U.S. is considered rich by world standards and capable of caring for others, not just themselves and do not merit charity. Their next question was always why in the world do you need Obamacare if this is all true?
To the people of the third world, to take care of people first, and ask for money later is indeed quite generous. I told them multiple times that they had been duped by the press. The same words even in English simply do not mean the same things even to people in the U.S. The challenge of Medical care in the U.S. is taking care of the obese, the inactive and smokers before they were sick, because their care is so very expensive. That was a fact that they could fully comprehend, Americans are massively obese and justifiably mocked by the world. Money is being spent mostly to stop people from making poor choices; we call it “preventative care”, expensive public education that has no data to support its effectiveness that is Obamacare.
As I continued the discussion, including surrounding politics, the national debt they all realized that Obamacare was a great pipe dream but there was no long-term provision for financial sustainability. You can’t continually increase the premiums on the young healthy population to care for those who don’t want to do their fair share of working and financial contribution. And further, the amount of computer documentation and impersonal telemedicine using social media and the Internet was putting an unhealthy burden on both the physician/healthcare delivery person as well as the patient.
The interesting thing is as I spoke to more and more of the people from the European countries both my shipmates from around the world as well as those living in our cruise destinations I started getting some different views of their own healthcare systems, somewhat different than what I had written about last week.
The older people seemed to be fairly satisfied with the way things were, i.e. the basis of socialized medicine, that they were all cared for but that waiting was part of the system. They were also confident that the government would continue to care for each and every one of them.
The younger people including our cruise tour guides from these countries were concerned as they watched the possible need to raise taxes again. I was told and this was discussed and revealed multiple times that their taxes across the board was 55-64% in order to pay for their free care, medications, education, nursing facilities, and other social services. Today we visited the Czech Republic and I found out that with all their multiple taxes the total that they ALL paid was around 51%.
But with the increase in the immigration population the feeling is that there may be another increase in one or more of there taxes and the quality of care was already not optimal, but adequate. The waiting periods to see physicians were often months; surgical services were often delayed for months depending on the patients other co-morbidities. That is if your diabetes was not well controlled your surgical procedure would be delayed until you were “in better shape” for your surgery. However, emergencies seemed to be cared for in a timely manner. The younger population wanted choices. These were educated people who were waking up to the realities of a socialistic system, enjoyed by many with multiple areas of differences to our freedom of choices that we enjoy here in the U.S.A.
I saw examples of the care given to their patients as a male patient who broke his arm was placed into a plaster cast with a “handkerchief” type of sling for support. I don’t think I have seen a plaster cast in 10 years here in the “States.”
We use fiberglass casts, which are sturdier, waterproof and slings that are more supportive. They do it cheaper and maybe this is not such a bad thing.
But I also examined a male patient with Dupuytren’s disease of the hand who had a finger amputated instead of treating the hand deformity either non surgically or with the appropriate surgical procedure to correct the flexion deformity and give the patient a functional hand.
The patients do get emergency care as I mentioned and as experienced by one of our shipmates who was diagnosed with a small aneurysm in his brain and had a titanium coil placed in the dilatation/enlargement of the blood vessel avoiding leakage or bursting of the blood vessel in his brain.
However, he and his wife stated that their healthcare system was indeed breaking down both financially and in the delivery of care to all except to those who had money.
The older population was comfortable with socialism and that care and resources had to be rationalized to those who need it, i.e. the youth, etc.
I found this all fascinating and it reinforced my beliefs in the power of a government-run socialized medicine system, but more important was the failure of this type of system including the prioritizing of care based on age, multiple morbidities, etc.
We also discussed the education system. It was pointed out that education is free but lately some countries are charging a “small amount” of money to attend the university system and maybe for medical school. There just doesn’t seem to be enough money to go around with an aging population, the cost of “new” equipment, etc.
Remember, I have already pointed out that the influx of the large population of immigrants, 90% who are not employed are placing a financial drain as well as a drain on the healthcare and social system. These 90% unemployed therefore don’t pay their fair share of taxes and still require food, housing, and healthcare. But the older Germans that I spoke with today are still accepting the need to take in these immigrants and pay them their monthly checks even though they are not contributing to the financial support of the socialized system The youth are starting to see the fallacy in this thinking and wonder how are they, the taxpayers are going to be able to sustain this system.
So, what are they, the multiple European countries except for those countries who already pay huge taxes like the Scandinavian countries who pay 64%, going to do next? Maybe we should pay attention to the history of health care in the various European countries, the past, the present situation and the future.
At the end of all of our discussions during our cruise, we all agreed that we Americans in the U.S.A. were truly spoiled and wanted their cake and wanted to eat it without the investment and the difficult decisions and restrictions, delays in service or in fact the lack of service.
Most of what I learned during my visit to these various countries was not really news but did confirm my research, which many of my liberal colleagues don’t believe.
The questions still are:
1. What is the best health care delivery system and how does the government or the system pay for it? Is it Medicare for All or another Single-Payer system or a combination including Medicare for Many and Medicaid for those who cannot afford Medicare or even a system like the Veterans Association medical system?
2. Should the government pay for the education of healthcare workers including doctors, nurses, physician assistants, nurse practitioners, and others as is done in most other countries?
3. Should tort reform/ medical malpractice be considered in our reform of the health care system?
4. How do we strategize and develop this health care delivery system?
5. What have we learned from our own mistakes as well as those mistakes made by other countries?
Onward in our search for the answer to our healthcare conundrum.
And remember if you get a chance to pick up our new book: The Search for Excellence in Clinical Practice A Handbook on Clinical Process Improvement for Providers, Sentia Pub.

5 People from Around the World Share What it’s Like to Have Single-payer Healthcare

30703799_1511615715634749_8690206414615871488_nAs I prepare for my vacation through Europe I thought that I would review a sample of what other people around the world feel about the single-payer health care system. As we consider the single-payer health care delivery system I thought that those already living with such a system deserve to be heard, especially as the Democrats rev up the mid-term election rhetoric to include the healthcare system, Obamacare, and a single-payer system.

Chris Weller wrote that the United States is the only wealthy, industrialized country that lacks universal healthcare. The U.S. Supreme Court’s recent ruling on Obamacare subsidies kept the program rolling, and Sen. Bernie Sanders was totally celebrating.  Still, the independent from Vermont who is running as a Democrat for president told ABC News host George Stephanopoulos that the nation was far from out of the woods on health care.

“We still have 35 million Americans without insurance,” Sanders said on June 28, 2015, during an interview on This Week. “We need to join the rest of the industrialized world. We are the only major country on Earth that doesn’t guarantee health care to all people as a right.”

We wanted to check Sanders’ claim that the United States is “the only major country on Earth that doesn’t guarantee health care to all people as a right.”

This is a common theme for Sanders but the words he used this time muddied his message on two fronts — which countries and what guarantee?

A spokesman for Sanders, Michael Briggs, said Sanders was referring to nations that make up the Organization for Economic Cooperation and Development. We’re not sure Sanders made that entirely clear (for instance the OECD doesn’t include China or Russia, which many people would consider a major country), but we’ll put that aside for the moment.

Anyway, Briggs directed us to a 2014 OECD report that found only two member countries, the United States and Mexico, lack universal health care coverage.

“However, Mexico passed a law in 2004 with the goal of establishing universal coverage, and they’re currently at 90 percent,” Briggs said. “The ACA was never intended to establish universal coverage, and according to the January CBO estimate, 90 percent is about as good as it’s going to get.”

We checked and Briggs is close to his numbers. In Mexico, as of 2013, public insurance reached about 86.7 percent of the people. That’s actually not much different from where America stood if you combine public and private coverage. The figure in the United States was 84.9 percent.

However, in 2015, the CBO estimated that 89 percent of American residents — excluding undocumented immigrants — have coverage. The number drops to 87 percent if you include undocumented residents.

The median income in Mexico is so low, about a third that in the United States, that some would not group it with the stronger OECD countries. In fact, Mexico is often referred to as an emerging or developing economy as opposed to an industrialized or developed one

Some proponents of the US model say this increases people’s level of choice, allowing citizens to pick the plan that is right for them.

Advocates for a single-payer model argue government-funded care significantly reduces cost and provides a stronger social safety net.

Business Insider spoke with a handful of people around the world to find out how single-payer actually shakes out.


What’s it like living in a country with single-payer healthcare?

In Canada, doctors have waiting lists and the process is more like getting into a country club where you have to be recommended by other members. Once I finally got “inside” the system, I was pleasantly surprised.

The wait to see my doctor is never more than a few days, but referrals to specialists can take a bit longer. Special equipment, like MRI machines, always have a waiting list and work around the clock, so it is not unusual to get an appointment a month or two out, with a middle of the night time slot. It is a little strange to drive an hour to a hospital, which seems deserted at 2 a.m. and find the radiology waiting room packed.

What do you really like about it? What do you think people might overestimate?

Aside from some system glitches, I would say that Canadian healthcare, like an American HMO, works pretty well most of the time, especially if you don’t get sick!

I have had my Canadian medical coverage since 2012, and the biggest challenge has been getting the US to acknowledge it is real.

Can you share how much you pay in a typical month for your healthcare?

In Ontario, there is no monthly out of pocket cost, though each province is different. We do carry an additional plan, which covers prescriptions, massage etc.

– Heidi Lamar, business owner, dual citizenship in the US and Canada

United Kingdom

What’s it like living in a country with single-payer healthcare?

Basically, it’s a lot easier. You don’t worry about healthcare, ever, for any reason. It’s just there. Like the police or the fire department. There are no bills, no paperwork, no deductibles, no insurance companies to deal with, no “patient statements,” no risk of going bankrupt if you get the “wrong” disease.

What do you really like about it? What do you think people might overestimate?

Brits over-estimate how good the care is going to be for non-serious conditions. The NHS is geared toward preventative care and emergency care, so if you have a non-serious condition, like tinnitus, for example, you are going to wait many weeks to see a specialist. Your treatment will be free, but the wait might be a couple of months.

Can you share how much you pay in a typical month for your healthcare?

Zero. My only costs are: over the counter medicines like aspirin and allergy meds, which cost the same in the UK as they do in the US. If you go to the doctor (free) and need a prescription there is a token prescription charge, which is £8.60 ($11.17) per drug.

– Jim Edwards, Editor-in-Chief, Business Insider UK


What’s it like living in a country with single-payer healthcare?

Life is much easier when your healthcare is covered without thinking about it. I have lived many years in a country where people have to choose whether they have or don’t have coverage for their health. Single-payer healthcare is easy and fair, providing basic security for all people regarding their health.

More specifically, what do you really like about it? What do you think people might overestimate?

I think healthcare is one of the basic public services together with education, dental care, and childcare that belongs [to] all citizens. I think there is enough evidence to show that when people have access, or sometimes responsibility to take care of their health, it will be cheaper for the society and those who pay taxes for in the long run.

I also like a public healthcare system that provides all mothers with free pre- and post-natal health care and parental leave for both parents – that is one way to reduce problems with newborns’ health.

Can you share how much you pay in a typical month for your healthcare?

In total, for most people who are employed, the healthcare is about 2.5% of taxable income. That is shared between employer and employee in a rate of 1% to 1.5%, respectively. Unless a person has an optional private healthcare plan, no other payments are necessary.

– Pasi Sahlberg, Director General, Centre for International Mobility


What’s it like living in a country with single-payer healthcare?

In [Australia], you know, if you get sick you can be treated. We have a system called Medicare. Basically, you get your Medicare card and you can go and see a doctor. Some doctors charge premiums on top of Medicare. It basically means that if you are sick in any way the public system will find a way to treat you.

The doctors won’t always be the best in their field and there will also at times be waiting lists, but overall it’s pretty good.

What do you really like about it? What do you think people might overestimate?

One observation is that [in the US] when you visit a doctor you have a nurse and a doctor in the room. We don’t have that. One doctor, in and out much faster and more efficient. We also don’t have teams of admin people working behind the counter. I would think this drives [US] costs up and is why everything costs so much.

Can you share how much you pay in a typical month for your healthcare?

It’s possible to pay zero for healthcare in Australia. It’s a little extreme, but it is possible.

– David Boldeman, Account Director, Business Insider


What’s it like living in a country with single-payer healthcare?

I love living in a country with publicly-funded, universal healthcare, paid for by government taxes. I especially like the fact that every Icelandic citizen, irrespective of his or her economic status, has the same healthcare coverage.

What do you really like about it? What do you think people might overestimate?

What I like about universal healthcare is that it gives you peace of mind.

The shortcomings we have do not stem from the single-payer model, but from the fact that the government needs to spend more on healthcare – that is, build additional hospitals and nursing homes, improve and subsidize mental health care, and reduce out-of-pocket expenditures, particularly for marginalized populations.

Can you share how much you pay in a typical month for your healthcare?

I do not know how much my family and I pay per month for healthcare. That in itself says a lot; the typical Icelander does not have to fret over healthcare costs as a critical part of the family budget.

In the Icelandic system, the government pays 80 to 85% of all healthcare expenditures, funded by taxes. The rest is mostly paid for through service fees.

  • Gummi Oddsson, Sociology Professor, Northern Michigan University

Why the left is betting on single-payer as their litmus test

With the mid-term elections on the horizon and the pollsters predicting a possible shift of the majority to the Democrats, they could be in charge of getting their wishes, either back to Obamacare or a single-payer system of some type. Gregory Krieg analyzed the left’s rationale for the single-payer system. (CNN)When Sen. Bernie Sanders hit the road in July to gin up resistance against Republican efforts to raze Obamacare, he delivered a two-part message: First, protect the current law. Second, push on and make the case for a single-payer system, or “Medicare for all.”

Recently, at the Democratic Socialists of America national convention in Chicago, delegates and observers buzzed about that budding campaign to organize and rally for single-payer legislation on the federal level.

Those discussions were a break from the mainstream discourse on health care right now, which tends to fixate, appropriately enough, on how the GOP’s “repeal and replace” pledge failed, the fixes required to sustain the Affordable Care Act, or the contours of Sanders’ forthcoming “Medicare for all” legislation.

But there is an additional dimension on the left, which increasingly views health care policy as a beachhead — one they are now well-positioned to capture — from which to launch a wider effort to promote socialist ideas to more diverse audiences. What’s feasible or not, in the current climate, and how to tinker with the equation, is essentially beside the point.

Democratic Socialists are taking themselves seriously. Should Democrats?

“We chose that issue for a reason: it will help mostly working people and marginalized people more than everyone else,” DSA’s Jess Dervin-Ackerman, an organizer with DSA East Bay chapter in Northern California, told me at this past weekend’s convention. Her colleague, Jeremy Gong, tagged it to abortion rights, saying, “This is an economic issue in addition to an issue of gender. We need to create a universal, single-payer health care system that guarantees abortion access to all women, everywhere, with no questions asked.”

Health care is where the grassroots energy is, organizers in Chicago agreed, and for new recruits, the hard work of canvassing is brightened by the opportunity to sing the single-payer gospel. The resulting surge in recruitment, Dervin-Ackerman said, has the knock-on effect of getting activists off social media, an often unproductively exhausting medium, and plugged into their actual communities.

On the broader left, taking into account Democrats of all stripes, single-payer is increasingly popular. A recent Pew survey found 52% support for the policy among Democrats, a nearly 20-point spike in a little more than three years. The number jumps to 64% when narrowed to self-described liberal Democrats.

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Public support for ‘single payer’ health coverage grows, driven by Democrats

The outlook is much less rosy when Republicans are thrown into the mix. Nationally, only 33% support single-payer. But that number is 12 points higher than in 2014 and approximately three in five Americans, across partisan lines, now say the federal government should be responsible for “ensuring health care coverage for all Americans.”

But as gun control activists are keenly aware, it takes more than positive polling to drive legislation. The reality of national politics today, in which Democrats are out of power and on the defensive in Washington, means that single-payer is a nonstarter in the House and Senate. Even then, top officials on Capitol Hill remain cautious. Senate Minority Leader Chuck Schumer only recently conceded the policy was “on the table,” while Nancy Pelosi, his counterpart in the House, has been less willing, even rhetorically, to entertain it.

The left, though, is seizing on that lack of direction — and a diminished incentive for the party to act given its inability to move legislation — by working to make health care the defining issue in Democratic politics. The absence of actionable legislation also provides space for litmus testing potential allies. Potential 2020 primary candidates are facing them, along with party leadership up and down the midterm ballot, from city council candidates to gubernatorial and congressional hopefuls.

Most politicians are, of course, constitutionally uncomfortable offering categorical answers to yes-or-no questions, especially when the queries center on issues that can divide public opinion. The Democratic Party establishment is currently mired in a fight over whether support for abortion rights should be a litmus test for potential candidates. Unsurprisingly, party leaders with a mandate to win back power oppose it. California’s lame-duck governor, Jerry Brown, in an appearance Sunday on NBC’s “Meet the Press,” made an appeal for Democrats to open their ranks.

“The litmus test should be intelligence, caring about, as Harry Truman or Roosevelt used to call it, the common man,” Brown said. “We’re not going to get everybody on board. And I’m sorry but running in San Francisco is not like running in Tulare County or Modoc, California, much less Mobile, Alabama.”

But the left is betting that, at this early stage, single payer — as an overarching priority if not a singular concern — represents the best vehicle to proactively address all those issues in vast swaths of the country historically unwelcoming to mainstream liberals.

“Every social and economic crisis presents in the hospital,” said Bonnie Castillo, health and safety director for National Nurses United, the first national union to back Sanders’ 2016 primary run. “Nurses care every day for people harmed by environmental pollution, climate change, the opioid epidemic, malnutrition, homelessness, joblessness, inadequate mental health care services. Health impacts everything, (which is) exactly why Medicare for all should be a priority for every Democrat.”

The message is resonating with elected officials, like California Rep. Ro Khanna, a pro-Sanders Democrat from Silicon Valley who supported policy during his insurgent run in 2016. Speaking on Tuesday, he framed single-payer as a job-creating mechanism.

“There are a lot of entrepreneurs and tech leaders who say their biggest disadvantage competitively is the cost of healthcare. It’s not tax policy, it’s not wages, it’s health care costs,” Khanna said. “So you have the moral argument for it, but it’s also something that you can get business leaders and technology leaders excited about.”

I thought that next week I would try to reveal how an American would describe our health care system to our foreign neighbors.

And remember, if you get a chance to read our new book: The Search for Excellence in Clinical Practice, Published by Sentia Pub.

Some U.S. Experience with Single-Payer Systems-Six Reasons and Why Vermont’s Single-Payer Health Plan Was Doomed; Then what’s up for California?

17201136_1131265140336477_6000204883258090829_nI chose this article because it points to many of the same issues that will be impediments to all single Payer healthcare systems. A while ago, Vermont Governor Peter Shumlin (D.) announced that he was pulling the plug on his four-year quest to impose single-payer, government-run health care on the residents of his state. “In my judgment,” said Shumlin at a press conference, “the potential economic disruption and risks would be too great for small businesses, working families, and the state’s economy.” The key reasons for Shumlin’s reversal are important to understand. They explain why the dream of single-payer health care in the U.S. is dead for the foreseeable future—but also why Obamacare will be difficult to repeal.

Shumlin’s predecessor in Montpelier was a Republican, Jim Douglas. In 2009, Douglas announced that he would not be seeking a fifth two-year term; five Democrats joined the contest to replace him. Progressive activists demanded that each candidate promise to enact single-payer health care if nominated; all five complied. Shumlin got the nod and assumed office in January 2011.

Shumlin a Republican and other leading left-wing economists got right to work on the Vermont plan. In February 2011, a trio of health economists, including Harvard’s William Hsiao and MIT’s Jonathan Gruber, sent Vermont a 203-page report describing the feasibility, and the alleged virtues, of single-payer in the state. Gruber signed a $400,000 contract to work with Vermont on the project.

Hsiao has spent a good chunk of his career helping governments install single-payer systems; for example, he helped the Taiwanese government install “Medicare for all” in 1995. He’s also responsible for Medicare’s Byzantine price-control scheme known as the Resource-Based Relative Value System, or RBRVS.

Gruber you know; at a hearing to discuss the Vermont report, the Obamacare architect was confronted by a letter from a former state senator, who argued that “any Hsiao-Gruber type health care mega-system will inevitably lead to coercive mandates, ballooning costs, increased taxes, bureaucratic outrages, shabby facilities, disgruntled providers, long waiting lines, lower quality care, special interest nest-feathering, and destructive wage and price controls.” In response, Gruber wisecracked: “Was this written by my adolescent children by any chance?”t is

Hsiao and Gruber promised that single-payer health care in Vermont could save $1.6 billion over ten years. With that endorsement in hand, Shumlin and the legislature passed Act 48, a law instructing the state to figure out how to finance a single-payer system. They dubbed it Green Mountain Care. “If Vermont gets single-payer health care right, which I believe we will, other states will follow,” pronounced Shumlin. “If we screw it up, it will set back this effort for a long time. So I know we have a tremendous amount of responsibility, not only to Vermonters.”

Spoiler alert: they screwed it up. But think of it like one of those murder mysteries where the victim gets shot in the first scene; the real story lies in what led to the poor slob’s demise.

  1. Vermont insisted on platinum-plated insurance coverage

The market-oriented way to bring prices down is to give consumers more control over their own health care dollars like they have in every other aspect of the economy. If you as an individual control the money, you’re going to shop around for the best combination of quality and price. If somebody else is paying for the care, you’re less likely to care about how much anything costs.

Unfortunately, that basic insight is anathema to the progressive left. Single-payer advocates believe, on principle, that health care is best when it is “free to the patient at the point of care.” On the back end, of course, you pay for it in taxes, and in between the government decides whether or not you should be allowed to have that knee replacement or that mammogram. This is what we call rationing.

Sure enough, the Vermont plan insisted on not merely gold-plated health insurance for all Vermonters, but platinum-plated health insurance. As a point of comparison, the Bronze-level plans on the Obamacare exchanges have an actuarial value of 60 percent: meaning, for every dollar in health costs that a policyholder incurs, the insurance company will plan to pay 60 percent, and the patient will pay 40 percent in the form of co-pays, deductibles, and the like. Silver plans, used as the benchmark for Obamacare’s subsidies, have an actuarial value of 70 percent; Gold plans, 80 percent; Platinum plans, 90 percent.

According to Hsiao and Gruber, the actuarial value of the average Vermont private plan was 87 percent in 2011. The Hsiao-Gruber calculation of single-payer savings assumed that Green Mountain’s actuarial values would also line up at 87 percent. But instead, the Vermont plan mandated an actuarial value of 94 percent—more generous than even the costliest Obamacare plans.

In a post-mortem presentation on December 17 by Michael Costa, Shumlin’s deputy director for health care reform, Costa said that Vermont, out of desperation, considered the idea of reducing the required actuarial value to 80 percent—the Obamacare “Gold” tier—but couldn’t stomach the idea of offering Vermonters such “poor” benefits. “It would be a step down in benefits for many Vermonters,” said Costa.

  1. ‘We can move full speed ahead…without knowing where the money’s coming from’

In other words, not only would Green Mountain Care cost more by covering more people than Obamacare, it would cost more by forcing everyone to obtain more financially generous coverage than people currently have. Is it any wonder that the costs of such a plan were prohibitive?

But Vermont’s single-payer religionists were not to be deterred. “We can move full speed ahead with what we need without knowing where the money’s coming from,” assured Anya Rader-Wallack, Shumlin’s special counsel for health care reform. Doesn’t this statement remind us of Nancy Pelosi’s statement-let’s pass this bill and read it later?

But not forever. Shumlin postponed issuing a report on the plan’s proposed costs until January 2013, a few months after the 2012 elections. “When the statutory January 2013 report date arrived, the governor refused to produce the mandated report,” chronicles John McClaughry in an excellent write-up of the episode. 2013 came and went. It got so bad that a Democratic state representative, Cynthia Browning, sued the governor to force the release of the report. (She lost.)

In 2014, Republican Scott Milne ran against Shumlin and his single-payer plan. “I said during our debates: the difference between Peter Shumlin and Scott Milne is that I will tell you before the election that single payer is dead.”

The long-awaited report has still not been published. Shumlin defeated Milne in deep-blue Vermont by 2,095 votes, a mere 1.1 percent of the electorate. Would Milne have won if Shumlin had been more transparent about Green Mountain’s costs?

  1. The Vermont plan would have required a 160 percent tax increase

The Shumlin administration, in its white-flag briefing last week, dropped a bombshell. In 2017, under pre-existing law, the state of Vermont expects to collect $1.7 billion in tax revenue. Green Mountain Care would have required an additional $2.6 billion in tax revenue: a 151 percent increase in state taxes. Fiscally, that’s a train wreck. Even a skeptical report from Avalere health had previously assumed that the plan would “only” cost $1.9 to $2.2 billion extra in 2017.

In 2019, Costa estimated that Green Mountain Care would have required $2.9 billion in tax revenue vs. $1.8 billion under the pre-existing law: a 160 percent increase in revenue.


And the Shumlin administration was already backtracking from raising that kind of levy. After small businesses pushed back against a proposed 11.5 percent payroll tax, Gov. Shumlin promised to offer a grace period to businesses with fewer than 100 workers. That would have reduced Green Mountain funding by another $500 million or more, according to Costa, funding that would have to be made up in taxes elsewhere.

A big part of the reason why the Vermont plan was so expensive is that it tried to replace federally-subsidized insurance with state-subsidized insurance.

Today, over 150 million Americans receive employer-sponsored health insurance that is heavily subsidized by the federal government, because workers don’t pay income or payroll taxes on the value of their health coverage. The Vermont plan would have forced local businesses to offer the single-payer plan, financed by the new payroll tax, and substantial premiums for workers.

Under Obamacare, if you qualify for insurance subsidies, your income has to be under 400 percent of the Federal Poverty Level, or $46,680 for a childless adult. For example, if you make $45,000 a year, Obamacare will subsidize your premiums once you’ve paid 9.5 percent of your income—$4,435—yourself.

The Vermont plan applies the same subsidy standard to all state residents. In other words, if you make $70,000 a year, you’d have to pay $6,650 in premiums before state subsidies would kick in. That is to say, you’d lose a large insurance subsidy and pay far more in taxes for the privilege. In what counts for mercy, no Vermonter would have to pay more than $27,500 a year in premiums before gaining coverage.

  1. Hospitals and insurance companies had every reason to fight the plan

So if you’re going to offer every Vermonter more generous insurance coverage than they currently have, and somehow make the math work, you have to do two things: (1) raise taxes, and (2) pay doctors and hospitals less. We covered #1 above, now let’s talk about #2.

The Green Mountain plan sought to require hospitals and doctors to accept Medicare-like reimbursement rates for their privately-insured populations. Because private insurers pay providers more than Medicare does, this would have amounted to a 16 percent cut in payments to doctors and hospitals, according to the analysis by Avalere Health. Needless to say, the doctor and hospital lobbies weren’t big fans of the Vermont plan and fought furiously to sink it.

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This isn’t to say that Shumlin and colleagues were wrong to seek lower prices for health care services. Healthcare in America is far too expensive. But brute-force price controls are going to face understandable resistance from these powerful interests.

This is where single-payer crashes on the rocks, both at the state and national level. The nearly $1 trillion U.S. hospital industry is not going to sit around quietly and let single-payer advocates impose price controls. This is good if you oppose single payer. But a word of warning for conservatives: hospitals have lobbied as furiously in favor of Obamacare, because it spends more money on them, as they have against single payer.

And we haven’t even started talking about the local health insurance industry, which would have been practically abolished by the Vermont plan. Understandably, health insurers weren’t too fond of that idea.

The point here is that you might want to believe that Vermont’s single-payer plan failed because it was unpopular with the voters. But an equally big factor was how unpopular it was with the healthcare industry.

  1. Other cost savings weren’t going to materialize

Michael Costa’s briefing outlined several other rosy scenarios from earlier estimates that didn’t pan out. Vermont originally assumed that the state would receive $267 million from Washington in the form of an Obamacare waiver. The revised estimate was only $106 million.

They originally estimated $637 million in state Medicaid funding; that number had to be reduced by $150 million due to budget constraints. The ongoing recession reduced Vermont tax revenues by $75 million over the 2016-2017 time frame.

  1. The Vermont plan wouldn’t have achieved true single-payer

The basic problem with any kind of state-based health reform—right or left—is that the federal government is by far the primary player in U.S. health care. The federal government subsidizes employer-sponsored health insurance to the tune of $500 billion a year, through the tax code. It spends even more on Medicare for the elderly and finances the majority of Medicaid for the poor.

The Vermont plan aimed to replace employer-sponsored and individually-purchased private insurance with a single, state-run insurer. But the state couldn’t preempt Medicare, or military health care, or large companies that directly pay for their workers’ health care using a process called self-insurance. Indeed, the Hsiao-Gruber report makes clear that for the Vermont plan to work, the state would need to gain waivers from Medicare, Medicaid, and Obamacare.

In addition, the state couldn’t prevent people from getting private health insurance in neighboring states like New Hampshire.

Hence, one of the key purported advantages of single-payer health care—that doctors and hospitals would only have to work with one insurer, simplifying their paperwork—turned out to be impossible.

As it is, Vermont only has three major private insurers: Blue Cross Blue Shield of Vermont, Cigna, and MVP. Because Vermont doesn’t have many insurers, and because those insurers have worked hard to reduce administrative costs, Avalere estimated that the Green Mountain plan wouldn’t have reduced paperwork by much.

Vermont single payer: An unmitigated failure and for that matter, so was Massachusetts experience.

What’s remarkable, then, about Shumlin’s attempt at single-payer health care is not that it failed. What’s remarkable is that he wasted the state’s time and resources on something that attempted to refute the laws of arithmetic. That’s four years Shumlin wasn’t spending on making the Vermont economy better for the people who live there. Small wonder that his reelection margin was razor-thin.

If there’s one quote that sums up the whole episode, it’s the one from Anya Rader-Wallack, declaring that “we can move full speed ahead…without knowing where the money’s coming from.” Green Mountain Care attempted to offer Vermonters more generous coverage than they currently had, but couldn’t figure out how to convince doctors and hospitals to accept pay cuts, nor workers to accept tax hikes.

A few years back, I was in Ohio debating a prominent progressive think-tanker, someone closely tied to President Obama and Hillary Clinton, and a veteran of the health-reform wars. At one point she declared, “we will never see single-payer health care in the United States.” Other experienced Democrats have said the same thing to me over the years. What those Democrats have learned is that slashing payments to hospitals, doctors, and drug companies—the only way to finance single-payer coverage—is politically impossible.

The temptation among conservatives is to do a victory dance of the “I told you so” variety. But that would be a serious mistake.

Hospitals and other industry stakeholders love Obamacare because the law expands coverage without cutting costs. The law basically accepts what hospitals and doctors are paid now, and simply writes a check to cover those costs for people who are uninsured. For-profit hospital chains like Tenet, Community Health, and HCA are enjoying record profits under the new health law.

As my colleague Bruce Japsen notes, Tenet just announced that it will be the “presenting sponsor of the fourth annual Clinton Health Matters Activation Summit,” during which you can be assured that Tenet will not be complaining about Obamacare, but rather enthusiastically supporting it.

In other words, Republicans will array the same health-industry forces arrayed against single-payer in Vermont against a repeal of Obamacare.

So, no. Obamacare won’t hasten the arrival of single-payer health care in the U.S. But it will retard the arrival of truly affordable health care for most Americans.

Let’s Review the Failure of ‘Single Payer’ Health Care For the US Indian Health Service (Remember the VA system?).   Paul Hsich, a contributor to Forbes wrote that it is a common scenario: A distraught mother brings her young child to the pediatrician, seeking antibiotics for her child’s cold. The doctor determines that the child has a viral infection, not bacterial. Most responsible physicians would explain that prescribing antibiotics could harm to the child (in the form of side effects without benefits) and would worsen the public health problem of drug-resistant bacteria. They understand that antibiotics would be a false “solution” to the problem, and instead help provide other supportive care appropriate to the child’s condition.

Unfortunately, politicians are too prone to advocating false “solutions” to problems which will be ineffective (at best) or downright harmful (at worst). In the realm of healthcare policy, one recurrent wrong solution is the continued advocacy by the political Left in a “single payer” government-run health system.

Newsweek recently profiled the many serious problems in the federal government’s Indian Health Service (IHS), which is responsible for the health care of 2 million Native Americans. Government health care is theoretically a “right” provided to these Native Americans, as part of federal legislation as well as federal treaties with the recognized Indian tribes.

The federal government funds the IHS +% and employs approximately 2,700 nurses, 900 physicians, 500 pharmacists, and 300 dentists in what is essentially a “single payer” system for these patients. Yet the quality of healthcare is considered abysmal:

There’s a cruel joke often told in Indian country: “Don’t get sick after June.” The sick truth beneath those words is that by summertime the Indian Health Service — tasked with providing basic health care to the nation’s 2 million Native Americans and Alaska Natives — has typically blown its meager fiscal year budget for its Catastrophic Health Emergency Fund.

Victoria Kitcheyan of the Winnebago Tribe of Nebraska described the horrifying conditions to the US Senate:

I am not talking about unpainted walls or equipment that is outdated. I am talking about a facility which employs emergency room nurses who do not know how to administer such basic drugs as dopamine; employees who did not know how to call a Code Blue; an emergency room where defibrillators could not be found or utilized when a human life was at stake; and a facility which has a track record of sending patients home with aspirin and other over-the-counter drugs, only to have them airlifted out from our Reservation in a life-threatening state.

I have already reviewed the Biggest Single-Payer Government run system- the VA and the travesties in this system that never gets any better no matter who heads up the system. Massachusetts’ health care system is still trying to fix the Romney fiasco and now we have another state that is attempting to go to a single-payer system-California. California is now “battling choices for healthcare reform. They are battling it out whether to have a system called “Care4All California” — a new advocacy group formed last month to push for a wide range of legislative action this year not only to protect and maintain the gains the state made under Obamacare, but to expand coverage to the state’s remaining 3 million uninsured, about half of whom are living here illegally versus a universal and single-payer system. At the same time, an Assembly select committee that’s been holding hearings over the past six months on achieving statewide universal coverage released a report on its goals and recently introduced 14 bills toward that end. The measures include such proposals as establishing a public option, increasing state-funded subsidies to help people pay for coverage and requiring insurers to spend more of their premiums on actual medical care. “Single-payer is just not going away as an issue for Democrats, no matter how many healthcare-related Assembly bills are introduced as a diversionary tactic,” said Garry South, a longtime California Democratic strategist.

Democrats “control California lock, stock, and barrel,” South said. “If our state health care system starts to implode because Obamacare itself collapses,” he added, “neither Democratic voters nor Californians at large will let the Legislature off the hook for having just tinkered around the edges.” More on California’s strategic decisions on health care reform.

So, the outcome here in California should be interesting to follow the sides and different policies vie for the “ultimate” decisions and remember the midterm elections are on the horizon. If the House changes the majority the next question based on these attempts at bolstering Obamacare or single payer systems will we see additional changes?

If you get a chance check out our new book on Process Improvement, a sourly missing component of decision making today: “The Search for Excellence. A Handbook on Clinical Process Improvement for Providers”. But don’t let the title confuse you; this is not just for healthcare providers. Easy read and interesting.


Is the Grass Greener Across the Pond in Healthcare?



29542433_1496072063855781_546521568945876114_nI was going to continue my discussion regarding a single-payer healthcare system but I was wondering why we wanted to reinvent our healthcare system and which system we wanted to use as a model for our system. So, I will hold off my discussion regarding the single-payer model. As we celebrate the start of spring and Easter and Passover I thought that I would look at the multiple pundits who favor the health care system established in Europe, the systems in other countries, especially England.

As related by a British physician, a mother has blasted her local surgery after a bungling medical practitioner misdiagnosed her five-year-old daughter’s leukemia as a cold.

Kayleigh Chapman, 29, visited their GP when Lily-Mae Filmer’s spluttering cough started to get worse last month.

The mother-of-three also noticed bruise-like rashes appearing on her daughter’s skin, which can be a telltale symptom of some forms of cancer.

But instead of being referred to a GP or hospital, a nurse practitioner sent them on their way, saying she probably just had a virus.

However, Mrs. Chapman, of Pershore, Worcestershire, followed her mother’s intuition and returned just 48 hours later when more rashes started to appear.

Eventually, they were allowed to see a GP and the schoolgirl was referred straight away to Worcestershire Royal Hospital.

Following a series of blood tests, Mrs. Chapman was given the devastating news earlier this month that her daughter had acute lymphoblastic leukemia.

The youngster now faces a grueling two-year chemotherapy battle and has already started losing her hair and experiencing side effects.

Kayleigh Chapman, 29, visited her doctor’s surgery when Lily-Mae Filmer’s spluttering cough started to get worse on April 23 – only to be told that it was just a cold. The pair returned 48 hours later and were referred them to the hospital, where they found she had leukemia

Mrs. Chapman, who runs a gardening business with her husband Craig, said: ‘It was absolutely horrendous.

‘I am quite angry because she should have been referred straight away. I had wanted to see a doctor rather than a nurse, with all due respect.

‘I know they want to keep GPs free for more serious cases but what could be more serious than cancer.

‘I was just made to feel like a paranoid mum, who was over-reacting but I knew there was something wrong with my daughter.

‘We are devastated but we’ve got to stay strong for her. What I want to do is raise awareness of how fast it can all happen.’

The youngster now faces a grueling two-year chemotherapy battle and has already started losing her hair and experiencing side effects (pictured in hospital)

Mrs. Chapman said: ‘I am quite angry because she should have been referred straight away. I had wanted to see a doctor rather than a nurse, with all due respect’ (pictured together at Birmingham Children’s Hospital where a biopsy confirmed the leukemia diagnosis)

It all started with a cold and a cough on April 23, according to Mrs. Chapman.

Lily-Mae was ‘looking a bit off’ so she decided to keep her off of school as her symptoms worsened the next day.

Red spots started to appear on her skin alongside bruises, like that of a rash.

“I am quite angry because she should have been referred straight away. I had wanted to see a doctor rather than a nurse, with all due respect.”

So my question is, as we discuss health care and the virtues of the European system, is, is the Grass Greener on the other side of the pond?

“… I have never seen such a symbiotic relationship between a country’s health system [NHS] and its national identity. It runs very deep and every politician knows it.

However, he related statistics, such as that their continental neighbors can boast better health outcomes in some cases, such as cancer. Survival rates in England are around 10% lower than the EU average, particularly for colon, ovarian and lung tumors. We are catching up in some areas, including breast and stomach cancer but too many people are still being diagnosed too late.

Some European systems have a different way of financing, funding and providing healthcare. For example, Germany created the first social insurance sickness funds under Bismarck in 1883, which are still based on the principles of solidarity, subsidiarity and corporatism. Similarly, the widely admired French system is founded on the concept of “médecine libérale”, offering a greater choice of doctor and clinical freedom. The Dutch are consistently lauded for patient focus, their system is based on the principles of both competition and social solidarity. Switzerland is similar and is the least distressed health service I have worked in. A case of “you get what you pay for”.

But it’s glaringly obvious that these countries spend much more than the UK. We, i.e. England, commit 9.1% of our GDP to health while Germany spends 11.3%, Switzerland 11.5%, France 11.7% and the Netherlands 12.9%. Having worked in 60 countries over the last six years, he came to the conclusion that a single – or dominant – funder as in the UK offers their best hope for improved population health, patient care and taxpayer value. Germany and France have many health insurers, which pushes costs up. So does Japan, but the government sets a single price so, effectively, it is the dominant payer.

I returned to England from India only to learn that the NHS was already overspent [see link below] by almost £1bn. Soon, there will be siren voices that either scorn the lack of efficiency in the NHS or question its long-term sustainability. Either position is too simplistic…”

“Ministers are under growing pressure to give the NHS a multibillion-pound emergency cash injection after official figures showed hospitals overspent by £930m in three months and are on course to rack up an unprecedented £2bn deficit by the end of the year…

Heidi Alexander, the shadow health secretary, said ministers were in denial about the gravity of the NHS’s deepening black hole, which their policies had created.

“It is now clear why these figures weren’t released ahead of Tory party conference – they show an NHS in crisis. The alarming deterioration in NHS finances is a direct result of actions this government has taken. Cuts to nurse training places has left the NHS with a shortage of nurses, forcing hospitals to hire expensive agency staff. With a difficult winter approaching, hospitals are facing a stark choice between balancing the books and delivering safe care,” she said.”

“…I want junior doctors to know that their bosses aren’t going to be angry with them when they strike. I want them to know that they are going to be supported. I want them to know that we are shoulder to shoulder with them in what they are planning to do and we will help keep our patients safe. We are joined by the nursing staff. The nurses I have spoken to and work with want to lend their support and have similar concerns.

This solidarity exists because everyone in healthcare is anxious about how junior doctors are feeling. There are a large number who are deciding whether or not they want to continue to work as a doctor in this country. Many have traditionally worked overseas for a year or 18 months, and return having seen a different healthcare system, which often enriches their career. But now a lot of them are starting to talk about not coming back…”

He goes on to state that nurses and docs – frustrated by Ireland’s HSE and Britain’s NHS – are emigrating in larger and larger numbers.  If you’re in the minority that purchase private health insurance (as we do) and are willing to advocate for yourself and your family, you can sometimes bypass queues, minimize though not eliminate delays, and generally access care.  Our small county of Leitrim, for example, has no pediatrician or plastic surgeon; but the girls receive good care from local GPs and there’s an excellent plastic surgeon in neighboring Roscommon County (trained at NYU and Cornell) who, with a requisite letter of introduction, accepts referrals. Notably, Ireland’s healthcare is both implicitly and explicitly rationed and is a two-tier system of private and public sectors.  Public patients (the majority of Irish) experience difficulties accessing basic care, waiting times to see a consultant (specialist) can be anywhere from months to a year or more, and A&Es (ERs) are a “slow coach” where overcrowding and long stays in chairs and/or on gurneys, rather than beds, are commonly decried in the news.

“Waiting lists in the State’s public hospitals are continuing to rise with the numbers waiting for an out-patient appointment now close to 400,000, figures published [December last] by the HSE show.

The figures reveal increases in numbers on waiting lists for out-patient appointments, as well as in-patient and day-case procedures in hospitals…”

“…[A] study in May found young Irish doctors and nurses are not choosing to go abroad only for financial reasons, but because of poor working conditions, training and career opportunities here.

The survey of more than 500 junior doctors and nurses, by the Royal College of Surgeons in Ireland (RCSI), reported a feeling of “general disrespect” for health professionals in Ireland from the media and HSE.  Many said they had “rediscovered the joy” of practicing their profession in Australia, the UK and US…”

Without anyone noticing, doctors are leaving the NHS in droves

“Increased paperwork, increased hours, and ever more pressure are forcing GPs out of the NHS – either to the private sector, or abroad…”

“Almost half of all junior doctors are opting not to continue their training in the NHS, threatening a “disaster” that senior medics fear will worsen the service’s shortage of frontline clinicians.

This year only 52% of junior doctors who finished the two-year foundation training after medical school chose to stay in the NHS and work towards becoming a GP or specialist – the lowest proportion in the health service’s history and down from 71.3% as recently as 2011.

The official figures reveal sharp rises in the number of junior doctors shunning the NHS and opting instead to work in academia, as a locum medic or simply taking a career break…”

So you might ask, “What country has the world’s best health system?”

“…The problem with these exercises is that no one can really agree on what should be measured and, even when they do settle on measures, data are not always reliable and comparable.

“Of course, there is no such thing as a perfect health system and it certainly doesn’t reside in any one country,” Mark Britnell, global chairman for health at the consulting giant KPMG, writes in his new book, In Search of the Perfect Health System. [published Sept 2015, might be worth a read]

“But there are fantastic examples of great health and health care from around the world which can offer inspiration.”

As a consultant who has worked in 60 countries – and who receives in-depth briefings on the health systems of each before meeting clients – Mr. Britnell has a unique perspective and, in the book, offers up a subjective and insightful list of the traits that are important to creating good health systems.

If the world had a perfect health system, he [Mark Britnell] writes, it would have the following qualities: the values and universal access of the U.K.; the primary care of Israel; the community services of Brazil; the mental-health system of Australia; the health promotion philosophy of the Nordic countries; the patient and community empowerment in parts of Africa; the research and development infrastructure of the United States; the innovation, flair and speed of India; the information, communications and technology of Singapore; the choice offered to patients in France; the funding model of Switzerland; and the care for the aged of Japan…”

In my humble opinion, Kate, at its core this usually reverts to each individual’s willingness to pay – an unsurprising conclusion considering the Western world’s widely divergent theories of justice.

So what’s fair?  What’s morally right?  In a democracy, it may simply reflect majority rule; but an individual might readily argue the “tyranny of the majority”.  Enough for today.

It brings up the statement that the Grass Is Not Always Greener: A Look at National Health Care Systems Around the World.

Michael Tanner of the No. 613 Policy Analysis back in 2008 wrote that critics of the U.S. health care system frequently point to other countries as models for reform. They point out that many countries spend far less on health care than the United States yet seem to enjoy better health outcomes. The United States should follow the lead of those countries, the critics say, and adopt a government- run, national health care system.

However, a closer look shows that nearly all health care systems worldwide are wrestling with problems of rising costs and lack of access to care. There is no single international model for national health care, of course. Countries vary dramatically in the degree of central control, regulation, and cost sharing they impose, and in the role of private insurance. Still, overall trends from national health care systems around the world suggest the following:

  • Health insurance does not mean universal access to health care. In practice, many countries promise universal coverage but ration care or have long waiting lists for treatment.
  • Rising health care costs are not a uniquely American phenomenon. Although other countries spend considerably less than the United States on health care, both as a percentage of GDP and per capita, costs are rising almost everywhere, leading to budget deficits, tax increases, and benefit reductions.
  • In countries weighted heavily toward government control, people are most likely to face waiting lists, rationing, restrictions on physician choice, and other obstacles to care.
  • Countries with more effective national health care systems are successful to the degree that they incorporate market mechanisms such as competition, cost sharing, market prices, and consumer choice, and eschew centralized government control.

Although no country with a national health care system is contemplating abandoning universal coverage, the broad and growing trend is to move away from centralized government control and to introduce more market-oriented features.

The answer then to America’s health care problems lies not in heading down the road to national health care but in learning from the experiences of other countries, which demonstrate the failure of centralized command and control and the benefits of increasing consumer incentives and choice.

And now look at the latest announcement regarding the British health care system.    U.K. Hospitals Are Overburdened, But The British Love Their Universal Health Care!                                                                                                                                            Lauren Frayer wrote that when Erich McElroy takes the stage at comedy clubs in London, his routine includes a joke about the first time he went to see a doctor in Britain. Originally from Seattle, McElroy, 45, has lived in London for almost 20 years. A stand-up comedian, he’s made a career out of poking fun at the differences in the ways Americans versus Britons see the world — and one of the biggest differences is their outlook on health care.                                                                                                                                            “I saw a doctor, who gave me a couple pills and sent me on my way. But I still hadn’t really done any paperwork. I was like, ‘This isn’t right!’ ” McElroy says onstage, to giggles from the crowd. “So I went back to the same woman, and I said, ‘What do I do now?’ And she said, ‘You go home!’ ”                                                                                                                 The mostly British audience erupts into laughter. McElroy acknowledges it doesn’t sound like much of a joke. He’s just recounting his first experience at a U.K. public hospital. But Britons find it hilarious, he says, that an American would be searching for a cash register, trying to find how to pay for treatment at a doctor’s office or hospital. It’s a foreign concept here, McElroy explains.

Onstage, McElroy recounts how, when the hospital receptionist instructed him to go home, he turned to her and exclaimed, “This is amazing!”

Amazing, he says, because he didn’t have to pay — at least not at the point of service. In Britain, there’s a state-funded system called the National Health Service, or NHS, which guarantees care for all. That means everything from ambulance rides and emergency room visits to long hospital stays, complex surgery, radiation, and chemotherapy — are all free. They’re paid for with payroll taxes and the Value Added Tax, which is like a National Sales Tax. In addition, any medication you get during a hospital visit is free, and the cost of most prescription drugs at a pharmacy are cheap — a few dollars. (Private health care also exists in the U.K., paid out-of-pocket or through private insurance coverage, but only a small minority of residents opt for it.)

Since the 2008 financial crisis, the U.K., like many countries, has been taking in less tax revenue — so it’s had to cut spending. Its expenditure on the National Health Service has still grown, but at a slower pace than before. That means drugs are now being rationed. Tens of thousands of operations have been postponed this winter. Wait times at the emergency room are up, says Richard Murray, policy director at the King’s Fund, a health care think tank.

“If the ER is really busy, it makes the ambulances queue outside the front door — not great,” Murray says. “And in some cases, the hospital is simply full.”

In recent months, there have been several “Save the NHS” marches across Britain, where thousands have demonstrated to demand improved care and more funding for the health system. One such march, on Feb. 3 on Downing Street in central London, caught President Trump’s attention.

Two days later, Trump tweeted that the NHS is “going broke and not working.” He accused Democrats of pushing for a similar system of universal health care in the United States. “Dems want to greatly raise taxes for really bad and non-personal medical care. No thanks!” the president wrote on Twitter.

The Democrats are pushing for Universal HealthCare while thousands of people are marching in the UK because their U system is going broke and not working. Dems want to greatly raise taxes for really bad and non-personal medical care. No thanks!

That tweet offended many in Britain. It prompted Prime Minister Theresa May’s office to issue a statement saying the U.K. premier is “proud” of her country’s system. The U.K. health secretary, Jeremy Hunt, tweeted back at Trump, saying he may disagree with some of the claims of those attending “Save the NHS” marches, but that “not ONE of them wants to live in a system where 28m people have no cover” — a dig at the uninsured in America. Hunt wrote that he’s proud that Britons “all get care no matter the size of their bank balance.”

I may disagree with claims made on that march but not ONE of them wants to live in a system where 28m people have no cover. NHS may have challenges but I’m proud to be from the country that invented universal coverage – where all get care no matter the size of their bank balance

The National Health Service spends less than half of what Americans spend per person on health care, and yet life expectancy is higher in Britain.

Defense of the NHS runs straight across the British political spectrum.

“You wouldn’t find a single leading politician on either the left wing the Labour Party or the right wing in the Conservative Party that would talk about privatizing the NHS,” Murray says. “That would be electoral poison.”

The NHS polls better than the queen. U.K. politician Nigel Lawson once said, “the NHS is the closest thing the English people have to a religion.” It featured prominently in the opening ceremony of the 2012 London Olympics, with doctors dancing to swing music and hospital beds arranged to spell out the letters N-H-S in aerial views from above.

Britain’s National Health Service celebrates its 70th birthday this summer. It was founded on July 5, 1948.

After the pain of World War II, Britons decided to provide health care for all, and they’re still very proud and protective of that choice, says Roberta Bivins, a historian of medicine at the University of Warwick.

“The war was barely over. The rubble was still smoking,” Bivins says. (She is also an American expatriate who’s lived in the U.K. since the 1990s, when she arrived to study for a Ph.D. She, too, describes being in disbelief the first time she went to a doctor and wasn’t asked to pay anything.)

“People here are very, very uncomfortable that companies should profit from someone getting sick,” she says. “In the U.S., we’re much more comfortable with the idea that the market will provide services.”

McElroy, the comedian, says state-funded health care means his family doesn’t have to worry about needing coverage through an employer. He and his wife Erin McGuigan are both self-employed. McGuigan works as a birth and postnatal doula, alongside NHS midwives. She gave birth to the couple’s two children, in the NHS system, for free.

“You get follow-up care, where the midwives and health visitors come to your home, for a number of days after you give birth, to do checks and ensure breastfeeding is established and [the] baby is well — just to get new parents on their way,” McGuigan says. “I’ve had excellent care.”

She says she has had to wait four to six weeks for a doctor’s appointment if it’s not something urgent.

McElroy says there is one thing he would like to change about the NHS. His comedy routine includes another joke about what happened after he had minor surgery in Britain.

“The first thing they gave me when I came out of surgery was a fish pie — which I say in the routine, put me straight back into the hospital, because it was so disgusting!” he says.

“They might give us health care,” he jokes, “but the food is still terrible in this country.”

So, is universal health care the answer? Based on other countries experience maybe it isn’t. Then what is the answer?

Happy Easter and Best wishes for those of my friends who celebrate Passover.