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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.

ObamaCare’s 8th birthday is an unhappy one for all Americans; and does Trump or Anyone Understand What is Really Needed?

22089429_1321816227948033_8179037606811800274_nSince Obamacare turns eight on yesterday I thought that I would spend some more time on the problems with Obamacare. Sally Pipes of Fox News had a nice review. Consider that when Obamacare turns eight on Friday, the law will have exactly one impressive accomplishment to its name: surviving as long as it has.

Many people now believe that Americans are worse off than we were before ObamaCare was enacted. Health insurance premiums and deductibles are soaring, and consumers face a shrinking number of insurance options. More Americans than ever are now covered by Medicaid – a costly and unsustainable entitlement that, in many cases, is worse for patients’ health than going without insurance altogether. And U.S. life expectancy has dropped for two consecutive years for the first time in over half a century. But, and I have to say this, more people have healthcare insurance coverage.

ObamaCare bears much of the blame for this disastrous state of affairs.

The Affordable Care Act’s most glaring shortcoming has been a failure to make good on its eponymous promise – affordability. President Obama assured Americans in 2010 that the law’s insurance exchanges would create “a competitive marketplace” where Americans could “purchase affordable, quality insurance.”

On the marketplace, however, average premiums in 2017 were 25 percent higher than in 2016 – and more than double average individual-market premiums in 2013. Premiums have continued to soar this year – midlevel Silver Plan premiums increased by an average of 34 percent in 2018, relative to 2017.

Out-of-pocket costs have skyrocketed as well. The average deductible for an individual Silver Plan this year was nearly $4,000.

The combination of high premiums and high deductibles has put health care out of reach for millions. In a June survey, one-quarter of Americans said that they or someone in their family had gone without needed medical care because of cost.

Nor have the exchanges been especially competitive. ObamaCare’s mandates have cost insurers hundreds of millions of dollars. Insurers have responded by fleeing the marketplaces in droves. Over half of U.S. counties currently have only one provider selling exchange coverage.

ObamaCare’s defenders have long cited the drop in the uninsured rate as proof of the law’s success, but that argument no longer holds water. The number of uninsured Americans actually increased by 3.2 million last year, in part because ObamaCare has made insurance so expensive.

The law has also managed to funnel 15 million new patients into Medicaid – the health insurance entitlement for low-income Americans. But it’s far from clear whether that’s a blessing or a curse for new enrollees.

Medicaid beneficiaries are no healthier than uninsured people. One recent study compared uninsured Oregon patients with a group that was randomly selected to receive Medicaid. After two years, researchers found “no significant improvements in measured physical health outcomes” among Medicaid patients compared to their uninsured counterparts.

Worse, the Medicaid expansion has exacerbated our nation’s deadly opioid epidemic – at least according to a recent report from the Senate Homeland Security Committee. The expansion made prescription painkillers cheaper and more widely available. People who were eager to abuse these medications – or sell them illegally on the black market – quickly capitalized on this new government-subsidized drug supply.

Medicaid fraud cases related to opioids have increased by 55 percent since ObamaCare’s expansion of the program. Eighty percent of fraud cases have been filed in expansion states. Even more troubling, overdose death rates are rising nearly twice as fast in Medicaid expansion states as in non-expansion states.

Since ObamaCare took effect, insurance coverage has become more expensive, out-of-pocket costs are more onerous, insurance choices have dwindled and Americans are dying sooner. Let’s hope the law’s eighth birthday is its last.

The Glaring Question is Why Did the Uninsured Rate See Its Biggest Increase Since 2008?

One particular type of insurance buyer had the most substantial drop in coverage.

Christy Bieber discussed that question. From the last quarter of 2016 to the last quarter of 2017, there was a 1.3% increase in the uninsured rate, according to Gallup. This 1.3% increase means 3.2 million Americans became uninsured in 2017. It’s the biggest year-to-year increase in the uninsured rate since 2008, which was before the passage of Obamacare.

Why did so many more Americans become uninsured? There are a lot of reasons, and we’ll take a look at some of them here.

The individual market saw the biggest change

First and foremost, it’s clear where the increase in the uninsured population came from: the individual insurance market — the people who buy private policies on the Obamacare exchange or directly through insurers. In the final quarter of 2016, a total of 21.3% of Americans indicated they purchased insurance coverage themselves in the private marketplace. By the last quarter of 2017, this number had fallen to 20.3%, a full percentage-point decline.

According to Gallup, this is a direct reversal of a multi-year trend. In 2013, Obamacare’s mandate — the penalty for not buying insurance — went into effect. Then, from 2013 to 2016, there was a 3.7% increase in Americans buying insurance on the private market.

But from 2016 to 2017, the number of Americans buying these policies went down for the first time since the mandate became enforceable, even as other sources of health insurance coverage such as Medicare, Medicaid, military insurance, and union-provided insurance remained steady. The number of policyholders covered by an employer also declined from 2016 to 2017, but the decline was just .6 percent.

Let’s look at what happened in the private marketplace that caused fewer consumers to take part.

Policy premiums rose — driving out the young and healthy

Gallup cites rising premiums as one of the likely reasons for the decline in the number of Americans buying private policies. When insurance coverage becomes more expensive, fewer people buy it. And insurance became more expensive in 2017.

Kaiser Family Foundation indicated premium increases on the ACA marketplace would be greater in 2017 compared with prior years, thanks, both to insurers adjusting for past losses and the phasing out of a reinsurance program in place from 2013 to 2016. The reinsurance program also left insurers with larger-than-expected losses when it failed to provide promised payments to insurers with a disproportionate share of costly claims.

Changes in insurer participation in the individual market also drove costs upward and left insurance buyers in the private marketplace with fewer choices. While 85% of insurance buyers had a choice of three or more insurers in 2016, just 58% had that same level of choice in 2017.

Unfortunately, when costs go up, the young and healthy are the first to drop out — and Gallup data shows this occurred. In 2017, the uninsured rate among Americans between the ages of 18 and 25 rose 2%. If this trend continues, an insurance death spiral is a real risk.

Americans were confused about whether the insurance mandate will be enforced

The insurance mandate was a key component of Obamacare before it was repealed as part of the 2017 tax reform bill. The sharp uptick in Americans buying coverage in the individual marketplace when the mandate went into effect showcases the importance of this mandate in driving the purchase of insurance. The Congressional Budget Office also estimated the repeal of the mandate beginning in 2019 would result in 4 million people fewer people obtaining coverage during the course of the 2019 year alone.

While the mandate wasn’t actually repealed until December of 2017 and it’s still in effect until 2019 even after repeal, many Americans were confused in 2017 about whether the mandate still applied. More than half of Americans responding to an October 2017 poll either didn’t know whether Obamacare was still in effect or thought it had been totally or partially repealed. Even among those who knew the law and mandate were still in place, it was an open question whether Trump would actually enforce it.

Given that there was so much uncertainty about whether the requirement to purchase health insurance would survive, it’s no surprise that significantly fewer people bought plans for this year.

There was way less advertising and outreach for Obamacare

The Obama administration spent more than $100 million advertising open enrollment in 2016 and partnered with outreach groups to target populations with high uninsured rates. These efforts were credited with helping to secure insurance coverage for more than 4 million Latinos. As a result, Latinos experienced the most substantial drop in the uninsured population of any demographic group.

The Trump administration essentially ended outreach efforts and dropped the advertising budget down to $10 million. The result: Hispanics saw a 2.2% increase in the uninsured population in 2017, and black Americans saw a 2.3% increase. Lower-income Americans saw a 2% increase.

By comparison, middle-income Americans had a 1.4% increase in uninsured rates, and high-income Americans saw just a .8% increase.

What happens now?

Whether the uninsured rate continues to rise in 2018 will depend upon what, if anything, is done to bring premiums down. While there’s a bipartisan effort to stabilize insurance premiums, a dispute over abortion policy may make passage of legislation impossible. And with some prominent Republicans still hoping to move forward with Obamacare repeal — which has little chance of passage — little likely will be done to stabilize Obamacare in the short term.

However, the November 2018 election could potentially change the calculation, depending upon which party ultimately winds up in control of the House and Senate.

The only thing that’s certain is that fights over Obamacare may continue. Insurers tend to dislike uncertainty, and those who buy individual coverage probably will be the ones who’ll suffer due to a continued lack of solutions. If fewer of those insurance buyers decide to get coverage, the uninsured rate will continue to rise.

What Trump doesn’t get about Obamacare and health insurers’ profits!

Tami Luhby wrote that the Trump administration has once again pointed to health insurers’ robust stock market performance as proof that they are profiting from Obamacare.

The White House’s Council of Economic Advisers issued a report this week declaring that insurers have made a lot of money since the Affordable Care Act took effect, primarily thanks to large premium increases and generous federal funding of premium subsidies and Medicaid expansion. The release coincided with an unsuccessful attempt in the Senate to restore funding for the second set of Obamacare subsidies — which helped to reduce low-income enrollees’ deductibles and co-pays — that President Donald Trump eliminated last fall.

“Despite an initial rough patch in the ACA marketplaces, the ACA Medicaid coverage expansion and subsidies to insurers have resulted in a large increase in health insurer profits,” the four-page report said.

The council’s main argument: That the stock prices of health insurance companies rose by 272% since the health reform law’s implementation in January 2014 — more than double the gain of the S&P 500 over that period.

This is a flawed rationale that the Trump administration has used before.

Despite Trump’s attacks, Obamacare sign-ups dip only slightly, which I did point out a few weeks ago.

While it’s true that Obamacare insurers are finally becoming profitable, they aren’t exactly rolling in the dough because of their involvement in the individual market, experts say. And carriers’ stock prices are a poor measure of their performance on the exchanges given how many other factors contribute to their bottom line.

Let’s take a closer look:

In the first few years of Obamacare, many insurers priced their plans too low, resulting in big losses. This prompted many carriers — including most of the large publicly traded ones — to downsize or exit the market completely. There are just over 130 insurers on the exchanges this year, down from 237 two years earlier, according to data from the Centers for Medicare & Medicaid Services.

Anthem (ANTM) is the only large public insurer with a sizable presence on the exchanges, but even it pulled out of several states for 2018.

At least two years of big rate hikes have helped the insurers that remain get on a more solid financial footing. Several recent studies, including ones by the Kaiser Family Foundation and S&P Global, have found that many insurers’ premiums in 2017 were more than adequate to cover policyholders’ medical expenses.

The average monthly gross margin per member was nearly $79 in the third quarter of 2017, up from $9.90 two years earlier, according to the Kaiser Family Foundation. (The gross margin doesn’t take into account administrative expenses.)

Several insurers have reported their first profits in their Obamacare businesses. Highmark Health in Pittsburgh, Pennsylvania, announced earlier this week that its Affordable Care Act division generated income for the first time in 2017, calling it “a substantial turnaround.”

“The fact that it has taken so long to achieve some level of profitability speaks to the challenges that have long existed in the individual market,” said Kristine Grow, a spokesperson for America’s Health Insurance Plans, an industry trade association.

Still, the individual market is not likely to be a font of big profits for insurers. It’s expected to generate margins of only 1% or 2%, which is why many of the larger public carriers left, said Deep Banerjee, a director at S&P Global. The employer insurance market, on the other hand, generally produces profit margins of 8% to 10%.

The Affordable Care Act also boosted enrollment in insurers’ Medicaid divisions, which are generally profitable, experts said. States are increasingly contracting with insurers to manage the health care needs of their Medicaid enrollees, said Larry Levitt, a senior vice president at Kaiser. This includes the more than 11 million low-income adults who entered the program through Medicaid expansion.

Nearly two-thirds of plans in states that expanded Medicaid said that it has had a positive effect on their financial performance, according to Kaiser’s 2017 Survey of Medicaid Managed Care Plans.

As for the insurers’ stock prices — that’s usually driven more by their employer and Medicare divisions, which are typically much larger, as well as by carriers’ efforts to control costs, Banerjee said.

I still believe that Obamacare was and still is a step in the right direction. The main problem is that no one ever really figured out the long-term financial sustainability strategy. So, back to our evaluation of a single-payer healthcare system.

Elizabeth Warren Has New Plan to Improve Health Care – and It Isn’t Medicare for All!

A recent poll found that likely voters want the Democratic Party to prioritize health care if it controls Congress and the White House in 2021. Sen. Elizabeth Warren (D-MA) is on it.

Warren on Wednesday introduced a new health care bill — and unlike the Bernie Sanders bill that Warren still co-sponsors, it does not call for a single-payer system. Instead, the legislation, called The Consumer Health Insurance Protection Act, aims to make insurance within the existing Obamacare system more affordable and protect more enrollees from insurance company policy changes and premium hikes. It would increase federal subsidies for people buying Affordable Care Act plans, allow more people to qualify for ACA tax credits and impose tighter controls on private insurers.

Health policy expert Charles Gaba calls Warren’s bill, and similar House legislation that was introduced recently, “ACA 2.0.” Here’s some of what Warren’s plan would do:

  • Limit insurance premiums to no more than 8.5 percent of income
  • Cap out-of-pocket prescription drug costs for those on private plans at $250 a month, or $500 per family
  • Require insurers who sell Medicare Advantage or Medicaid managed care plans to offer coverage on ACA exchanges that have limited competition
  • Require private insurance plans to spend 85 percent of the premiums they receive on paying out claims, up from 80 percent under the ACA currently
  • Set limits on insurance company profits to match what those private insurers can earn from Medicare and Medicaid
  • Provide more money for ACA outreach and enrollment efforts.

You can read more about what the bill would do at HuffPost or FierceHealthcare.

“We need #MedicareForAll – and until we get it, there’s no reason private insurers can’t provide coverage that lives up to the high standards of our public health care programs,” Warren tweeted in announcing the bill.

Democratic Sens. Sanders, Kamala Harris (CA), Maggie Hassan (NH), Kirsten Gillibrand (NY) and Tammy Baldwin (WI) are co-sponsoring the Warren bill, which means it has “total buy-in from the senators most likely to run on the more liberal side of the Democratic Party in the 2020 presidential nomination contest,” Bloomberg’s Jonathan Bernstein notes.

Why it matters: This bill isn’t going anywhere right now, but Democrats appear to be pulling together a plan that could win broad support within the party and thus actually pass in some form if they retake Congress and the White House in 2020. “None of these senators is giving up on single-payer as an aspiration,” Bernstein adds. “But they apparently recognize that ‘Medicare for all’ is a long-run goal, and that they have a serious responsibility to also have a short-term, achievable and significant plan to improve on the post-Donald Trump, post-Paul Ryan status quo.”

As I mentioned last week, we need a bipartisan solution to solving the healthcare crisis. Nothing will be accomplished by fighting each other and attempting to derail the parts of the Affordable Care Act that make so much sense and correcting the parts that will eventually lead to its demise or make things worse.

Maybe more people should start by reading our book The Search for Excellence in Clinical Process Improvement published bt Sentia Publishing.

And We are Still Working on Obamacare-Susan Collins Moves The Goalposts On An Obamacare Bailout, and More

29197151_1482598261869828_1397170286071119872_nWith the 2018 midterm elections looming on the horizon, one wonders how will the GOP and the Democrats spin the issues and especially the healthcare issue.

Have we made any progress and which party is winning in the fight to get their health care system program the sustainable/stable system for “We the People?

It seems that there are a number of backroom political plans being discussed. Consider the discussions between Senator McConnell and Senator Susan Collins. The White House and McConnell should never have made an agreement on an Obamacare ‘stability’ bill with Collins in the first place.

Christopher Jacobs, an author for the Federalist, wrote that the 19th-century showman P.T. Barnum famously claimed that, “There’s a sucker born every minute.” Apparently, Republican Sens. Susan Collins and Lamar Alexander think that Barnum’s dictum applies to their Senate colleagues. Both have undertaken a “bait-and-switch” game, constantly upping the ante on their request for an Obamacare “stability” bill — and raising questions about their credibility and integrity as legislators in the process.

Flashback to last December, when Congress considered provisions repealing the individual mandate as part of the tax reform bill. At that time, Collins engaged in a colloquy with Senate Majority Leader Mitch McConnell, who said he would support legislation funding Obamacare’s cost-sharing reductions, as well as Collins’ own reinsurance proposal.

Collins described her bill in their exchange:

I thank the majority leader for his response. Second, it is critical that we provide States with the support they need to create State-based high-risk pools for their individual health insurance markets. In September, I introduced the bipartisan Lower Premiums Through Reinsurance Act of 2017, a bill that would allow States to protect people with preexisting conditions while lowering premiums through the use of these high-risk pools….

I believe that passage of legislation to create and provide $5 billion in funding for high-risk pools annually over 2 years, together with the Bipartisan Health Care Stabilization Act, is critical for helping to offset the impact on individual market premiums in 2019 and 2020 due to the repeal of the individual mandate. [Emphasis mine.]

Collins viewed McConnell’s commitment as so iron-clad that she put a transcript of the colloquy up on her website. Unfortunately, however, Collins didn’t find her side of the bargain as an iron-clad commitment.

One week after that exchange on the Senate floor, Alexander wrote an op-ed on a potential “stability” package. That op-ed claimed that Collins’ reinsurance bill included “$10 billion for invisible high-risk pools or reinsurance funds.” However, the text of the Collins bill itself would appropriate “$2,250,000,000 for each of fiscal years 2018 and 2019” — that is, $4.5 billion and not $10 billion. I noted that discrepancy at the time, writing that, “Alexander seems to be engaged in a bidding war with himself about the greatest amount of taxpayers’ money he can shovel insurers’ way.”

It turns out I was (slightly) mistaken. Alexander wasn’t in a bidding war with himself over giving the greatest amount of taxpayer funds to insurers — he is in a bidding war with Collins. Just this week, both Collins and Alexander issued press releases touting a (flawed and overhyped) premium study by Oliver Wyman. The press releases claimed that “Oliver Wyman released an analysis today showing that the passage of a proposal based on … the Collins-Nelson Lower Premiums through Reinsurance Act will lower premiums … by more than 40 percent.” [Emphasis mine.]

But the release went on to note that, “Oliver Wyman based its analysis on a proposal that would fund [cost-sharing reductions] … and provide $10 billion annually for invisible risk pool/reinsurance funding in 2019, 2020, and 2021.” Not $2.25 billion for fiscal years 2018 and 2019, as the actual Collins-Nelson bill would provide — but more than four times as much annually, for a 50 percent longer duration.

Not even Common Core math can explain the gaping chasm between the funding amounts in the two bills. Does Alexander really want to make a straight-faced claim that an estimate assuming $30 billion in funding is “based on” a bill providing only $5 billion in funding? And if so, then why should a Senator who fails a math test even a first-grader could comprehend chair the committee with jurisdiction over federal educational policy?

Collins and Alexander went to all this trouble because they want to have their cake and eat it too. Collins expects McConnell to abide by his commitment from December — she reportedly cursed out a senior White House aide when the “stability” package failed to pass late last year. But she has no place criticizing McConnell or others for not keeping their word when she has proved unable to keep hers, by upping the ante on her asks for a “stability” bill — and putting out misleading press releases to hide the fact that she ever asked for “only” $5 billion in taxpayer funds.

Collins has no place attacking the White House, or anyone else, for “reneging on the deal.” She reneged on the deal herself — by not sticking to her original commitments, and then putting out misleading press releases to cover her tracks. The White House and McConnell should never have made an agreement on a “stability” bill with Collins in the first place. But if they did, the unscrupulous way in which she has handled herself since then should have nullified it.

You wonder what they are drinking or smoking down there in D.C. when you read that the “House Democrats are Hopeful that ACA Fix Can be Passed”

It’s hard to believe, but Congress can come together. Really???

Our friend Joyce Frieden the News Editor of MedPage noted that at least one Democratic lawmaker is optimistic that Congress can pass legislation to help shore up the Affordable Care Act (ACA).

“It’s hard to believe, but Congress can come together,” Rep. Kyrsten Sinema (D-Ariz.) said here Monday at the annual policy meeting of the Federation of American Hospitals, a trade group for for-profit hospitals. “I’m part of a group [in the House] called the Problem Solvers … and all we do is work together to find lasting solutions to country’s challenges. One area we’ve been working on diligently for the last year is the stabilization of the [ACA’s insurance] market.”

The bill that the caucus is developing would fund the cost-sharing reduction (CSR) payments that the federal government sends to insurers on the ACA’s healthcare marketplace to help low-income enrollees pay their out-of-pocket costs. The Obama administration had been making the payments, but the Trump administration cut them off.

In addition to funding the CSR payments, the bill “creates patient and state stability funds that can be used for reinsurance,” Sinema said. “It [also] leaves the current Medicaid system in place, which has been hugely important to Arizonans’ ability to have access to care.”

The caucus is hoping that the bill will be included in the omnibus budget legislation expected to be introduced on March 23rd, “so, fingers crossed,” she added.

Audience members also heard from Sen. Tim Kaine (D-Va.), who said he was part of a group of senators discussing a similar bill which “involves [first] making sure the federal government makes good on its cost-sharing promise and second, making sure states have the ability to tailor programs in a way that most fits their population,” he said. “And third, reinstating the reinsurance provision that was part of the ACA for the first several years. Reinsurance really works to provide stability and bring down premiums for average folks. That’s why we use reinsurance in crop insurance — it’s a time-tested strategy that brings costs down.”

Kaine, like Sinema, said that CSRs and reinsurance “are very much [talked about] as part of the omnibus bill.” He also decried the current debate in Congress about repealing the ACA — a debate that he pointed out has been going on for 7 or 8 years — and said that Congress instead needs to “talk about the next steps forward … I want to be in a position… where we’re not afraid to talk about big ideas.”

Kaine listed three big ideas he thought Congress should be discussing:

Block granting: This is the idea that instead of states receiving a “match” from the federal government for every dollar they spend on federally approved Medicaid expenses, the government would give each state a lump sum of Medicaid money, regardless of how much the state itself spent, and free up the state to run the program as it wished. “Is there a block grant strategy that would work?” Kaine said. “As a [former] governor [and] mayor, I love the flexibility, but I’m really concerned about what block grant proposal would do — but I am not afraid to have that discussion.”

Single-payer: This idea, championed most vocally by Sen. Bernie Sanders (I-Vt.) would replace the current public/private health insurance system with an entirely government-financed one. Because more than 100 million Americans get their health insurance through their employer “and 80% of them are generally happy with their plan, I don’t think they’re going to believe [it]” when supporters say a single-payer plan will be just as good, but it’s still worth discussing, Kaine said.

Public option: This concept — initially discussed before the ACA was passed but left out of the final bill — would give people buying insurance on the ACA’s health insurance exchange the option of a publicly run healthcare plan. A bill that Kaine introduced along with Sen. Michael Bennet (D-Colo.) “would direct [the Centers for Medicare & Medicaid Services] to develop an insurance policy that they would sell to working families on the exchange,” Kaine explained. The policy, which Kaine called “Medicare X,” would cover all the “essential health benefits” defined under the ACA, and would be sold at a competitive rate. Kaine emphasized that no government funding would be involved because the policy would be financed entirely by enrollee premiums. “We think … it would give people additional options and bring costs down,” he said.

“What I hope we will do is get out of the mode where it’s just about ACA repeal and put on the table all the ideas — block grant, single payer, Medicare X and I’m sure there are other ideas as well … and we’ll hear from all the stakeholders,” Kaine said, including doctors, hospitals, and patients. “I don’t think [we can] limp along playing defense and fighting off rear-guard repeal actions and do justice to the healthcare needs of our country.”

I had mentioned a few weeks ago about how a number of wealthy and successful CEO’s were going to design their healthcare solutions/systems, but I ran across an article that cautions them about their journey.

To Amazon and Partners: Thoughts from a Healthcare Entrepreneur

Alex Heinosz, a co-founder of CipherHealth, has led the company through significant growth since inception. He directs the company’s commercial side, working to bring CipherHealth’s integrated patient engagement and care coordination solutions to healthcare systems around the country. He noted that how we spend our days is how we spend our lives, then I am dedicating my life to transforming how healthcare is delivered, experienced, and perceived. In 2009, Randy Cheung, Zach Silverzweig, and I started CipherHealth to help hospitals reduce avoidable readmissions using big data. Today, we’ve built a team driven by our shared vision of revolutionizing the patient and provider experience with one unified platform for all patient communication and coordination. I’ve chosen healthcare because health, or lack thereof, touches all of us: our loved ones and we all are, or at some point, will become patients. Because healthcare is measured in lives, the joint venture between Amazon, Berkshire Hathaway, and JPMorgan Chase is very much welcomed. We need all hands on deck – not only to address the “hungry tapeworm” of ballooning healthcare costs but to secure the future of healthcare delivery for generations to come.

As giants of their respective industries, Amazon, Berkshire Hathaway, and JPMorgan Chase are already well positioned to create healthcare’s “tipping point”. Although any new venture presents some degree of risk, the sheer size of these partners affords many resources that are unavailable to most other players within the healthcare industry. As publicly traded companies that are held financially accountable by shareholders and investors, these partners are confident that their joint venture will be successful. After all, with the combined revenue of these three behemoths totaling $501 billion, Amazon and partners have a deep well of financial, technical, and human resources from which to draw upon. By focusing initially on high-quality healthcare for their U.S. employees at a lower cost, these partners designed the most receptive audience to test their first healthcare venture. With nearly 1.2 million employees working across all three companies, they have the critical mass necessary to develop a continuous feedback loop for improvement.

As a healthcare entrepreneur and consumer, I am optimistic that this partnership will accelerate innovation for the healthcare industry. To help Amazon and partners as they embark upon their journey, I’d like to share important lessons that I’ve learned.

  1. The Inexperience Advantage: The optimism that comes with a lack of experience is an asset. If you don’t know what you’re getting yourself into, you’re more likely to jump into it. Venturing into uncharted territory requires the specific sort of optimism and courage to take risks that often diminishes with experience.
  2. Patience, Patience, Patience: The healthcare industry moves at a slower pace than that of other industries. Since change happens very slowly, progress can only be measured by the sustained improvement. In their early days, Amazon experienced success by taking a slow, deliberate approach to new markets. Since then, they have become a fast-moving company that anticipates consumer preferences. As the company that pioneered two-day shipping, the slow pace of healthcare may initially feel like a regression to the old days. When evaluating their impact on cost savings and patient outcomes, Amazon and partners need to take the long view in addition to looking at short-term “wins.”
  3. Solving Bigger Problems: Rather than focusing on cutting costs, how can we deliver more value in healthcare? By joining forces, these partners have the tremendous opportunity to increase the scope of the problem that they are trying to solve. Over time, this group can widen their gaze to address some of the fundamental challenges of the healthcare industry. At CipherHealth, one of the problems that we want to solve is closing the gap between the robust body of medical literature and everyday patient care. To do this, we are integrating evidence-based health information into clinically validated care plans to reveal insights into care gaps and population-specific outcomes.
  4. Achieving the Quadruple Aim: Healthcare delivery is often framed through the lens of enhancing the patient experience, improving population health, and reducing costs. Caring for the healthcare provider is a prerequisite to achieving the Triple Aim. Thus, to truly optimize and scale high-quality healthcare delivery, it is important to integrate staff satisfaction as the fourth success metric. By delegating repetitive processes to healthcare technology, staff can dedicate their specialized expertise and time to high-value patient care activities. Technology can reduce staff burnout by automating activities that are limited in their potential impact. To drive systemic, long-term improvements in healthcare, Amazon and partners need to address clinician engagement in addition to “checking the rise in health costs while enhancing patient satisfaction and outcomes”.

The joint venture between Amazon, Berkshire Hathaway, and JPMorgan Chase can only serve as a catalyst for innovation in the healthcare industry. If successful, this partnership could inject a healthy dose of competition into the American healthcare delivery system – ultimately, driving better patient care. As a company committed to improving the lives of patients and providers, we are rooting for the success of our fellow innovators.
Jo Ann Jenkins the CEO of AARP recently wrote that as I reflect on the current health care debate, I am reminded of a quote about the definition of politics by the late Groucho Marx. “Politics,” he said, “is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies.”

Even though the measures proposed in the Senate failed, that doesn’t mean the health care debate is over. It is clear the “remedies” that were proposed by both the House and Senate bills would have resulted in higher costs and less care, especially for older Americans, and huge windfalls to pharmaceutical companies and health insurance companies.

That’s why AARP conducted an all-out effort to urge senators and representatives in Congress to vote “no” on these bills. We ran an extensive campaign urging our members to contact their lawmakers and held tele-town halls across the country. AARP volunteers and staff in every state made more than 400 visits to their congressional representatives, expressing opposition to the bills. AARP members continue to make their voices heard.

Don’t get me wrong — the Affordable Care Act is not perfect. Aspects of the law need to be fixed in order to lower costs and maintain vital protections and coverage that millions of Americans rely on. But instead of overcharging older Americans and threatening access to affordable coverage, Congress should focus on bipartisan solutions that will increase coverage, lower costs and improve care. There are many ways to reduce health care costs that would not harm ordinary people. For example, AARP has long advocated for Medicare to be allowed to negotiate lower drug prices with pharmaceutical companies.

We urge Congress to follow the advice of John F. Kennedy, who as a senator in 1958 said, “Let us not seek the Republican answer or the Democratic answer, but the right answer. Let us not seek to fix the blame for the past — let us accept our own responsibility for the future.” Our responsibility for the future is to create a world-class health care system that is affordable and gives all Americans access to the care that they need.

Politics has also been described as the art of the possible. We believe it is possible to craft a health care bill that provides all Americans quality, affordable care. But that requires getting the best ideas from all stakeholders and having a full and open debate.

We and I agree, urge Congress to turn the page on fighting over “Obamacare” and “Trumpcare” and open a new chapter working together on commonsense solutions to increase coverage, lower costs and improve health care for all Americans. Not only is that the right answer, but it would also prove Groucho wrong.

So, back to our discussion regarding the Single Payer health care system and hopefully the idea of a bipartisan solution to the healthcare crisis.

And as I pointed out last week, yeah, we have finally published our book “The Search for Excellence in Clinical Practice- A Handbook on Clinical Process Improvement for Providers”, published by Sentia Publishers.

The Single Payer system/ Medicare for All and now Bernie Sanders seeks ‘citizen co-sponsors’ for a ​single-payer health care bill

26993261_1432436440219344_4607508862949775129_nNicole Gaudiano reported that Sen. Bernie Sanders is now seeking “citizen co-sponsors” for a “Medicare-for-all” health care bill he plans to introduce in a few weeks.

While pledging to fight GOP efforts to repeal Obamacare, the Vermont independent told supporters in a Wednesday email that the ultimate goal is a single-payer system, a federally administered program that would eliminate the role of private insurers in basic health care coverage. He suggested a Medicare for all system.

He asked supporters to sign on as citizen co-sponsors because — in a reprise of his 2016 presidential campaign’s clarion call — “getting there will require nothing short of a political revolution.”

“It is time to wage a moral and political war against a dysfunctional health care system in this country,” he wrote. “When I introduce the legislation, I want it to be clear that the American people believe health care should be a right in this country.”

Republicans say the single-payer approach to health care is a “government takeover” of insurance that will cost trillions and be financed on the backs of taxpayers. They point to an Urban Institute study of Sanders’ proposal during his presidential campaign that said it would increase federal expenditures by $32 trillion over 10 years, though a Sanders aide says the forthcoming bill will cost less than the campaign plan.

Sanders, in his email, said the system would save lives and “hundreds of billions” in annual health care costs.

“The savings for businesses would be astronomical and allow them to compete on equal footing with companies in Europe,” he wrote. “And for the millions of Americans who are currently in jobs they don’t like but must stay put because of health care access, they would be free to explore more productive opportunities as they desire.”

But is it really the answer and do we really want it?

Why Bernie’s Universal Healthcare System Would Be A Disaster

The Staff at TWD and Associates wrote that this past week, Senator Bernie Sanders of Vermont proclaimed in a New York Times op-ed that the time has come to create a program of “Medicare for all,” a government-run single-payer healthcare system that would over a four-year period displace all existing private healthcare plans, Newsweek writes.

His new program, rightly denounced as delusional, purports to provide to over 325 million Americans coverage that would be more extensive and costly than the rich benefits supplied to the 55 million Americans on Medicare—which itself teeters on the edge of insolvency.

Sanders proposes to fund his new plan with a variety of heavy taxes on productive labor and capital, without noting that his program will cut into the very tax revenues needed to support such a system. Incentives matter, even in la-la land.

None of this matters to Sanders, for whom noble aspirations cure all technical defects. He believes that the United States, like all other modern states, should “guarantee comprehensive healthcare to every person as a human right.”

In his view, the simplification of administrative costs should remove frustration from a beleaguered citizenry constantly at war with its insurance carriers, while simultaneously slashing the expense of running a healthcare system.

It is fortunate that the odds of getting this plan enacted soon are low, notwithstanding that his position is swiftly becoming mainstream in the Democratic Party. Of greater import is the catastrophic consequences that would follow its enactment.

Most fundamentally, Sanders and his many acolytes never ask hard questions about what the term “comprehensive” means. Many public healthcare plans, like that of Great Britain, wrestle with this challenge, knowing that aggregate demand for expensive medical services explodes whenever these are offered for free.

The extra services demanded cannot be supplied from existing personnel and facilities, so finding additional resources is expensive, given the inevitable diseconomies of scale. It is only possible to survive the onslaught by defining protected benefits relatively narrowly.

These systematic shortages are aggravated as the existing supply of medical goods and services shrinks, with the government imposing caps on salaries, drugs, and procedures. These shortages impose high costs as services are rationed by queuing, not money.

These queues spawn intrigue: the rich (who under the Sanders plan would be barred from paying private providers of goods and services) go either overseas or into the black market in order to obtain vital goods and services that less fortunate individuals cannot afford.

This grim picture is no idle abstraction. These incentive effects are so powerful that they will swamp any effort to improve national healthcare by government fiat.

It is conceptually indefensible and politically naïve to assume that healthcare is somehow “special” and therefore follows economic rules that don’t apply to other markets. In housing, it has been known for decades that rent control only aggravates shortages by creating massive distortions in housing markets.

In agriculture, ethanol subsidies for gasoline have wrecked the operation of both food and energy markets. In transportation, endless queues formed when price controls at the pump created systematic gasoline shortages. The lesson is that basic economic principles apply to all goods and services, no matter their elevated position in the social discourse.

We already have good evidence of the destructive effect of regulation on healthcare markets. The individual mandate of the Affordable Care Act (ACA) does in miniature exactly what the Sanders plan will do in the aggregate.

By mandating benefits and coverage formulas, it requires huge public subsidies to keep the program alive and then makes matters worse with its system of community rating. The combined effect of these initiatives is to contract severely the insurance market for individual healthcare policies.

The failure of central planning to work should lead people to shy away from universal healthcare, which will only magnify the same set of dangers. But instead, the constant refrain one hears today is that the public wants single-payer to ease the frustration and complications of the current healthcare system.

This common position makes the disease the cure. But there is another way: deregulation. Removing regulation can do two things that a national healthcare system cannot.

First, it reduces administrative costs by removing the role of government in decisions insurers should make about what goods to supply and what prices to charge.

Second, it increases the level of choice in the selection of healthcare coverage. There is no reason to think that every American needs exactly the same set of benefits regardless of age, health, sex, and income.

Choice is generally regarded as a virtue in markets that deal with food, transportation, housing, and other goods. It is a fatal conceit to think that healthcare is so unique that a central planner can decide at a low cost which of the thousands of permutations of goods and services belong in the one comprehensive nationwide healthcare plan, especially after dismantling the private sector—which would take away the essential information needed to best allocate scarce resources.

In contrast to central planning, markets tend to bring supply and demand into balance, as higher prices draw in more suppliers in case of shortages, while lower prices draw in more consumers in case of surpluses.

Price controls for healthcare services operate just like price controls everywhere else: the shortages they create ripple quickly through the entire economy. Delays in the provision of healthcare allow serious medical conditions to fester until emergency care becomes necessary, but prompt access to such treatment is far from certain.

Bernie Sanders misses the point because he lives in a Pollyannaish universe in which these fundamental structural principles somehow do not apply. Accordingly, he finds it all too easy to pin the breakdown in the current healthcare system on the villains of “the medical industrial complex.”

In so doing, he foolishly assumes that the high salaries paid to executives are unearned and should be plowed back into better services for the population at large. Wholly foreign to his way of thinking is that people who command these salaries function in a competitive market in which few players long prosper if they do not deliver to their customers benefits in excess of what they receive in exchange.

Unfortunately, Sanders starts from the Marxist premise that all contracts are forms of exploitation. He thus finds it hard to fathom the essential truth that markets work precisely because of the gains from trade that follow from voluntary exchange.

In 2016, Pfizer, for example, offered its CEO a compensation package of over $17 million, which is small potatoes against its nearly $53 billion in sales that year. On a daily basis, the CEO and his team have to make high-stakes decisions that go straight to the bottom line.

You pay top talent top dollar because complex businesses are exceptionally hard to run, especially in today’s regulatory environment. Perhaps Sanders thinks that every compensation committee in the land is afflicted with some deep confusion concerning the worth of its key officers.

Perhaps he also believes that institutional shareholders, to whom this information is disclosed in a myriad of ways, are duped just as easily.

Indeed, when he writes that the United States should negotiate down the prices of key drugs, he ignores the well-established point that a cut in prices will necessarily lead to a decline in pharmaceutical innovation. The large payments to drug companies would be a proper source of concern if they resulted from some improper use of monopoly power.

But under competitive conditions, these prices reflect both the high cost of getting drugs to market through the approval maze set up by the Food and Drug Administration, and, once some drugs run that gauntlet, the huge benefits they provide by stabilizing chronic conditions, responding to acute illnesses, and eliminating costly surgeries and other forms of intervention.

There is much that can be done to fix the American healthcare system. All sides of the debate agree that it costs too much to operate and supplies too few benefits. But there is no way that a system can control costs while catering to unlimited consumer demand. The law of unintended consequences applies to all social activities, healthcare included. It is this message that has to be hammered home in the upcoming debate over healthcare reform.

Maybe we should be getting away from the Medicare for all and consider other single payer ideas.

Democrats push ‘Medicare for All’ bills, but not all in the party are onboard and with the Mid Term elections almost upon us what should we expect?

Hunter Walker a correspondent for Yahoo wrote that Minnesota Rep. Keith Ellison, who is also a vice chair of the Democratic National Committee, became the lead sponsor of the House single-payer health care bill on Wednesday. The legislation has detractors among his fellow Democrats, but Ellison said he’s eager for a “debate” on the policy.

“Our movement is ascending, but the truth is that, for many years, people weren’t there,” Ellison said of the “Medicare for All” push in an interview with Yahoo News on Sirius XM’s politics channel, POTUS. “So more and more people are coming on every day, but not everyone is on. We have to convince them, we have to talk to them, we need to engage in a respectful, fact-based debate about which systems are the best.”

Ellison’s House colleagues voted unanimously to let him assume leadership of the bill, which is officially named “The Expanded & Improved Medicare for All Act” (H.R. 676). It was originally sponsored by Rep. John Conyers, D-Mich., who stepped down late last year amid allegations of sexual misconduct. The bill would establish a universal health care system akin to the Medicare program that currently exists for senior citizens and includes coverage for prescriptions, primary care, emergencies, and long-term care.

“Everybody would get a card, and you can get the care that you need, not unlike what they have in Canada right now. And truth be told, every major industrial country has a universal system; many of them have single-payer systems,” said Ellison.

Conyers first introduced the bill in 2003 with 25 co-sponsors. As of this writing, there are 121 co-sponsors of the bill, all of whom are Democrats. In the Senate, a separate Medicare for All bill has also been introduced by former Democratic presidential candidate Sen. Bernie Sanders, I-Vt.

No Republicans have signed on to the idea of Medicare for All, and the plan doesn’t enjoy universal support from Democrats. In the House, there are 72 Democrats who do not back the measure and 31 of the Senate Democrats don’t support Sanders’s bill in the upper chamber.

Polls show a growing number of people support a government-run health care system. The country is essentially split between those who want a public program and those who prefer private insurance.

Critics note Medicare for All would come with tax increases to pay for the trust fund that finances the program. “It would essentially be paid for through some taxes. One would be a 5 percent tax on high-net-worth individuals that just got a major tax cut a few weeks ago, so they got it,” Ellison said, adding, “There would be a financial transactions tax, and it would be a very small payroll tax to cover everybody.”

And overall, Ellison argued the program would “save a lot of money” by bringing down health care costs for individuals, including premiums, co-pays, deductibles and the price of medicine. “It would save the nation more than $500 billion a year, in large measure because of preventative care,” Ellison said.

Along with cutting down on expensive health emergencies due to lack of preventive treatment, Ellison claimed the bill would lower administrative costs associated with health care. Sanders has cited a similar $500 billion figure tied to those costs. Politifact called that claim “half-true” and said the number may be a high estimate, though there could still be “pretty substantial savings” of at least $300 billion.

Another sticking point for Medicare for All critics is the question of what might happen to people who currently have private insurance and are satisfied with their policies. Ellison did not answer directly when asked if he could make the infamous “if you like your plan you can keep it” promise that dogged President Obama following the implementation of the Affordable Care Act. However, he said there would be room for private insurance policies to exist under his plan.

“You would be able to take out private insurance policies for certain things,” Ellison said. “It’s not inconceivable that single-payer systems and private systems coexist. They certainly do in England right now, so it’s not really that big of a problem.”

While Ellison points to programs in Western Europe and Canada as exemplary models, some critics respond by noting that those programs are plagued by long lines and lower standards than the U.S. system. Ellison said health outcomes in this country have “lagged behind” other nations, a claim backed by some experts. He also pointed out Canadians are largely satisfied with their public health system and want to see it expand.

“I’ve never met a Canadian that wants to switch their system for ours,” Ellison said. “They like their system. Do they complain about it? Yes. Because guess what? People complain about stuff no matter where they live. … But I can tell you that people who live in Canada and benefit from that health care system, they like it.”

With all 435 House seats and 35 spots in the Senate up for election this year, Medicare for All has become a major question for Democrats on the campaign trail. The issue is in some ways emblematic of the divide that emerged in Sanders’s presidential primary race against Hillary Clinton and Ellison’s campaign for the DNC chairmanship, between the party’s progressive base and the establishment.

One Democratic candidate who has taken heat from progressives for not embracing Medicare for All is Talley Sergent, who is running to represent West Virginia’s second congressional district. Sergent also appeared on Yahoo News’ SiriusXM broadcast on Wednesday, and described Medicare for All as “an option.” We asked what she’d say if she won her race and Ellison called her up to ask her to sign on to his bill.

“Well, I’d appreciate the congressman calling me up, but I’m going to listen to the folks across West Virginia and make sure that it makes sense for people here,” Sergent said. “That’s who I care most about, and what they think and what they say.”

With his dual role as one of the top backers of Medicare for All and a leader of the DNC, Ellison is in a unique position. However, he said he doesn’t believe the party needs to take a side, and he thinks Democratic candidates can succeed regardless of their position on his bill.

“I think people can win for all kinds of things … all over the country. This is not a doctrinaire movement where we’re going to litmus-test people,” Ellison said.

Single payer: Yes! Well Maybe! but Medicare for all: No!

Shannon Tapia wrote last April that thankfully, the GOP did not pass Paul Ryan’s repeal and replace bill for Obamacare.  Immediately after, she saw a headline hopefully concluding, “Medicare for all may be next.”  In Medicare’s current form, this would be devastating for the health of America.  I am a young geriatrician; I know a heck of a lot about Medicare.  Most people don’t.  They just see it as a great perk of turning 65 in America and the social healthcare we offer to elderly and disabled.  I did too until I became a physician who only sees Medicare patients.

Medicare originated in 1966 in recognition that we needed to do a better job as a nation at caring for our aging and disabled who could not get employer-provided insurance.  In 1989 the Omnibus Budget Reconciliation Act established a fee schedule for Medicare payments.  This assigns “relative value units” or RVUs to everything we do for our patients in medicine.  The formula that determines RVUs disproportionately favors procedural care to time-based care.  Essentially, Medicare pays and incentivizes medical providers to do things to patients and actually disincentivizes physicians from taking their time with patients.

If you wonder why the doctor-patient relationship is not doing well right now, wonder no more.  Trust takes time.  Even family doctors who take Medicare have to turn their practice into a patient or low-risk procedure mill to make ends meet.  Medicare will pay a physician between $70 to $80 to freeze off a wart, a procedure that takes about 2 minutes to do, and 1 minute to document in an EMR.

In contrast, I can spend an hour with an elderly patient with multiple complicated issues, addressing their concerns, reviewing and adjusting their many medications, and coming up with a plan and then having to take 30 minutes later to document what happened and get paid essentially the same amount (about $80) had I just spent 3 minutes removing a wart and sending them out the door.  Is it any wonder that geriatrics is a dying field?

There was a time, however, when despite the RVU working against physicians who primarily use their time and knowledge to diagnose and care for patients, physicians still did it because they could make a decent living while being fulfilled in the solace they were helping.  But times have changed.  My father is a geriatrician.  He went to the equivalent of his state medical school from 1978 to 1982 for $5,000 a year in tuition.  No loans needed.  Had I gone to my state school (same as his) from 2006 to 2010, in-state tuition would have been $25,000 per year.  I came out of medical school with roughly $200,000 in debt at anywhere from 7 to 15 percent interest that accrues quarterly, and I’m lucky.

The physicians today in their fifties to seventies truly cannot comprehend the financial sacrifice new physicians make when committing to primary care today.  But, it’s not all about the money.  There is far more paperwork, tracking of useless data, non-patient care related work that we are forced to do that merely detracts from the already limited time we have to see patients and develop a relationship.  And we have to deal with this burden from day 1 of our practicing lives.  Many of the older docs have moved into administrative roles yet still remember clinical practice how they experienced it.  In turn, they create detrimental policies and regulations to feed metrics in the name of “quality” all while being clueless as to what it is like to actually treat patients in the modern era.

Some might argue that by expanding Medicare for all, it would cover less complicated patients so the current model shouldn’t be a problem.  I’d also beg to differ on that one.  Doing things to people, even prescribing medications, is dangerous and should not be taken for granted.  Medicare still incentivizes doing more invasive things for the least complicated patients.  Say we expand it to everyone, and a 22-year-old comes in with a cough she’s had for five days.  It’s viral.  Viruses are the worst.  There is no treatment other than time and support.  But convincing patients of this when they know I have the power to prescribe a Z-pak and they always get better on the Z-pak (20 percent of the effect of any treatment is placebo) takes a long empathetic conversation.

You know what is quick and easier?  You got it, just writing the darn script and moving on to the next person so I can get paid more.  And then we have massive bacterial resistance to azithromycin (the Z-pak) and C. diff is on the rise.

The numbers on all accounts point to the reality that Medicare’s RVU system of paying providers is causing worse outcomes, is unsustainable in cost and is not attracting young talented physicians to the most needed primary care fields.  I wonder how many of the new family docs will inevitably succumb to 10-minute visits with high procedures and more referrals to costly specialists or ultimately opt-out of Medicare and insurance for direct primary care?  Medicare spent 650 billion dollars in 2015.  An underestimate suggests 200 billion dollars (or 30 percent) was spent on beneficiaries in their final year of life.  That means we as a medical community, despite probably knowing the patients were dying, kept doing procedures and tests and more treatments to people because that is what we are paid to do.

American culture indoctrinates us that death is optional.  It’s really not.  But why would a physician take the time explain to a patient and family the reality of their situation, a conversation that is exhausting and challenging for everyone involved, when they are paid about 5x more to just offer another procedure or test and move on?  And then we spend billions of dollars doing things while ignoring the essentials that require time, and we get the worst outcomes.   The current Medicare, if expanded to all, will only exacerbate the costly failures of our current system.

A single-payer universal coverage system?  Maybe!  But, not Medicare as we know it.  Heed the geriatricians now and the patients covered by Medicare while you still can.  They are the most needed physician endangered species.

More on Single Payer Healthcare Systems to follow!

And the announcement- Our book is finally available from the Sentia Publishing Company: The Search for Excellence in Clinical Practice, A Handbook on Clinical Process Improvement for Providers. ISBN 978-0-997890-6-9.


Uber, Walmart, Amazon and Berkshire Hathaway Get into Healthcare; And Now Uber Launches Service To Get People To The Doctor’s Office!



28059229_1452381504891504_6986021347674518630_nUber wants to get you from your home to your doctor’s office — and you won’t even need to open the Uber app. The company announced Thursday that it’s teaming up with healthcare organizations to provide transportation for patients going to and from medical appointments.

Receptionists or other staffers can schedule the rides for patients through doctor’s offices. And they can be booked for immediate pickup or up to 30 days in advance. That means patients without a smartphone — who wouldn’t be able to use Uber otherwise — can become Uber customers.

Instead of operating through an app, Uber Health will send its passengers’ ride information through an SMS text message. The company also plans to introduce the option for passengers to receive a call with trip details to their landline instead. Drivers will still use the Uber smartphone app to pick up these passengers.

“Transportation barriers are the greatest for vulnerable populations,” says Chris Weber, the general manager of Uber Health. “This service will provide reliable, comfortable transportation for patients.”

Transportation is, indeed, a barrier to good health care. Affordable access to a vehicle is consistently associated with increased access to medical care, according to a study. Around 3.6 million Americans miss doctor’s appointments or delay medical care due to a lack of transportation every year, according to the National Conference of State Legislatures.

To meet the medical privacy standards outlined in the federal HIPAA law, drivers won’t know which of their passengers are using Uber Health. Like a typical Uber ride, only a passenger’s name, pickup and drop-off addresses will be given to the driver. So Uber drivers won’t be able to opt into the health service the same way that they opt into Uber Eats, a food delivery service.

Peter Whorley, who drives a Honda Odyssey minivan for Uber in Fort Lauderdale, Fla., often picks up passengers who need the extra space, including patients traveling to and from doctor’s offices.

“I just picked up someone with back surgery the other day,” he says. “I like to help people, if they need extra assistance, I personally don’t have that problem. But some people might be squeamish, and not want to.”

Whorley, who has been driving for Uber for more than two years, is more skeptical about picking up people without smartphones. He thinks location tracking on smartphones is vital to the efficiency of the ride-hailing service. “When you’re a good passenger, you should be able to have your phone out to communicate with your driver,” he says.

Uber’s Weber says that because health care providers will use their best discretion in scheduling the rides, they won’t call Ubers for people in need of urgent medical attention. “It’s not a replacement for ambulances,” he says, but a reliable means of transportation to non-urgent medical services that he hopes will curb missed appointments.

One hundred healthcare organizations in the U.S., including hospitals, clinics, rehab centers, senior care facilities, home care centers, and physical therapy centers have already used Uber Health’s test program. The service will be rolled out to healthcare organizations gradually. The only part of this program is that they plan on billing the physicians and their organizations. I can’t agree with this concept, especially with the discounted insurance reimbursements.

And Here Comes The Uber Of Healthcare. CONCIERGE KEY Health is the first mobile app to provide healthcare consumers with on-demand access to elite physician specialists, urgent care clinics, and hospitals. Founder Robert Grant thinks that app-based healthcare is about to take off, digital journal.

The aim of CONCIERGE KEY Health is to eliminate excessive appointment and in-office wait times in the U.S. health system, through a consumer subscription-based membership. The app is based on concierge medicine model and it includes elite providers in all fields, from general practitioners to dentists.

The model enables patients to expedite the process of connecting to and consulting with elite top-tier doctors across the healthcare spectrum. Speed, convenience, and connecting with elite medical providers are the basis of the business model.

To find out more about this different approach to securing medical services, Digital Journal spoke with the founder, Robert Grant. Grant has previously had tenures at the ALPHAEON Corporation, Bausch+Lomb Surgical, and Allergan Medical.

We began by asking about the state of U.S. healthcare.

Digital Journal: What are the major challenges facing healthcare?

Robert Grant: “Healthcare has been upside down for a long time now because it has forgotten who the ultimate customer is: the patient.

“The overly complex and highly opaque healthcare third-party based ecosystem of today prioritize in the following order: payors (insurance companies), pharma, physicians, and finally, patients. This is due in part to the well-organized lobby and narrative of the industrial complex of healthcare, which is made up largely of payors and pharma corporations.

“We believe the healthcare ecosystem should be prioritized in exactly the opposite way of how it is structured today: first, patients; second, physicians providing care; third, products and finally payors.

“Because today’s industrial complex prioritizes the benefit of payors and pharma above physicians and patients, the entire analysis begins and ends with the ‘see-saw’ and the purported zero-sum game of cost versus quality of care. Forgetting that the ultimate customer of healthcare is the patient, today’s ecosystem is not focused on the patients/customer experience.

DJ: Why has health care become so bureaucratic?

Grant: “Because it is not clear who the customer is. When your doctor writes a prescription for medication to you, who exactly is the customer of that pharmaceutical product? Is it the pharmacy that inventories it? Or, is it the patient that picks it up from the pharmacy? Or, is it actually the third-party payor (insurance company) that pays for it? Or, is it really the doctor who wrote the prescription in the first place? Or, is it actually the patient who pays the premiums to the payors in the first place?

“It is an extraordinarily complex and opaque ecosystem, with all parties self-interested to maximize returns, and it isn’t clear that the patient is actually the customer. That way there is so much dissatisfaction in healthcare among patients.”

DJ: How can digital technology and automation help?

Grant: “Technology empowers consumers and further clarifies and magnifies the link and balance between vendors and customer. Vendors must serve the needs and demands of their customers.

“In virtually every other non-monopolized industry, vendors who fail to adequately serve their customers cease to exist. Cost and quality are not the only measures of performance. Customer experience and satisfaction play a major role in the so-called ‘Experience-Economy,’ which has penetrated every industry with widespread adoption by vendors and customers alike. Healthy competition sustains this balance between vendor and customer. Healthcare has been and continues to be the exception thus far.”

DJ: Please explain your new app and how it aids the patient.

Grant: “The CONCIERGE KEY Health app upgrades the healthcare experience for consumers. It provides personalized and on-demand access to the world’s elite physicians, including specialists, urgent care facilities and hospitals.”

DJ: What are the advantages with the app for healthcare institutions?

Grant: “Institutions will benefit from the CONCIERGE KEY Health app as it will reduce their financial dependence on payors and improve the healthcare experience for their customers, the patients. It will also provide a new service and revenue source that consumers want and are willing to pay for.”

DJ: What has the interest been from the medical community?

Grant: “The interest for CONCIERGE KEY’s “on-demand” service has been very high from the medical community. It appeals equally to patients and doctors alike. Longer doctor wait times, a better process to inform doctor selection than paid advertising and Yelp provide and the desire for a distinctive and personalized health experience are the major drivers of consumer demand.”

DJ: Which demographic groups do you think the app will appeal to most?

Grant: “Recent third-party surveys of approximately 900 consumers across 11 metro areas nationwide revealed a very high demand among 25 to 50-year-old consumers. There is a strong bias in the data toward family participation in CONCIERGE KEY.”

DJ: How have you addressed data security concerns?

Grant: “Our CONCIERGE KEY on-demand app includes state-of-the-art security protections and is HIPAA compliant.”

DJ: What else are you working on?

Grant: “We are laser-focused on perfecting our on-demand service. The market potential for this first patient-centric service is massive. Once we achieve our initial goals of widespread adoption of our on-demand service here and abroad, we see CONCIERGE KEY as an innovative platform for patient-centered and simple solutions to other healthcare needs, where we can help untangle unnecessary complexity and upgrade the overall healthcare experience for our subscription members.

DJ: How else do you envisage healthcare technology evolving?

Grant: “The entire healthcare debate has focused solely on the see-saw of cost versus quality of care. To us, these are simply the hygiene factors of healthcare. No company has embedded a truly keen focus and understanding of the patient experience. Healthcare is the largest industry in the United States, representing almost one of every five dollars spent by Americans every year. No other industry is so late to emphasize the motivators for consumers related to the customer experience as healthcare is.

“While new technologies to treat our various ailments emerge every year by gaining FDA approval, we believe the next leap of technology expansion will address the personalization and overall experience of patients within the healthcare economy and we intend to lead that effort.”

While CONCIERGE KEY Health is the first mobile app that provides on-demand access to specialists, urgent care clinics and hospitals for U.S. patients, it will be intriguing to see if an Uber-like model can develop in the healthcare space.

Uber Cofounder’s ‘Uber For Healthcare’ Startup Raises $14 Million.

While dozens of startups today look to Uber as a template for how to bring on-demand convenience to a long-standing market, one “Uber for healthcare” startup has an advantage. Its co-founder Oscar Salazar, who helped build the first Uber prototype, knows a thing or two about the $46 billion-plus valuation company first-hand.

Pager announced Tuesday it had raised $14 million from Ashton Kutcher’s Sound Ventures and New Enterprise Associates, with existing investors Goodwater Capital, Lux Capital, and Montage Ventures rejoining. The money’s aimed at expanding the New York City-focused service to new markets including San Francisco and Los Angeles and building out the product.

While services like ZocDoc and Doctors On Demand have made it possible for customers to find and book doctors more easily by computer or phone, Pager tries to take the process further by making your appointment instant and for a flat fee. A first-time urgent care visit is $50, and $200 after that. A physical is $100 and a phone consultation $25.

The parallels to Uber are peppered throughout Pager’s product. The service finds and verifies doctors for its network and bills you automatically over a linked credit card. There’s a $10 cancellation fee if you bail on an appointment after more than 5 minutes. And because the service is out of network, for now, it favors those for whom convenience can come at a premium to healthcare network costs.

That’s why it’s no surprise that Salazar is involved. Since building the prototype of the Uber app with billionaires Garrett Camp and Travis Kalanick, Salazar’s become something of an on-demand Uber exporter. He’s got a co-founder title with Ride, an app to bring Uber-like convenience to carpooling. Last month he linked up with another startup to work on an “Uber for trash.” Salazar doesn’t work full-time or daily at any of these startups.

“I don’t build companies, I help people build companies,” says Salazar. “It’s part of my strategy to work with companies like Uber because I can do my job faster and I want to have value to add.”

As Salazar helps with high-level product issues and builds out technical teams, it’s up to operators lesser known than Kalanick to execute at each one. At Pager, that’s the job of CEO Gaspard de Dreuzy. “Pager is focused on delivering a broader range of care options on demand” that exist today, de Dreuzy says. “It could be a tele-consult via phone or messaging, or an in-person visit in the home, or a referral to the right specialist. We like to think of ourselves as the Amazon for healthcare.”

Eventually, Pager will build partnerships with national providers to improve their own customer reach, says new investor and NEA partner Mohamed Makhzoumi. That’s where Pager’s vision may translate into large numbers of users, as its technology helps push the rest of the industry to improve its tech. Otherwise, Pager’s pricing and pitch could come off—as Uber once did—as a service of convenience for the well-heeled Donotpaginate

The influence of Salazar’s background helped with investors and with the product. It also helps Pager stand out among a dozen of startups striving for attention. But Salazar himself makes it plain that he’s not helping any of his startups score major Uber partnerships trading off his reputation at Uber HQ.

Salazar’s already got a new area where he’s looking for an “Uber for X”: education. “ They all share a narrative, Salazar says. “All the projects I’m involved in have a social impact. That’s where startups can change the world faster.”

Amazon, Berkshire Hathaway, And JPMorgan Chase Launch New Health Care Company. Health care costs are “a hungry tapeworm on the American economy,” Berkshire Hathaway Chairman and CEO Warren Buffett says, and now his firm is teaming up with Amazon and JPMorgan Chase to create a new company with the goal of providing high-quality health care for their U.S. employees at a lower cost.

The new company will be “free from profit-making incentives and constraints” as it tries to find ways to cut costs and boost satisfaction with the health care plan for employees of Amazon, Berkshire Hathaway, and JPMorgan Chase. The trio unveiled their new venture in a news release.

“The initial focus of the new company will be on technology solutions that will provide U.S. employees and their families with simplified, high-quality and transparent healthcare at a reasonable cost,” the companies said.

The enterprise unites three of the largest and most envied companies in their respective sectors — from retail to banking, and including Berkshire’s wide portfolio of companies such as Geico and Fruit of the Loom. And in Buffett, Amazon’s Jeff Bezos and JPMorgan’s Jamie Dimon, the companies also have veteran leaders who have shown an ability to solve vexing business problems.

According to recent annual reports, taken together the three companies employ more than 950,000 people worldwide. The three CEOs say they’re aware of the enormous challenges they face. “The health care system is complex, and we enter into this challenge open-eyed about the degree of difficulty,” said Jeff Bezos, Amazon founder, and CEO. “Hard as it might be, reducing health care’s burden on the economy while improving outcomes for employees and their families would be worth the effort.”

Responding to the announcement Tuesday morning, White House economic adviser Gary Cohn told CNBC “we agree in that philosophy. We think that individual workers should have to pay less for health care.”

Still, the Trump administration already “created association health-care plans, which is the exact same thing that those companies did,” Cohn said, referring to an executive order last October that sought to make it easier for employers to combine efforts in offering insurance. That order also opened the possibility some groups could get coverage across state lines — “a move that Republicans have long advocated as a way to lower costs,” NPR’s Scott Horsley explained at the time.

“Smaller businesses could pool their employees together to get more purchasing power,” Cohn added Tuesday, “so they could save money on health care.” NPR’s Scott Hensley tells Morning Edition there is a precedent for the case of a non-health care company wading into the healthcare business — “in fact, it has happened repeatedly.”

“One of the most prominent examples is what is now Kaiser Permanente, a big provider of health care in this country. It started with the Kaiser shipyards and providing, first, workers comp kind of care and, later, more integrated health care for employees,” Scott explains. “So it is possible.”

The particulars remain scarce at the moment, though. Details such as the company’s name, a base of operations and long-term leadership weren’t included in a joint news release about the new company that was sent out Tuesday morning.

At the start, the new company will be led by executives from each of the troika of giant firms: Marvelle Sullivan Berchtold, a managing director of JPMorgan Chase; Todd Combs, an investment officer of Berkshire Hathaway; and Beth Galetti, a senior vice president at Amazon.

JPMorgan’s Dimon said, “The three of our companies have extraordinary resources, and our goal is to create solutions that benefit our U.S. employees, their families and, potentially, all Americans.”

Everyone seems to want to get the market for health care and thinks that they know what the solution is to the healthcare crisis. Remember that in 2014 Walmart decided to get into Primary care. Walmart’s New Primary Care Clinics Shake up Healthcare Market

Walmart has recently launched half a dozen primary care clinics across South Carolina and Texas, with plans to open six more before January. Staffed by nurse practitioners, in a partnership with QuadMed, these clinics are fully owned by the company and branded explicitly as one-stop shops for primary care.

Prior to this, Walmart’s 100-plus retail clinics were hosted through leases with local hospitals. With a walk-in visit price of a mere $40 (and $4 if you are a Walmart employee), Walmart’s goal for these clinics is to be a low-cost alternative to traditional options.  Additionally, the clinics will also stand out from competitors as they will be open for 12 hour days on the week and 8 hours (per day) on the weekend.

The rollout of clinics is beginning in rural areas, where doctors are scarce.  When comparing the number of hospitals in urban versus rural areas, Definitive Healthcare’s hospital database’s search accounts for 2,228 hospitals located in rural areas, but 3,871 hospitals located in an urban geographic location.

Previously, Walmart only offered what is known as “convenient-care-clinics” or “retail clinics,” which treat uncomplicated minor illnesses and provide preventative health care services.  Besides Walmart, CVS offers their Minute Clinic through this model, as well as Target’s Target Clinic.  With their new clinics, Walmart will be able to support a broader range of services such as chronic disease management.

The New York Times examines this news on Walmart, by also comparing their model to Walgreens.  In 2013 Walgreens also began offering primary care services in their 400 clinics across the country.  They were the first-ever chain retailer to become a direct provider of primary care services.  Walgreens, however, differs in that they are still reluctant to call their facilities primary care clinics, while Walmart put that label front and center.

Additionally, Walgreens differs because also last year, they became the first mover when they began partnerships with ACOs.  Their partnership with three providers, Advocare Walgreens Well Network (New Jersey), Diagnostic Clinic Walgreens Well Network (Florida), and Scott & White Healthcare Walgreens Well Network (Texas), was aimed at participation in the Medicare Shared Savings Program (MSSP).  This was the first retailer/provider partnership that will try and improve care and reduce costs of Medicare.

Definitive Healthcare’s healthcare database tracks intelligence on 600+ accountable care organizations (ACOs), including those affiliated with Walgreens. In addition to the three MSSP ACOs, Walgreen is also in collaboration with four other ACOs, such as Centura ACO Health of Colorado.  Definitive Healthcare’s database provides intelligence on 34 members of that ACO, as well as tracks their technology modules of HIE and EHR/EMR.

Instead of replacing one’s primary care physician, as what is intended with Walmart’s goal, Walgreens instead stresses that their collaboration will provide a comprehensive experience for the consumer.  They still want the majority of care coming from the patient’s physician group or health system, but Walgreens would just add distinct value to the ambulatory network, etc.

While it still is a bit too early to tell, The Advisory Board Company has already written on how the Walgreens’ ACO partnership is on the right track. As Walmart continues to roll out these physician centers, it will be interesting to track the success of these new clinics. Walmart’s clinics will accept Medicare but currently does not accept third-party insurance.  The timing of these new clinics could benefit greatly from the changes resulting from the Affordable Care Act.

And as another article reported Thomas M. Loarie Walmart To Put MRI Scanners In Stores and Will Charge $400/Scan. The US Healthcare System is Anti-Middle Class Says Healthcare Executive /  Middle-Class Friendly Walmart to Place MRI Units in its 3000 Stores by 2018. James Orlikoff, President of Orlikoff and Associates (Chicago), outlined the economic pressures related to healthcare that are going break the middle-class if we “do not break rather than bend the healthcare cost curve.” His comments were made during a pre-meeting workshop, “Something Disruptive This Way Comes: Preparing for Consumerism in Healthcare” at last week’s 23rd Annual Health Forum and American Hospital Association Leadership Summit in San Francisco.

“Rapidly increasing deductibles and co-pays along with means testing by Medicare are pushing healthcare financial risk to the patient.” And with a slow growth economy, personal income growth is being more than offset by healthcare expenses.

Orlikoff went on to say that despite the enactment of the Accountable Care Act (Obamacare), healthcare spending is forecasted to accelerate this year and continue for the foreseeable future.  The modest increase in healthcare spending over the last few years was due largely to the recession.

He went on to say “We have known this train wreck has been coming but we did nothing about it.” Its effects extend beyond healthcare to the general economy as healthcare continues to take a big bite out at 18% of GDP. We are at a significant competitive disadvantage with emerging economies where healthcare represents only 3-5% of GDP. He added that competitiveness is critical. Without it, we will be unable to create the jobs and income critical for the middle class that pays for healthcare.

“Even healthcare systems cannot afford to buy their own product for their employees.”

These economic factors are attracting consumer companies to the healthcare services market. CVS, Walgreens, Rite-Aid, Target, Walmart, Apple, and others eye the $30 trillion to be spent on healthcare over the next decade as an opportunity and see the consumer as the new decision-maker.  The retail pharmacies and rapidly growing urgent care centers are improving access, quality, and convenience while reducing cost.

As healthcare moves from wholesale to retail, cost-based pricing is being transformed to price-based costing. Walmart today offers a “truss” for those who have inguinal hernias in lieu of having surgery – $50 versus $5800-$10,000. Walmart has announced it will put MRI’s (diagnostic imaging) in all of its stores by 2018.Orlikoff said Walmart plans to price an MRI at $400.

Can they, the Walmarts, the Ubers, Amazon and Berkshire Hathaway know anything about healthcare or the solutions to health care?

Back to the discussion of a Single payer healthcare system!