Category Archives: Universal health care

Five Worrisome Trends in Healthcare and the VA Seeks to Redirect Billions of Dollars into Private Care and the VA Access to Healthcare

50065252_1872612819535035_7021591760191094784_nAs the idiots in Congress still fight over the wall and continue to act like spoiled children we, the intelligent voters should be looking at healthcare delivery reality. What can we expect from these liberals and their cultural revolution? Joyce Frieden, the News Editor of MedPage Today pointed out last year that a reckoning is coming to American healthcare, said Chester Burrell, outgoing CEO of the CareFirst BlueCross BlueShield health plan, here at the annual meeting of the National Hispanic Medical Association.

Burrell, speaking on Friday, told the audience there are five things physicians should worry about, “because they worry me”:

  1. The effects of the recently passed tax bill.“If the full effect of this tax cut is experienced, then the federal debt will go above 100% of GDP [gross domestic product] and will become the highest it’s been since World War II,” said Burrell. That may be OK while the economy is strong, “but we’ve got a huge problem if it ever turns and goes back into recession mode,” he said. “This will stimulate higher interest rates, and higher interest rates will crowd out funding in the federal government for initiatives that are needed,” including those in healthcare.

Burrell noted that Medicaid, 60 million by Medicare, currently covers 74 million people and 10 million by the Children’s Health Insurance Program (CHIP), while another 10 million people are getting federally subsidized health insurance through the Affordable Care Act’s (ACA’s) insurance exchanges. “What happens when interest’s demand on federal revenue starts to crowd out future investment in these government programs that provide healthcare for tens of millions of Americans?”

  1. The increasing obesity problem.”Thirty percent of the U.S. population is obese; 70% of the total population is either obese or overweight,” said Burrell. “There is an epidemic of diabetes, heart disease, and coronary artery disease coming from those demographics, and Baby Boomers will see these things in full flower in the next 10 years as they move fully into Medicare.”
  2. The “congealing” of the U.S. healthcare system. This is occurring in two ways, Burrell said. First, “you’ll see large integrated delivery systems [being] built around academic medical centers — very good quality care [but] 50%-100% more expensive than the community average.”

To see how this affects patients, take a family of four — a 40-year-old dad, 33-year-old mom, and two teenage kids — who are buying a health insurance policy from CareFirst via the ACA exchange, with no subsidy. “The cost for their premium and deductibles, copays, and coinsurance [would be] $33,000,” he said. But if all of the care were provided by academic medical centers? “$60,000,” he said. “What these big systems are doing is consolidating community hospitals and independent physician groups, and creating oligopolies.”

Another way the system is “congealing” is the emergence of specialty practices that are backed by private equity companies, said Burrell. “The largest urology group in our area was bought by a private equity firm. How do they make money? They increase fees. There is not an issue of quality but there is a profound issue on costs.”

  1. The undermining of the private healthcare market. “Just recently, we have gotten rid of the individual mandate, and the [cost-sharing reduction] subsidies that were [expected to be] in the omnibus bill … were taken out of the bill,” he said. And state governments are now developing alternatives to the ACA such as short-term duration insurance policies — originally designed to last only 3 months but now being pushed up to a year, with the possibility of renewal — that don’t have to adhere to ACA coverage requirements, said Burrell.
  2. The lackluster performance of new payment models.”Despite the innovation fostering under [Center for Medicare & Medicaid Innovation] programs — the whole idea was to create a series of initiatives that might show the wave of the future — ACOs [accountable care organizations] and the like don’t show the promise intended for them, and there is no new model one could say is demonstrably more successful,” he said.

“So beware — there’s a reckoning coming,” Burrell said. “Maybe change occurs only when there is a rip-roaring crisis; we’re coming to it.” Part of the issue is cost: “As carbon dioxide is to global warming, the cost is to healthcare. We deal with it every day … We face a future where cutbacks in funding could dramatically affect the accessibility of care.”

“Does that mean we move to move single-payer, some major repositioning?” he said. “I don’t know, but in 35 years in this field, I’ve never experienced a time quite like this … Be vigilant, be involved, be committed to serving these populations.”

VA Seeks to Redirect Billions of Dollars into Private Care

Jennifer Steinhauer and Dave Phillipps reported that The Department of Veterans Affairs is preparing to shift billions of dollars from government-run veterans’ hospitals to private health care providers, setting the stage for the biggest transformation of the veterans’ medical system in a generation.

Under proposed guidelines, it would be easier for veterans to receive care in privately run hospitals and have the government pay for it. Veterans would also be allowed access to a system of proposed walk-in clinics, which would serve as a bridge between V.A. emergency rooms and private providers, and would require co-pays for treatment.

Veterans’ hospitals, which treat seven million patients annually, have struggled to see patients on time in recent years, hit by a double crush of returning Iraq and Afghanistan veterans and aging Vietnam veterans. A scandal over hidden waiting lists in 2014 sent Congress searching for fixes, and in the years since, Republicans have pushed to send veterans to the private sector, while Democrats have favored increasing the number of doctors in the V.A.

If put into effect, the proposed rules — many of whose details remain unclear as they are negotiated within the Trump administration — would be a win for the once-obscure Concerned Veterans for America, an advocacy group funded by the network founded by the billionaire industrialists Charles G. and David H. Koch, which has long championed increasing the use of private sector health care for veterans.

For individual veterans, private care could mean shorter waits, more choices and fewer requirements for co-pays — and could prove popular. But some health care experts and veterans’ groups say the change, which has no separate source of funding, would redirect money that the current veterans’ health care system — the largest in the nation — uses to provide specialty care.

Critics have also warned that switching vast numbers of veterans to private hospitals would strain care in the private sector and that costs for taxpayers could skyrocket. In addition, they say it could threaten the future of traditional veterans’ hospitals, some of which are already under review for consolidation or closing.

 President Trump, who made reforming veterans’ health care a major point of his campaign, may reveal details of the plan in his State of the Union address later this month, according to several people in the administration and others outside it who have been briefed on the plan.

The proposed changes have grown out of health care legislation, known as the Mission Act, passed by the last Congress. Supporters, who have been influential in administration policy, argue that the new rules would streamline care available to veterans, whose health problems are many but whose numbers are shrinking, and also prod the veterans’ hospital system to compete for patients, making it more efficient.

“Most veterans chose to serve their country, so they should have the choice to access care in the community with their V.A. benefits — especially if the V.A. can’t serve them in a timely and convenient manner,” said Dan Caldwell, executive director of Concerned Veterans for America.

In remarks at a joint hearing with members of the House and Senate veterans’ committees in December, Mr. Wilkie said veterans largely liked using the department’s hospitals.

“My experience is veterans are happy with the service they get at the Department of Veterans Affairs,” he said. Veterans are not “chomping at the bit” to get services elsewhere, he said, adding, “They want to go to places where people speak the language and understand the culture.”

Health care experts say that whatever the larger effects, allowing more access to private care will prove costly. A 2016 report ordered by Congress, from a panel called the Commission on Care, analyzed the cost of sending more veterans into the community for treatment and warned that unfettered access could cost well over $100 billion each year.

A fight over the future of the veterans’ health care system played a role in the ousting of the department’s previous secretary, David J. Shulkin, center.

Tricare costs have climbed steadily, and the Tricare population is younger and healthier than the general population, while Veterans Affairs patients are generally older and sicker.

Though the rules would place some restrictions on veterans, early estimates by the Office of Management and Budget found that a Tricare-style system would cost about $60 billion each year, according to a former Veterans Affairs official who worked on the project. Congress is unlikely to approve more funding, so the costs are likely to be carved out of existing funds for veterans’ hospitals.

At the same time, Tricare has been popular among recipients — so popular that the percentage of military families using it has nearly doubled since 2001, as private insurance became more expensive, according to the Harvard lecturer Linda Bilmes.

“People will naturally gravitate toward the better deal, that’s economics,” she said. “It has meant a tremendous increase in costs for the government.”

A spokesman for the Department of Veterans Affairs, Curt Cashour, declined to comment on the specifics of the new rules.

“The Mission Act, which sailed through Congress with overwhelming bipartisan support and the strong backing of veterans service organizations, gives the V.A. secretary the authority to set access standards that provide veterans the best and most timely care possible, whether at V.A. or with community providers, and the department is committed to doing just that,” he said in an email.

Veterans’ services organizations have largely opposed large-scale changes to the health program, concerned that the growing costs of outside doctors’ bills would cannibalize the veterans’ hospital system.

Dr. Shulkin, the former secretary, shared that concern. Though he said he supported increasing the use of private health care, he favored a system that would let department doctors decide when patients were sent outside for private care.

The cost of the new rules, he said, could be higher than expected, because most veterans use a mix of private insurance, Medicare and veterans’ benefits, choosing to use the benefits that offer the best deal. Many may choose to forgo Medicare, which requires a substantial co-pay if Veterans Affairs offers private care at no charge. And if enough veterans leave the veterans’ system, he said, it could collapse.

Robert L. Wilkie, the secretary of veterans’ affairs, has repeatedly said his goal is not to privatize veterans’ health care.

One of the group’s former senior advisers, Darin Selnick, played a key role in drafting the Mission Act as a veterans’ affairs adviser at the White House’s Domestic Policy Council and is now a senior adviser to the secretary of Veterans Affairs in charge of drafting the new rules. Mr. Selnick clashed with David J. Shulkin, who was the head of the V.A. for a year under Mr. Trump and is widely viewed as being instrumental in ending Mr. Shulkin’s tenure.

Mr. Selnick declined to comment.

Critics, which include nearly all of the major veterans’ organizations, say that paying for care in the private sector would starve the 153-year-old veterans’ health care system, causing many hospitals to close.

“We don’t like it,” said Rick Weidman, executive director of Vietnam Veterans of America. “This thing was initially sold as to supplement the V.A., and some people want to try and use it to supplant.”

Members of Congress from both parties have been critical of the administration’s inconsistency and lack of details in briefings. At a hearing last month, Senator John Boozman, Republican of Arkansas, told Robert L. Wilkie, the current secretary of Veterans Affairs, that his staff had sometimes come to Capitol Hill “without their act together.”

Although the Trump administration has kept details quiet, officials inside and outside the department say the plan closely resembles the military’s insurance plan, Tricare Prime, which sets a lower bar than the Department of Veterans Affairs when it comes to getting private care.

Tricare automatically allows patients to see a private doctor if they have to travel more than 30 minutes for an appointment with a military doctor, or if they have to wait more than seven days for a routine visit or 24 hours for urgent care. Under current law, veterans qualify for private care only if they have waited 30 days, and sometimes they have to travel hundreds of miles. The administration may propose for veterans a time frame somewhere between the seven- and 30-day periods.

Mr. Wilkie has repeatedly said his goal is not to privatize veterans’ health care, but would not provide details of his proposal when asked at a hearing before Congress in December.

Access to VA Health Services Now Better Than Private Hospitals?

So, the question is with the shift of funding to the privatization of VA care is access better? Nicole Lou, contributing writer for the MedPage noted that efforts to stir up access to Veterans Affairs (VA) hospitals have cut down on wait times for new patient appointments, according to a report.

In 2014, the average wait for a new VA appointment in primary care, dermatology, cardiology, or orthopedics was 22.5 days, compared with 18.7 days in private sector facilities (P=0.20). Although these wait times were statistically no different in general, there was a longer wait for an orthopedics appointment in the VA that year (23.9 days vs 9.9 days for private sector, P<0.001), noted David Shulkin, MD, former VA secretary under President Trump, and now at the University of Pennsylvania’s Leonard Davis Institute of Health Economics, and colleagues.

The study, published in JAMA Network Open, found that wait times in 2017 favored VA medical centers (17.7 days vs 29.8 days for private sector facilities, P<0.001). This was observed for primary care, dermatology, and cardiology appointments — but not orthopedics, which continued to produce appointment lags in the VA system (20.9 days vs 12.4 days, P=0.01), the authors stated.

“Although the results reflect positively on the VA, we intend to continue improving wait times, the accuracy of the data captured, and the transparency of reporting information to veterans and the public,” the researchers wrote.

Their study included VA medical centers in 15 major metropolitan areas and compared them with private sector facilities. Wait times were calculated differently based on VA records and secret shopper surveys, respectively, which was a limitation of the study, the team said.

Shulkin and colleagues found that VA wait times trended toward improvement in 11 of 15 regions, whereas private medical centers had significant increases in wait times in 12 of the 15.

Prompting the scrutiny over VA hospital wait times was a 2014 report showing that at least 40 veterans died waiting for appointments at the Phoenix VA Health Care System in Arizona. Even worse, the wait times had apparently been deliberately manipulated to look better than they were.

“This incident damaged the VA’s credibility and created a public perception regarding the VA health care system’s inability to see patients in a timely manner,” Shulkin and co-authors said. “In response, the VA has worked to improve access, including primary care, mental health, and other specialty care services.”

Meanwhile, VA medical centers continue to suffer from staffing issues such as high turnover and employee vacancies in the tens of thousands.

The study authors noted a modest increase in the number of patients going to VA hospitals for the four services studied, although that number still stayed around five million per year.

From 2014 to 2017, patient satisfaction scores also increased by 1.4%, 3.0%, and 4.0% for specialty care, routine primary care, and urgent primary care, respectively (P<0.05 for all).

Another problem with the methodology of the study was that it failed to address how easily established patients could obtain return appointments, noted an accompanying editorial by Peter Kaboli, MD, MS, of Iowa City Veterans Affairs Healthcare System, and Stephan Fihn, MD, MPH, of the University of Washington in Seattle and JAMA Network Open’s deputy editor.

Furthermore, they pointed out, a patient returning for a 6-month follow-up visit may show up in the scheduling system as having a long delay.

“As this study highlights, measuring access to healthcare remains dodgy. Even so, the seven million veterans who receive care from the VA seem able to obtain routine and urgent care in a time frame that is on par for other Americans despite increasing demand, although there are and always will be exceptions,” Kaboli and Fihn noted.

“As resources in the VA are increasingly diverted to purchase care in the community, it remains to be seen if access to healthcare services can be maintained while access in the private sector continues to deteriorate,” they continued, adding that virtual care may be one way to improve access given the non-infinite supply of face-to-face appointments.

The VA experience seems to say that privatization of healthcare delivery is the way to go with improved access to care. So, onward to discuss universal healthcare and single payer systems of health care delivery. What would they all look like and what are the strategies to develop any of these systems.

 

 

‘Medicare for all’ proposal headed for House hearings and More States Expanding Medicaid

 

 

49025855_1851541661642151_2035183627737759744_nFirst, as we all are frustrated because of the government shutdown, most Federal Health Agencies are OK despite the shutdown. The FDA is feeling the pinch; IHS, ATSDR are affected also. However, it does point out the problems that Congress will face in the next 2 or more years because of political differences and the lack of civility.

News Editor Joyce Frieden pointed out that the partial shutdown of the federal government doesn’t appear to have had an immediate effect on most healthcare-related agencies, but observers expressed concern over what the shutdown might mean for the long term.

The Department of Health and Human Services (HHS), obviously the largest healthcare-related agency, has been largely unaffected by the shutdown, which began at 12:01 a.m. December 22, since most of the department is already funded through fiscal year 2019. However, the FDA is affected because its appropriations fall under a different authorization bill than the rest of HHS, so the agency had to furlough 7,053 staff members; the remaining 10,344 staff members were retained, either because they were performing functions critical to public health and safety, such as protecting ongoing experiments, or because their programs — such as tobacco regulation or new drug development — are funded by user fees.

The Alliance for a Stronger FDA — a group of patient organizations, trade associations, and pharmaceutical and biomedical companies that support adequate funding for the agency — expressed some concerns about the shutdown. “The FDA regulates products that make up 20% of consumer spending,” the organization said in a statement. “The agency’s responsibilities cannot be fully met when 7,000 employees are furloughed. Further, when the FDA is not fulfilling its critical public health responsibilities, there is no backstop to the agency’s work.”

However, “having said that, we have confidence that [FDA Commissioner] Dr. [Scott] Gottlieb and FDA leadership have ensured the emergency and critical public health and safety functions will be covered during a shutdown,” the statement continued. “Consumers should not panic — the FDA is still on the job. The immediate problem, quite a serious one, is the slowing of work on longer-term priorities and items that aren’t absolutely essential. Managing only those items that could turn into an immediate crisis is no way to run an agency that is critical to public health.”

The shutdown also hits the Indian Health Service (IHS), although direct patient care is not affected, HHS explained in its FY 2019 Contingency Staffing Plan, which was issued before the shutdown actually began. In the event of a shutdown, “IHS would continue to provide direct clinical health care services as well as referrals for contracted services that cannot be provided through IHS clinics,” the document noted. As for other IHS services, “many administrative activities are impacted due to the lapse in funding for the IHS,” a spokeswoman said in an email to MedPage Today.

Asked for examples of administrative services that IHS would continue to perform, the spokeswoman said, “The IHS can only perform administrative, oversight, and other functions that are necessary to meet the immediate needs of its patients, medical staff, and medical facilities.” Other media are reporting that some tribes will need to furlough staff and cut back services at their tribally run health clinics if the shutdown continues.

The National Institutes of Health (NIH) is largely unaffected by the shutdown except for the National Institute of Environmental Health Sciences, based in Research Triangle Park, North Carolina. There, Superfund Research Program staff are furloughed and oversight work dealing with about 50 grants is suspended, according to the staffing plan. An NIH spokeswoman confirmed in an email that no other NIH divisions have been affected.

The Agency for Toxic Substances and Disease Registry in Atlanta is another HHS division affected by the shutdown. Although the agency, which deals with environmental health threats and emergencies, will continue carrying out emergency-related functions, it cannot “support most environmental health professional training programs, continuous updating of health exposure assessments and recommendations, and technical assistance, analysis, and [provide] other support to state and local partners,” the staffing plan noted.

Susannah Luthi noted that a new single-payer health system concept will have a set of congressional hearings in the new Democratic House, and a new draft of a so-called “Medicare for all” proposal could be released as soon as next week.

Washington state progressive Democratic Rep. Pramila Jayapal, who over the summer launched the Medicare for All Caucus, said the hearings, with the support of House Speaker Nancy Pelosi (D-Calif.), will start in the House Rules and Budget committees before moving on to the House Energy and Commerce Committee.

“My goal is that these are opportunities to make the case not to the American people—the American people already had the case made to them—but to members of Congress, to really put forward what the legislation looks like,” Jayapal said Thursday after the new Congress elected Pelosi to the speakership.

Pelosi spokesperson Henry Connelly confirmed the speaker supports holding the hearings, although Jayapal acknowledged House Energy and Commerce Chair Frank Pallone (D-N.J.) hasn’t yet committed his panel.

“But I have the speaker’s commitment that she will help me do this, and I’ve spoken to Frank Pallone and he is not opposed,” Jayapal said. “He just hasn’t said ‘yes’ yet.”

A Pallone spokesperson did not respond to a request for comment by deadline.

Jayapal has not yet discussed possible hearings with the head of the other key health panel, Chair Richard Neal (D-Mass.) of the House Ways and Means Committee, but Neal said he is open to discussing the policy as one of the “many options that are out there” as part of holding his committee to regular order.

“That’s what committees are supposed to do, to flesh out alternatives,” Neal said.

This will be the first House hearing since the Affordable Care Act debate when the health panel of the House Committee on Education and Workforce looked at the option.

Details of the bill, a draft of which Jayapal said should be available in the next couple of weeks, are under wraps but she said it does vary from the legislation introduced by Sen. Bernie Sanders (I-Vt.) in 2017. Sanders catapulted talk of “Medicare for all” to the fore during his 2016 presidential bid and key Democratic senators has signed on to his policy since.

This is a different bill, Jayapal said. It’s largely the work of her staff and the staff of Rep. Debbie Dingell (D-Mich.), who sits on the Energy and Commerce Committee.

This new momentum for single payer—an issue that sharply divides the party—comes as Democrats are focused on defending Obamacare and as insurers hold out hope for more funding to shore up the law and draw more people into the individual market.

House Democrats will formally intervene in the lawsuit to overturn the Affordable Care Act following a Texas federal judge’s invalidation of the law—largely a political move around litigation that proved to help the Democrats in November’s elections.

In his first hearing announcement of the new Congress on Thursday, Pallone said his panel will focus on the lawsuit and its impacts. “This decision, if it is upheld, will endanger the lives of millions of Americans who could lose their health coverage,” the release from the Energy and Commerce Committee said. “It would also allow insurance companies to once again discriminate against more than 133 million Americans with pre-existing conditions.”

Judge Reed O’Connor, the Texas judge presiding over the case, ordered that the law is to remain in place as the lawsuit winds its way through the courts on appeal. It is headed next to the Fifth U.S. Circuit Court of Appeals in Louisiana.

The lawsuit was a political winner for Democrats in their campaign to reclaim the House in November, denouncing the GOP state attorneys general who filed the lawsuit and the Trump administration, which sided with the plaintiffs and refused to defend the ACA.

New Maine governor orders Medicaid expansion

Harris Meyer pointed out that the new Democratic Gov. Janet Mills signed an executive order Thursday implementing Maine’s Medicaid expansion, which was overwhelmingly approved by the state’s voters in 2017.The previous governor, Republican Paul LePage, had strongly resisted the expansion, resulting in a court battle that dragged through most of last year and ended with a judge ordering him to move forward with the Medicaid changes. In previous years, he vetoed five bills passed by the legislature to expand the program. An estimated 70,000 low-income adults will be eligible for Medicaid coverage under the expansion. Maine will become the 33rd state to extend the program under the Affordable Care Act to people with incomes up to 138% of the federal poverty level. Voters in Idaho, Nebraska and Utah approved similar Medicaid expansions.

‘Medicare for all’ advocates emboldened by ObamaCare lawsuit

Nathaniel Weixel looked at the ObamaCare lawsuit and its relationship to Medicare for All. Progressive groups and lawmakers plan to use a Texas judge’s ruling against ObamaCare to jump-start their push for “Medicare for all” in the next Congress.

Supporters of a single-payer health system are arguing that now is the time to start moving in a new direction from the Affordable Care Act, in part because they feel the 2010 health law will never be safe from Republican attempts to destroy or sabotage it.

“In light of the Republican Party’s assault, a version of Medicare for all is necessary for the future,” said Topher Spiro, vice president for health policy at the Center for American Progress. “There are just too many points of vulnerability in the current system.”

The court decision in Texas that invalidates ObamaCare in its entirety came on the heels of sweeping Democratic victories in the midterm elections, a combination that has energized advocates of Medicare for all.

“We need to do everything we can to ensure every single American has access to affordable, quality healthcare. Medicare for all has the potential to do just that as it can reduce the complexity and cost with a single payer health care system,” Rep. Debbie Dingell (D-Mich.), co-chair of the Medicare for All Caucus, said in a statement to The Hill.

Yet the effort could very well create divisions within the Democratic Party, as leaders who want to protect and strengthen the health law are reluctant to completely embrace government-run universal health insurance.

In the House and Senate, leading Democrats have said their priorities should be strengthening ObamaCare, rather than fighting over single-payer.

The lawsuit in Texas is almost certain to be overturned, they argue, and their time is better spent making sure people with pre-existing conditions remain free from discrimination by insurers.

“I think the ruling gets overturned within a couple months, so I’m not sure it matters in the long-term fight over the next generation of health-care reform,” said Sen. Chris Murphy(D-Conn.).

Sen. Ron Wyden (D-Ore.) said Democrats should focus on making sure the insurance landscape doesn’t revert to what it was before ObamaCare.

“The first thing we have to do is make sure people don’t lose what they have today — the pre-existing conditions protections — and going back to the days when there was health care for the healthy and the wealthy,” he said.

U.S. District Court Judge Reed O’Connor this month struck down the Affordable Care Act, throwing a new round of uncertainty into the fate of the law.

O’Connor ruled that the law’s individual mandate is unconstitutional, and that because the mandate cannot be separated from the rest of the law, the rest of the law is also invalid.

The court case, brought by 20 GOP-led states, was at the center of this year’s midterm campaign after Democrats attacked Republicans for supporting the lawsuit and seeking to overturn ObamaCare’s protections for pre-existing conditions.

The Trump administration, in a rare move, declined to defend the law in court, arguing instead that the pre-existing condition protections should be overturned.

“This is an outrageous, disastrous decision that threatens the health care and lives of millions of people. It must be overturned,” Sen. Bernie Sanders (I-Vt.) tweeted shortly after the decision was published. “We must move forward to make health care a right for every American.”

Rep. Ro Khanna (D-Calif.), who will be vice chairman of the House Progressive Caucus next year, said the decision “absolutely” makes a case for Medicare for all.

“There’s no doubt that would be constitutional. Medicare is already constitutional and what we’re saying is extend it to everyone, so there can be no constitutional argument,” Khanna told The Hill.

Eagan Kemp, a health-care expert with the advocacy group Public Citizen, also noted how uncontroversial Medicare is compared to ObamaCare.

“This is one more example of how tenuous the law really is,” Kemp said. “You don’t see the same type of sabotage to Medicare. So to me it highlights that the Medicare program remains the third rail of politics, so if we’re going to build a new health-care system, it’s something that can be safe.”

Some lawmakers said they understand the need to be pragmatic since centrist Democrats might not take the same message from the Texas ruling as progressives.

Khanna said he doesn’t think protecting ObamaCare from Republican attacks has to be a separate endeavor from Medicare for all.

Rep. Jan Schakowsky (D-Ill.), a member of the Medicare for All Caucus, told The Hill the fallout from the lawsuit “may help us move in an even more bold and aggressive agenda” on health care.

“We’ll see, though. I think this is the kind of issue that needs a broad consensus, may need some more outreach to the public,” Schakowsky said. “But I am interested in pursuing that agenda.”

Judge grants stay after ruling Affordable Care Act unconstitutional, Obamacare stays in effect

William Cummings of USA Today, reviewed the latest wrinkle in the Obamacare sage,  a federal judge on Sunday said his decision declaring the Affordable Care Act unconstitutional will not take effect while the appeals of his ruling move through the courts.

U.S. District Judge Reed O’Connor wrote in a 30-page court filing that while he believes the Fifth Circuit Court of Appeals “is unlikely to disagree” with his ruling, he agreed to stay his decision because “many everyday Americans would otherwise face great uncertainty” while the appeals play out.

On Dec. 14, O’Connor sided with a coalition of conservative states in a lawsuit challenging the constitutionality of former President Barack Obama’s signature health care law. He found that the individual mandate requiring people to buy health insurance was unconstitutional and said that meant the rest of the law was invalid as well.

In 2012, the Supreme Court upheld the law on the grounds that mandate fell within Congress’ taxation powers. When Congress removed the tax penalty for not buying insurance, that constitutional foundation was knocked out, O’Connor reasoned.

The Trump administration announced in June that it would not defend the individual mandate and other provisions of the law – such as protections for people with pre-existing conditions. But the Justice Department argued those provisions of the law could be thrown out without striking down the entire. O’Connor disagreed.

A group of Democratic states and congressional Democrats have said they plan to appeal O’Connor’s decision, which will next head to the Fifth Circuit. Although O’Connor did not grant an injunction blocking Obamacare in his initial ruling, the coalition led by California asked the judge on Dec. 17 to issue a stay and make it clear that the law will stay in place pending the appeal.

Many experts expect that appellate court to disagree with O’Connor’s ruling that the individual mandate can’t be separated from the rest of the law. If O’Connor’s ruling is upheld it is expected that the case would head to the Supreme Court.

Calif. Medical Assn. President Shares Medical Horror Story

Cheryl Clark, a contributing writer for MedPage Today wrote that the new president of the California Medical Association was expecting to spend New Year’s at a wedding in Las Vegas.

Instead, David Aizuss, MD, posted on Facebook about his “eye opening” first-hand view of “American medicine at its worst.” (The post is visible only to his Facebook friends and he declined MedPage Today‘s request to elaborate, citing ongoing “medical issues.”)

In his post, Aizuss said he was rushed by ambulance to a hospital Monday morning. “I spent hours in the emergency room where I received inadequate treatment of mind boggling pain, was never touched or examined by a physician, was mixed up with another patient and almost inadvertently transferred to another hospital, (and) was scheduled for emergency surgery based on a third patient’s lab work that was confused with mine,” he wrote.

He “finally signed out of the hospital against medical advice so I could obtain care from physicians that I know and trust.” He did not name the hospital.

Aizuss, an ophthalmologist who practices in Calabasas, northwest of Los Angeles, posted his complaint New Year’s Eve, apparently while at the LAX International airport in Los Angeles, where he said he was “just returning from Las Vegas where we were supposed to attend a wedding.”

Dozens of Facebook friends, several apparently also physicians, expressed their shock that the CMA president could receive such poor emergency room response, and some said they were happy he was speaking out about poor quality of hospital care.

“If you get terrible care like this (at least you know the difference) think about the care that Joe Sixpack gets; he doesn’t have the resources to get better care. This system is broken and we need to fix it,” posted one.

Wrote another, “As president of the CMA, your voice can be loud! Don’t be timid and do not be afraid of making enemies. Remember our patients know and respect us when we stand against poor medicine.”

Aizuss ended the post by saying, “Truly an eye-opening experience for the President of the California Medical Association. Happy New Year to all!”

He began his one-year term as CMA president in mid-October, saying he wanted to focus on physician burnout, practice sustainability, and payment. He is also past chairman of the CMA Board of Trustees.

He is a medical staff member at Tarzana Hospital and West Hills Hospital, in Los Angeles County, and serves as an assistant clinical professor of ophthalmology at the UCLA Geffen School of Medicine.

The CMA represents about 43,000 physicians in the state and is the second largest organized medicine group of any state, next to the Texas Medical Association, which represents about 52,000 physicians.

Why did I end with this article? It points out the fact that whatever the politics, we all have to continue to forge a better health care system. We need to get rid of the biases and the politics and strive, no demand a better healthcare delivery system. But we also have to realize that it will take some radicle changes, but it will be worth it in the end.

Let us continue the research and discussion  into what the healthcare system will look like in our future!

Yes, Medicare for All is expensive. That’s not the point but who loses?

37913774_1639263202869999_2457300851903954944_nI’m more confused as I read more and more about Medicare for All. Who is telling the truth? Diane Archer, founder and former president of the Medicare Rights Center and president of JustCareUSA.org. recently wrote that something interesting is happening in the age of Trump: 63 percent of Americans support a national health insurance plan, or Medicare for All, in which the federal government would guarantee health insurance for everyone in the country.

Mounting support for Medicare for All has left conservatives hyperventilating. Commercial insurers and their Republican allies are working overtime to convince Congress and the electorate that we simply can’t “afford” Medicare for All. A report by the Mercatus Center’s Charles Blahous, who spearheaded President George W. Bush’s attempt to privatize Social Security, is the latest entry in this fuzzy math sweepstakes.

Happily, for those of us who seek health-care security for all Americans, Blahous and his friends miss the point. Our commercial health insurance system is crazy and unsustainable, and Medicare for All is the only realistic path to reduce national health spending and improve the quality of our health-care system.

Sen. Bernie Sanders’s Medicare for All proposal improves and expands the current Medicare program, replacing commercial health insurance with federally administered coverage for all Americans. The proposal eliminates premiums, deductibles, and co-pays, and includes new coverage for vision, hearing and dental care. It allows everyone to use the doctors and hospitals they know and trust, anywhere in the country, without the restrictive networks, arbitrary denials and high out-of-pocket costs that go hand in hand with commercial insurance.

Medicare for All, like Social Security, is social insurance, designed to pool and broadly distribute the costs of care across the entire population. At its core, Medicare for All gives doctors and hospitals the freedom to compete for patients without insurers getting in the way.

Blahous writes that Medicare for All is expensive. That’s correct, but it’s the wrong starting point. The current commercial health insurance system is much more expensive than Medicare for All and is unsustainable by any measure.

We spend more than $3.3 trillion a year on health care — about 18 percent of the gross domestic product. That’s twice as much per capita on health care as the average of other high-income countries. In return, we get health-care outcomes that rank dead last among our peers. Health-care costs in this country are projected to increase by 5.5 percent a year over the next eight years. You do the math: The status quo doesn’t work. Period.

Medicare for All, by contrast, provides a compelling path to keeping health-care costs in check. To begin with, Medicare for All would eliminate the administrative waste and profit margins created by the commercial insurance system with hundreds of insurers negotiating different agreements with thousands of health-care providers. Total annual savings on administrative costs under Medicare for All are estimated as high as $500 billion a year (far more than Blahous estimates in his report).

Most important, Medicare for All would empower the federal government to use the collective bargaining power of 330 million Americans to reduce the cost of health care, something that commercial insurers have been unable to do. Blahous himself estimates that the extension of current Medicare rates to all health-care services coupled with lower prescription drug prices under Medicare for All would eliminate $445 billion in annual costs in 2022.

In all, Blahous concedes that Medicare for All would reduce national health spending by $2 trillion over 10 years; even after accounting for the cost of guaranteeing everyone coverage and offering better benefits. (And again, many health economists would say Medicare for All would drive far greater savings.)

Blahous’s concern is that Medicare for All will transfer the rest of the cost of health care from the private sector to the federal government. Okay. So how will we pay for Medicare for All? The same way we pay for the defense budget and everything else: through taxes. Does that mean that ordinary Americans will pay more under Medicare for All that they pay for healthcare today? No.

Think about it. Today, the typical family of four spends more than $28,000 on health care a year. Individuals pay that cost indirectly through lower wages (which fund the employer’s share of health insurance) and directly through out-of-pocket costs. Under Medicare for All, the typical family will see higher wages and lower expenses and spend much less on health care than it does today.

To be sure, the transition to Medicare for All will disrupt the health-care marketplace. Insurers will wind down. Pharmaceutical companies and medical device manufacturers likely will see their profits drop. Hospitals and doctors will need to work smarter and more efficiently; they will see an overall reduction in their rates, but they will save on administrative costs and their bills will all be paid.

There are always winners and losers in policy reform. Today, commercial insurers and other corporate interests in the health-care industry are the winners, and the American people are the losers. Medicare for All flips that paradigm. We can’t afford to live without it.

But at what cost to patient and caregiver?

Bernie Sanders Supporters Admit His Socialized Medicine Plan Will Ration Care

If Bernie Sanders wants to take a ‘victory lap’ for a study arguing that millions of health workers will receive the same amount of money for more work, I have four words: Good luck with that.

Christopher Jacobs noted that the move to enact single-payer health care in the United States always suffered from major math problems. This week, it revived another: Common sense.

On Monday, the Mercatus Center published an analysis of single-payer legislation like that promoted by socialist Sen. Bernie Sanders (I-VT). While conservatives highlighted the estimated $32.6 trillion price tag for the legislation, liberals rejoiced.

Sanders even released a video thanking Mercatus for its study, claiming that it showed how his bill would reduce overall national health expenditures by $2 trillion. In other words, Sanders claims his bill will provide more health care coverage to more Americans, and at less cost.

Riiiiiigggggggghhhhhhhhhttttt. As the old saying goes, if something sounds too good to be true, it usually is. Given that even single-payer supporters have now admitted that the plan will lead to rationing of health care, the public shouldn’t just walk away from Sanders’ plan—they should run.

National Versus Federal Health Spending

Sanders’ claim arises because of two different terms the Mercatus paper uses. While Mercatus emphasized the way the bill would increase federal health spending, Sanders chose to focus on the study’s estimates about national health spending.

Essentially, the $32.6 trillion figure—the amount of taxes that a single-payer bill must raise over its first decade—represents the cost of bringing the entire health-care system on to the federal government’s books. While bringing the health-care system on-budget will obviously require massive tax increases, the Mercatus paper assumes that doing so will cause overall national health spending to drop slightly.

Although it sounds large in absolute terms, the Mercatus paper assumes only a slight drop in health spending in relative terms. It estimates a total of $2.05 trillion in lower national health expenditures over a decade from single-payer. But national health expenditures would total $59.7 trillion over the same time span—meaning that, if Mercatus’ assumptions prove correct, single-payer would reduce national health expenditures by roughly 3.4 percent.

Four Favorable Assumptions Skew the Results

However, to arrive at their estimate that single-payer would reduce overall health spending, the Mercatus paper relies on four highly favorable assumptions. Removing any one of these assumptions could mean that instead of lowering health care spending, the single-payer legislation would instead raise it.

First, Mercatus adjusted projected health spending upward, to reflect that single-payer health care would cover all Americans. Because the Sanders plan would also abolish deductibles and co-payments for most procedures, study author Chuck Blahous added an additional factor reflecting induced demand by the currently insured, because patients will see the doctor more when they face no co-payments for doing so.

But the Mercatus study did not consider whether providing completely free health care to all U.S. residents will induce additional migration, adding even more costs to the system. As Hillary Clinton testified before Congress in 1993: “We do not think the comprehensive health care benefits should be extended to those who are undocumented workers and illegal aliens. We do not want to do anything to encourage more illegal immigration into this country. We know now that too many people come in for medical care, as it is.”

Second, the Mercatus study assumes that a single-payer plan can successfully use Medicare reimbursement rates. However, the non-partisan Medicare actuary has concluded that those rates already will cause half of the hospitals to have overall negative total facility margins by 2040, jeopardizing access to care for seniors.

Expanding these lower payment rates to all patients would jeopardize even more hospitals’ financial solvency. But paying doctors and hospitals market-level reimbursement rates for patients would raise the cost of a single-payer system by $5.4 trillion over ten years—more than wiping away any supposed “savings” from the bill.

Third, by its own admission, Mercatus assumes “virtually perfect success” for a single-payer system in replacing brand-name drug usage with generics. If the government cannot achieve “virtually perfect success” in increasing generic drug utilization—and a cynic might ask whether the government has achieved even imperfect success in anything—or greater government “negotiating” power has little effect in jawboning down prices, then the estimated costs of single-payer will rise.

Finally, the Mercatus paper “assumes substantial administrative cost savings,” relying on “an aggressive estimate” that replacing private insurance with one single-payer system will lower health spending. Mercatus made such an assumption even though spending on administrative costs increased by nearly $26 billion, or more than 12.3 percent, in 2014, Obamacare’s first year of full implementation.

Likewise, government programs, unlike private insurance, have less incentive to fight fraud, as only the latter face financial ruin from it. The $60 billion problem of fraud in Medicare provides more than enough reason to doubt many administrative savings from a single-payer system.

Apply the Common Sense Test

But put all the technical arguments aside for a moment. As I noted above, whether a single-payer health-care system will reduce overall health expenses rests on a relatively simple question: Will doctors and hospitals agree to provide more care to more patients for the same amount of money?

Whether single-payer will lead to less paperwork for doctors remains an open question. Given the amount of time people spend filing their taxes every year, I have my doubts that a fully government-run system would generate major improvements.

But regardless of whether providers get any paperwork relief from single-payer, the additional patients will come to their doors seeking care, and existing patients will demand more services once the government provides them for “free.” Yet doctors and hospitals won’t get paid any more for providing those additional services. The Mercatus study estimates that spending reductions due to the application of Medicare’s price controls to the entire population will all but wipe out the increase in spending from new patient demand.

If Sanders wants to take a “victory lap” for a study arguing that millions of health care workers will receive the same amount of money for doing more work, I have four words for him: Good luck with that.

Also, consider the health care workers, especially the physicians.                        Libertarian think tank: Providers would pay for Medicare for All                     Susannah Luthi reviewed libertarian take on the Medicare for All concept further and found that the Medicare for All plan backed by Sen. Bernie Sanders would put the brunt of the proposals costs on provider pay cuts.
In a white paper released Monday by the Mercatus Center of George Mason University, senior research strategist Charles Blahous claimed healthcare spending constraints laid out in the plan from the Vermont independent senator fall almost totally on providers. The plan could save the U.S. more than $2 trillion over 10 years in national health care spending but could increase the federal government’s costs to nearly $33 trillion above current levels, according to Blahous’ calculations.
Nearly all the savings for national health spending come from across-the-board Medicare rate cuts, which Blahous projects would reduce provider payments by $384 billion in the first year, and by nearly $660 billion in 2030.
This analysis will likely push single-payer advocates to hone their message on healthcare pricing to make their proposal viable, said Benedict Ippolito, a health economist with the right-leaning American Enterprise Institute.
“Provider payment cuts are doing a lot of heavy lifting here,” Ippolito said. “Changes to provider payments, whether you love them or not, have real consequences. And those real consequences extend beyond a budgetary score.”
While the U.S. healthcare system does need to grapple with the “right price to pay for healthcare,” Ippolito said, proponents of the Sanders plan and others like it need to determine what the right rate could be and how it will impact provider behavior, which determines major components of the healthcare system—investments in equipment and buildings, patient access and health outcomes.
“It’s easy to think about prices as one piece of a broader market, but the thing that’s special about prices is that it’s the key that unlocks the whole thing,” he added. “Whatever price you set will be highly consequential for the entire market. The decision you make for good or bad is extremely consequential, and you can’t get around that.”
Single-payer advocates lauded the paper’s findings that the projected provider cuts would roughly pay for universal coverage. The Mercatus analysis also estimated the health care system would save billions every year on drug spending since the Sanders Medicare for All plan allows the HHS secretary to negotiate prescription drug prices with the manufacturers—and presumably refuse to buy certain high-priced drugs.
But Blahous warned that the Sanders blueprint for coverage would likely lead to a huge spike in overall healthcare utilization, not only because more people would automatically be covered for services like dental and vision care but also because it bans any co-pays or deductibles.
“As a general rule, the greater the percentage of an individual’s health care that is paid by insurance … the more healthcare services an individual tends to buy,” Blahous wrote.
Blahous maintained that the jury is still out on whether MACRA effectively reins in provider costs, warning that the Medicare for All transition could disrupt access to health care as universal coverage goes into effect. He also noted that while some Medicaid-dependent providers would see a pay boost in the early years as their traditionally much-lower Medicaid reimbursements would rise to Medicare rates, they would start losing money soon after.
To back up his warning, Blahous cited the CMS’ Office of the Actuary’s projections that current payments would lead to negative operating margins for nearly half of hospitals by 2040. By 2019, over 80% of hospitals will lose money treating Medicare patients. A dramatic structural change to reimbursement structure could shutter many provider doors, Blahous wrote.
The paper acknowledged that phasing out employer-sponsored health care would translate into a huge increase in taxable wages, as it would free individuals, families, and employers from hefty healthcare spending. States would also no longer have to fund Medicaid, consistently their largest budget item.
“These offsetting effects should be considered when weighing the implications of requiring federal taxpayers to finance the enormous federal expenditure increases under M4A,” Blahous wrote. “These estimates should be understood as projecting the added federal cost commitments under M4A, as distinct from its net effect on the federal deficit. To the extent that the cost of M4A is financed by new payroll taxes, premium collections, or other revenue increases, the net effect on the federal budget deficit would be substantially less.”
The picture the Mercatus study paints for utilization in the healthcare system runs counter to the latest House Republican push to leverage health savings accounts to cut spending on superfluous services.
Last week, the House passed a packet of bills originally projected to cost more than $90 billion to expand the use of HSAs. In a subsequent speech before the conservative Heritage Foundation, HHS Secretary Alex Azar praised HSAs as a way to lower unnecessary spending, saying that from his own behavior when he had an HSA he was much more cautious about the number and manner of services on which he was willing to spend a limited number of dollars.
The Democratic Party at large is keeping Sanders’ Medicare for All plan at arm’s length, but its principles are gaining traction within the party. Prominent Democratic senators including Elizabeth Warren of Massachusetts, Kamala Harris of California and New Jersey’s Cory Booker have signed onto Sanders’ bill.
In the House, progressive Washington Democrat Pramila Jayapal founded a Medicare for All caucus to try to hammer out a comprehensive, streamlined platform over the next conference. More than 60 House Democrats have joined Jayapal’s group.
But Ippolito said the new paper highlights that single-payer proponents will need to acknowledge the political fight on their hands.
“In my time of listening to these single-payer proposals, a lot of emphases is on administrative savings—they appeal to that because they don’t rile up constituencies,” he said. “But going after provider payment rates means taking on one of the most well-organized constituencies in domestic policy. When I read this, it struck me as: this really wants to pick a fight. It promises the moon, but it does set up, surely, that something’s got to give here.”                                                                                                                                Health Care Rationing Ahead                                                                                                       I’ll give the last word too, of all things, a “socialist perspective.” One blog post yesterday actually claimed the Mercatus study underestimated the potential savings under single-payer: “[The study] assumes utilization of health services will increase by 11 percent, but aggregate health service utilization is ultimately dependent on the capacity to provide services, meaning utilization could hit a hard limit below the level [it] projects” (emphasis mine).                                                                                                                                 In other words, spending will fall because so many will demand “free” health care that the government will have to ration it. To socialists who yearningly long to exercise such power over their fellow citizens, such rationing sounds like their utopian dream. But therein lies their logic problem, for any American with common sense.

More to follow next week as we get closer to the truth.

First Boys Rescued From Thailand Cave as Rest of Youth Soccer Team Awaits Safety. But What About the Thai Health Care System?

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Karen Mizoguchi of People magazine reported this morning that rescue operations have begun for the 12 boys and their coach trapped at the Thailand cave for more than two weeks.

On Sunday, after at least eight hours since a team of divers started rescue efforts, at least four boys have emerged from the cave, as reported by multiple news outlets. The Thai Navy SEAL official Facebook page also confirmed four players were evacuated.

In addition, two ambulances were seen leaving the site with one boy believed to be in each. A team of 13 international cave diving experts and five Thai Navy SEALs entered the cave with the mission of accompanying each boy one by one through the flooded tunnels, that claimed the life of a former Thai Navy SEAL diver on Friday.

“Two kids are out. They are currently at the field hospital near the cave,” Tossathep Boonthong, chief of Chiang Rai’s health department and part of the rescue team, told Reuters. “We are giving them a physical examination. They have not been moved to Chiang Rai hospital yet.”

The bobbleheads then when on to taut the wonder of the Thai healthcare and how wonderful it is and that it is free universal health care.

Well, even as I have only one or two more edits on my original post for the week on Bernie Sanders and his Medicare for All policy, I thought that I would look at the Thai health care system. Is it as great as the commentators have been suggesting?

So, what is the health care system in Thailand all about?

Wikipedia states that Thailand has had “a long and successful history of health development,” according to the World Health Organization. Life expectancy is averaged at seventy years and a system providing universal health care for Thai nationals has been established since 2002.

Health and medical care are overseen by the Ministry of Public Health (MOPH), along with several other non-ministerial government agencies, with total national expenditures on health amounting to 4.3 percent of GDP in 2009.

Non-communicable diseases form the major burden of morbidity and mortality, while infectious diseases including malaria and tuberculosis, as well as traffic accidents, are also important public health issues.

Infrastructure                                                                                                                               Most services in Thailand are delivered by the public sector, which by 2010, included 1,002 hospitals and 9,765 health stations. Universal health care is provided through three programs: the civil service welfare system for civil servants and their families, Social Security for private employees, and the universal coverage scheme that is theoretically available to all other Thai nationals. Some private hospitals are participants in the programs, but most are financed by patient self-payment and private insurance. According to the World Bank, under Thailand’s health schemes, 99.5 percent of the population have health protection coverage.

The MOPH oversees national health policy and also operates most government health facilities. The National Health Security Office (NHSO) allocates funding through the universal coverage program. Other health-related government agencies include the Health System Research Institute (HSRI), Thai Health Promotion Foundation (“ThaiHealth”), National Health Commission Office (NHCO), and the Emergency Medical Institute of Thailand (EMIT). Although there have been national policies for decentralization, there has been resistance in implementing such changes and the MOPH still directly controls most aspects of health care.

Thailand introduced universal coverage reforms in 2001, one of only a handful of lower-middle income countries to do so. Means-tested health care for low-income households was replaced by a new and more comprehensive insurance scheme, originally known as the 30 baht project, in line with the small co-payment charged for treatment. People joining the scheme receive a gold card, which allows them to access services in their health district and, if necessary, to be referred for specialist treatment elsewhere.

The bulk of health financing comes from public revenues, with funding allocated to contracting units for primary care annually on a population basis. According to the WHO, 65 percent of Thailand’s healthcare expenditure in 2004 came from the government, while 35 percent was from private sources. Thailand achieved universal coverage with relatively low levels of spending on health, but it faces significant challenges: rising costs, inequalities, and duplication of resources.

Although the reforms have received a good deal of criticism, they have proved popular with poorer Thais, especially in rural areas, and they survived the change of government after the 2006 military coup. Then, the Public Health Minister, Mongkol Na Songkhla, abolished the 30 baht co-payment and made the scheme free. It is not yet clear whether the scheme will be modified further under the military government that came to power in May 2014.

In 2009, annual spending on health care amounted to 345 international dollars per person in purchasing power parity (PPP). Total expenditures represented about 4.3 percent of gross domestic product (GDP). Of this amount, 75.8 percent came from public sources and 24.2 percent from private sources. Physician density was 2.98 per 10,000 population in 2004, with 22 hospital beds per 100,000 population in 2002

Data for utilization of health services in 2008 include 81 percent contraceptive prevalence, 80 percent antenatal care coverage with at least four visits, 99 percent of births attended by skilled health personnel, 98 percent measles immunization coverage among one-year-olds, and 82 percent success in the treatment of smear-positive tuberculosis. Improved drinking-water sources were available to 98 percent of the population, and 96 percent were using improved sanitation facilities (2008).

Most hospitals in Thailand are operated by the Ministry of Public Health. Private hospitals are regulated by the Medical Registration Division. Other government units and public organizations also operate hospitals, including the military, universities, local governments, and the Red Cross.

Government Health Services                                                                                                            In Thailand, government-funded health care is funded by the Department of Medical Services at the Ministry of Public Health. The Ministry is in charge of public health services, government hospitals, and medical services. Public health facilities in Thailand offer good medical services, but government hospitals are often crowded, which means waiting times can be long. In addition, facilities in public hospitals may not be as good as those in private hospitals in Thailand. Treatment is completely free for Thai citizens holding a Universal Coverage Health card, except on Saturdays, when a charge is made. The National Health Security Office issues this Universal Coverage Health card. Normal charges apply for non-Thais, but these charges will be less than in a private hospital.

Private Medical Sector                                                                                                            Thailand is one of the leading medical tourism destinations in Asia. Most of the private hospitals in Thailand have excellent medical facilities and staff.

Non-Profit Health Organizations                                                                                                      A variety of agencies exist in Thailand to help disadvantaged people. These agencies include the Red Cross, World Vision, and Médecins Sans Frontières.

Doctors in Thailand                                                                                                                        Most of the doctors in Thailand are specialists. For this reason, it may be difficult for you to find a reliable general practitioner to treat you for minor medical issues. At a general hospital, a doctor who is a specialist in a certain field will most likely examine you. It may be difficult for this specialist to deal with a number of smaller medical conditions that you might have. The best idea for you might be to seek an internist as your first resort.

Please note that there are still major hospitals in Thailand that employ family doctors or medical practitioners. In addition, most doctors in Thailand do not have one specific place of work. Thai surgeons and physicians are employed at different hospitals that can be spread all over the city. Some of these doctors also have private clinics. For this reason, doctors in Thailand are likely to go from hospital to hospital to do their rounds. Some issues arise from this. For example, if you have just had surgery and a problem arises, your surgeon may have already left for another hospital and may have to deal with your situation over the phone.

Emergency Transport Facilities                                                                                       Emergency transport facilities in Thailand are unfortunately somewhat lacking. Although large hospitals in Thailand do have mobile intensive care units, you will rarely see an ambulance racing through the streets of Bangkok. Traffic accidents are attended to by volunteer organizations. The main obstacle in terms of emergency transport is the traffic in Bangkok; cars do not generally move out of the way for an ambulance.

Thailand has had a universal health-care coverage scheme since 2002. Apiradee Treerutkuarkul examines how renal-replacement therapy for the chronic end-stage renal disease is straining the scheme’s resources.

In 1998 21-year-old Thunyalak Boonsumlit fell ill so her worried parents took her to hospital. “I thought I had food poisoning,” she recalls. The doctor, however, told her she had acute kidney disease and would die without immediate treatment. There was more bad news: although her parents were insured by Thailand’s Civil Servant Medical Benefit Scheme, this scheme only covers dependents up to the age of 20. Boonsumlit was treated for a month and sent home.

In 2002 Thailand reformed its public health financing system. This extended the scope of coverage to 18 million people who were uninsured and to a further 29 million who were previously covered by less-comprehensive schemes.

It was the realization of a project that had been a quarter of a century in the making, starting with the creation of a social welfare scheme for the poor in 1975. The new scheme offered comprehensive health care that included not just basics, such as free prescription drugs, outpatient care, hospitalization and disease prevention, but more expensive medical services, such as radiotherapy, surgery and critical care for accidents and emergencies. But it did not cover renal-replacement therapy due to budget constraints. Boonsumlit and thousands of fellow sufferers were on their own.

“There was a concern that renal-replacement therapy could burden the system. Major health risks leading to kidney diseases, such as diabetes and hypertension, were still not well controlled,” says Dr. Prateep Dhanakijcharoen, deputy secretary general of the National Health Security Office, which oversees the Universal Coverage Scheme. And renal replacement therapy is expensive. The cost of hemodialysis is about 400,000 baht (US$ 12,100) per year. This is four times higher than the 100,000 baht (US$ 3,000) per quality-adjusted life year threshold set by the National Health Security Office’s benefits package subcommittee for drugs and treatments. This threshold was adopted as a national benchmark.

Dhanakijcharoen believes that the Universal Coverage Scheme plan should have included kidney disease from the outset, a view shared by Dr. Viroj Tangcharoensathien, director of the International Health Policy Programme at the Ministry of Public Health. It was a simple matter of fairness: “There are three health-care schemes in Thailand,” he says. “Only the Universal Coverage Scheme did not include renal-replacement therapy.”

In 2005 Boonsumlit became ill again and was diagnosed with end-stage renal disease. For a year her parents had to pay 400,000 baht (US$ 12,100) to cover her dialysis. This time she was told that if a suitable donor could be found, a kidney transplant was the best option. The procedure cost 300,000 baht (US$ 9,000). Boonsumlit’s mother donated a kidney, and once again she and her husband paid all the bills, including the cost of post-transplant medication required to prevent the rejection of a new kidney.

But there was increasing community pressure for change. People like Subil Noksakul, who had spent his life savings on medical treatment over a period of 19 years, were tired of being treated like pariahs. “I once managed to save 7 million baht. But all my savings are now all gone,” he says. Like everyone else, he found it unacceptable that the Civil Servant Medical Benefit Scheme and the Social Security Scheme, which rely on public funds, both offered treatment for kidney disease while the Universal Coverage Scheme did not.

In 2006 Noksakul founded the Thai Kidney Club, which raised kidney patients’ awareness of their rights and put pressure on the National Health Security Office to provide treatment. Finally, in January 2008, the then public health minister, Mongkol Na Songkhla, bowed to public pressure and included renal-replacement therapy in the scheme. For Boonsumlit, Noksakul and thousands of other kidney patients, it was a watershed moment.

Unsurprisingly, since 2008, demand for treatment has spiraled. According to Dhanakijcharoen, 2.5 billion baht (US$ 76 million) of the total annual National Health Security Office budget of 120 billion baht (US$ 3.62 billion) has been allocated to renal-replacement therapy with 8,000 patients receiving haemodialysis and 4000 receiving peritoneal dialysis: to meet the full need, this treatment would require a huge increase in funding.

“The cost of renal replacement therapy is still less than 2% of the total budget,” he says, but warns the cost could blow out should Thailand fail to focus on prevention and reduce new cases.

The Ministry of Public Health’s Tangcharoensathien paints an even starker picture: “Without alternatives, renal-replacement therapy, when fully scaled up to target end-stage kidney patients, could consume more than 12% of the Universal Coverage Scheme annual budget, and push it to the verge of financial crisis,” he says.

The National Health Security Office is trying to reduce some costs by encouraging patients to perform their own peritoneal dialysis at home. This is dialysis in which patients filter their own blood by periodically injecting fluid into the abdominal cavity, which is later drained. Tangcharoensathien believes nurses can play a crucial role in training patients and family members to use equipment that is provided free of charge under universal coverage. Meanwhile, those patients who continue with the more expensive hemodialysis must now pay one-third of the total cost of treatment.

It is debatable whether home-treatment would have a big impact on costs, given the increased risk of infection and subsequent expenses associated with peritoneal dialysis, which costs up to 240,000 baht (US$ 7,300) annually. However, it would save rural patients the twice-weekly fares to visit a hemodialysis center in a provincial city, which poor patients cannot afford. The National Health Security Office aims to reduce the cost of peritoneal dialysis to about 200,000 baht (US$ 6000) per year.

More promising perhaps is the government’s broader campaign to improve the nation’s renal health. Screening for diabetes and hypertension, as part of a 2.5 billion baht (US$ 76 million project) is due to start this year. According to the National Health Security Office’s Dhanakijcharoen, the project will cover 5500 communities and municipalities nationwide. “Although the current health-promotion fund is still insufficient, it is a good start for prevention and early detection of diabetes and hypertension among local residents,” Dhanakijcharoen says, adding that encouraging healthier lifestyles will also help to reduce the cost of chronic disease and the burden it places on the health budget.

Tangcharoensathien concurs: “If the government allocated more budget to run the scheme, the National Health Security Office would be able to invest more in reducing health risks, and people would not end up with kidney disease in the first place.”

Both men are eager to see the latest universal coverage initiative succeed. They are proud of what has been achieved on total health expenditure equivalent to 4% of gross domestic product (GDP) – compared to the world median of 6.2% of GDP and 4.5% for lower-middle income countries. Dhanakijcharoen says, “We would like to let the world know that it’s not necessary to launch a universal health-care system only when the money is there; what is important is to work steadily on it. But dedication is a must.”

The Question is what Thailand can teach the world about universal healthcare

The Asian nation proves that a well-researched system with dedicated leadership can improve health, affordably. In 10 years, its plan reduced infant mortality, decreased worker sick days and lightened families’ financial burdens

While countries all over the world are moving toward universal healthcare, for many it remains just a goal. But a handful of them have rolled out universal health coverage schemes, and there’s plenty to learn from these nations. Consider Thailand, where leaders successfully implemented sweeping healthcare reform without breaking the bank.

In 2000, about one-quarter of people in Thailand were uninsured, and many other people had policies that granted incomplete protection. As a result, the country was in a healthcare crisis. More than 17,000 children younger than five died that year, about two-thirds of them from easily preventable infectious diseases. And about 20% of the poorest Thai homes fell into poverty from out-of-pocket healthcare spending.

In 2001, Thailand introduced the Universal Coverage Scheme (UCS). It’s described as “one of the most ambitious healthcare reforms ever undertaken in a developing country” in the book Millions Saved: New The Center for Global Development reviewed the Thai healthcare system and found Cases of Proven Success in Global Health. The UCS, which spread to all provinces the following year, provides outpatient, inpatient and emergency care, available to all according to need. By 2011, the program covered 48 million Thais or 98% of the population.

Several things worked in favor of Thailand’s UCS, including a sustained support system and a broad reach. Reformers from the 2001 general election’s winning political party, Thai Rak Thai, held leadership positions, and they were able to help back the program. As described by Dr. Suwit Wibulpolprasert, the program’s policy director and Thailand’s deputy secretary of the ministry of health at the time, the UCS had to go wide quickly. “The challenge was to implement it fast,” he says. “It couldn’t be done over 10 years because there was huge political pressure.”

Thailand’s UCS was implemented in every province by January 2002, but this level of comprehensive care had taken decades to develop. Since the 1970s, free medical care had been available to some people in poverty, but the country had a range of health insurance schemes that left many without coverage. Developing infrastructure – hospitals, clinics, and trained staff – to support universal coverage took years.

According to Dr. Sara Bennett, associate professor at Johns Hopkins Bloomberg School of Public Health, quality is the most challenging aspect of universal healthcare in developing countries. Government-funded healthcare is often free, but it can be geographically inaccessible, limited to a few facilities and administered by poorly trained staff. In addition, what works in urban areas might not be suited to rural contexts and vice versa.

When Thailand established solid health infrastructure, universal healthcare “totally changed the relationship between patients and doctors”, Wibulpolprasert says. Before, patients paid a fee to their doctors when they visited the hospital. After 2001, the government paid hospitals, including salaries for staff, and financially incentivized medical professionals to serve unpopular rural areas.

The lessons in Thailand: a well-researched system with a dedicated leadership can improve health, and in an affordable way. As of 2011, the country’s health scheme cost just $80 per person annually, primarily funded by general income tax; it effectively reduced infant mortality, decreased worker sick days and lightened families’ financial burden for healthcare.

Meanwhile, in the US, securing agreement from political leadership is one of the most contentious issues over universal healthcare. The Patient Protection and Affordable Health Care Act, also known as Obamacare, was signed into law in 2010, yet is still embroiled in political controversy. However, the plan is paying off: more people than ever are insured and out-of-pocket spending has dramatically declined among those insured.

Around the world, many low- and middle-income countries are also moving toward universal care. “They are covering more people, who are paying less out of pocket and have access to a broader array of services,” Bennett says. “Many countries are making significant strides towards this, including the poorest.”

Paying for universal health care remains a challenge. In South Korea, for instance, care is funded by compulsory health insurance from all citizens and covers about 97% of the population. However, the country’s health system is in growing deficit.

Listen carefully, in Thailand, affordability is not currently an issue, though the cost of the program as a proportion of general income tax is rising yearly. The cost and payment for the system have to be considered in our country of the U.S.A. if we want a universal health care system of any type! Still, the UCS continues to have wide support from the country’s government, health workers, and the wider population.

“The challenge is to make it more efficient, to get more for less money, particularly with the introduction of new technology and new drugs,” Wibulpolprasert says.

According to Carolyn Hart, Washington office director at health consultancy John Snow Inc, a multisectoral approach is a key to global healthcare. “We are looking at the need to develop channels at all price points including free, subsidized and pay as you go, which could be insurance,” she says.

“How can [countries] afford not to invest in the health of their people?” she adds. “Poor health holds you back so badly.”

We just have to decide to make the right decisions and what the correct design of our health care system and how we are going to pay for it. There are many differences here as there are in many of the countries that have a universal health care system and we have to examine which we can adapt to create a successful, caring and sustainable system.

Onward to discuss Bernie’s proposal and luck and prayers to the divers and Thai children and their coach.