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State health law waivers: where will they take us?

The president supports state innovation in health care, but vigilance is required to ensure state reforms improve health as we continue to call for national reform

By Margaret Flowers, M.D. for PNHP –

President Obama announced at the National Governors Association on Monday that he supports an amendment to the health law that would allow states some flexibility to innovate with their own models of health reform beginning in 2014, rather than waiting until 2017, as is currently required by law. The president’s concession comes as the current federal health law is deteriorating and states are complaining that the financial burden of complying with the law are too onerous in the face of serious budget deficits.

The president’s endorsement of the Wyden-Brown amendment, known as the “Empowering States to Innovate Act” or S.248, allows states to apply for waivers from the health insurance exchange beginning in 2014 and would give them some federal dollars to experiment with alternative ways of providing health coverage. The federal health bill requires that any state seeking a waiver from the health insurance exchange must at a minimum provide coverage comparable to that specified by the federal bill (Section 1332). It is left to the discretion of the secretary of health and human services to determine if a state meets this requirement.

States that put in place a single-payer health system will surpass the coverage of federal law. A single-payer health system, improved Medicare for all, would be universal and would provide the necessary cost controls and savings that would fund comprehensive coverage, including much-needed mental health, dental and vision care.

States such as Vermont and California, which appear to be closer than any others to enacting a state single-payer health system, welcomed the president’s support for the Wyden-Brown amendment because it would remove one of the many barriers they face. The amendment will still need to be passed by Congress before it arrives at the president’s desk, which may in itself be a formidable feat in the current political climate.

In addition, for states that want to take the path of single payer, even with the amendment, there will still be many hurdles before they can implement such a plan. The amendment only moves up the date when waivers can be applied for. It does not guarantee federal approval of the many waivers a state single-payer system would need, such as being allowed to roll their Medicaid and Medicare populations into their single-payer system.

Of concern is that the president is signaling a greater willingness to allow states to opt out of the health reform bill not because states want to provide better coverage but because governors in some states are opposed to the federal health law altogether. Beginning shortly after passage of the law last year, there has been an effort to undermine it through court challenges to its constitutionality and more recently through efforts to repeal it entirely or in part by the House. Additionally, hundreds of waivers have been issued excusing businesses, union health plans and health insurers from having to comply with parts of the law. The Department of Health and Human Services now has a 24-hour turnaround time on such waivers.

Vigilance will be required to ensure that some states do not use the amendment, if it is passed, to gut important public health programs such as Medicaid and SCHIP and further privatize health care, which would be harmful to patients. According to a White House fact sheet released around the time of the president’s statement, “The law also allows states to submit a single application that includes Medicaid waiver requests which could, for example, seek to give people eligible for Medicaid the choice of enrolling in [health insurance] exchange plans.” A change such as this would undermine Medicaid and shift more people into more expensive and less protective private insurance plans.

Efforts are already underway in Wisconsin to take control of the state’s Medicaid programs away from the state Legislature and end the public’s ability to have a voice in the process and instead give full authority over the program to the governor’s office. Gov. Scott Walker appointed Dennis Smith, a former Heritage Foundation fellow who has written about moving people out of Medicaid and raising co-pays for those still in Medicaid, as his secretary of health.

Wisconsin is not alone in challenging Medicaid. According to the Wall Street Journal, more than half the states want permission to remove hundreds of thousands of people from Medicaid. Other states like New York and Arizona are cutting benefits of health programs that already provide insufficient coverage.

Decades of experience in the United States shows that the market model fails when it comes to financing health care. Health is a necessity, not a commodity. A system based on the purchase of private insurance results in higher costs and poorer outcomes. Patients who cannot afford necessary care get sick, defer treatment and develop preventable complications, sometimes fatal ones. Families experience personal bankruptcy when a serious illness or accident occurs. With increased political pressure and Secretary Sebelius already issuing hundreds of waivers, can further privatization of health care be prevented?

While some welcome the president’s support for the amendment and hope that if it passes a state will be able to demonstrate the benefits of a single-payer system, as happened in Saskatchewan (and which led to Canada’s national Medicare system), it is possible that the actual outcome of such an amendment will be a further attack on our necessary public health programs. For this reason, it is imperative that we continue to push for a national health program, improved Medicare for all in the U.S.

“It would require fewer waivers and be simpler to enact improved Medicare for all at the national level,” says Dr. Garrett Adams, president of Physicians for a National Health Program. “Not only is it simpler, but it would save lives and end personal bankruptcy caused by medical illness. We would like to see a national Medicare-for-all system enacted sooner rather than later. Every day that we wait, hundreds of Americans die of preventable causes.”

Physicians for a National Health Program advocates for a national publicly financed and privately delivered health system: an improved Medicare for All as embodied in H.R. 676, the “Expanded and Improved Medicare for All Act.” Among the benefits of such a program are that it is a simpler system for patients and health professionals, recaptures about $400 billion annually in unnecessary paperwork and bureaucracy and directs that money into care, allows freedom to choose one’s health provider and more control over one’s treatment, is universal and provides comprehensive health benefits while at the same time effectively controlling our soaring health care costs. In this time of fiscal and health crises, national Medicare for all is more important than ever.

Healthcare-Now of Maryland Annual Meeting and Public Forum a great success!

We had a great meeting Tuesday night! Thank you to all who attended. The Peabody Room was packed.

Bekah Mandell and Sandra Schlosser of the Vermont Workers Center “Healthcare is a Human Right Campaign” shared the story of their three year effort to build a strong single payer grassroots in Vermont. They used Truth Hearings, Accountability Sessions and Photo Petitions to educate and grow. The result has brought single payer to the forefront of the discussion in Vermont. You can see their presentation in the video below.

Bekah made the excellent point that during the last national health debate, the model for reform was Massachusetts. It is important that for the next national debate, which we anticipate will occur within five years, that there be a state single payer model. For this reason, it is important that we support the VT efforts.

To learn more about the Vermont Workers Center and to find out how to support them, visit www.workerscenter.org. At present they are in need of donations to support the hiring of organizers. They are also looking for Marylanders to join their May 1st rally in Montpelier.

We would like to thank The Silverbacks for opening the meeting with music. They were fantastic! Many thanks to
Vocalist: Marianna Mujica
Piano: Richard Schroeder
Bass: Kevin Shaner
Percussion: John Kessell
Trombone: Professor Anthony Lehman, MD
Woodwinds: Donn Teubner-Rhodes, MD

Many thanks also to Dr. Dick Humphrey, our emcee, and Rod Ryon of Healthcare-Now of MD. And thanks to Maurice Morales for videotaping the meeting.

Here are links to the videos:
Annapolis Health Care Update
National Update
Sandra Schlosser and Bekah Mandell

Have you gotten PIISD (pissed)?

Dr. Carol Paris the eminent psychiatrist from Southern Maryland has defined a new disorder; Private Insurance Induced Stress Disorder (PIISD) pronounced pissed.  To discover if you are one of the millions who has this disorder go to http://PIISD.org where you will find the diagnostic criteria.  The only known cure is Improved Medicare for All.  PIISD has been featured in the the Psychiatric Times and the Huffington Post.  While at http://piisd.org you can buy a shopping bag or t-shirt that will show your support for single payer.

Maryland Economic Impact Study

We need your help to pay for a State of Maryland Economic Impact Study. Maryland single-payer advocates are increasingly energized at the state level because of the general dissatisfaction with the health insurance reform that was recently passed into law by the federal government that:

• will leave more 20 million people uninsured and an even greater number underinsured.
• does little to lower the cost of healthcare and will therefore be financially unsustainable.
• does not prevent medical bankruptcies, over 60% of bankruptcies are caused in part or in total by medical bills.
• leaves the private insurers, not healthcare professionals and their patients, in control of medical decisions; we need to get the insurance companies out of the exam room.
• restricts choice of doctors and hospitals and breaks long term provider-patient relationships; when patients must change to a new insurer with a different approved panel of providers.

We are making a serious effort to pass legislation that will create a state single payer system in Maryland that would be publicly funded and privately delivered. The legislation is called the Maryland Health Security Act of 2010 and it was introduced in the Maryland State Senate (SB682) and House of Delegates (HB767) with 12 and 38 co-sponsors respectively. Both bills had hearings and committee votes but neither made it to the floor.

We need an economic impact study to persuade legislators and the community at large of the significant advantages of single payer/Medicare for all system. Numerous studies have shown that a one-payer system dramatically lowers health care expenditures by eliminating massive amounts of administrative waste and by enabling bulk buying of pharmaceuticals and medical equipment, enough savings to finance an Improved Medicare for All System. The study will also help specify the means of financing in the Maryland Health Security act.

We have negotiated with several vendors and have settled on the Lewin Group. They have a long track record with studies of this type and did one in 2000 on the effects of a single-payer system versus a multi-payer system in Maryland. Because we have teamed with Pennsylvania and Minnesota, we have gotten a significant discount. We have raised over $30,000 and our goal is $40,000.

The Lewin Group is now owned by Ingenix a subsidiary of United Health Care. Based on recent work by the Lewin Group we made the judgment that this has not affected their impartiality and may actually strengthen the believability of their study because some people would expect bias against single payer.

Your contribution is tax deductible and is made through PNHP (Physicians for a National Health Program), a 501.c.3 organization under the IRS code. You will receive a letter of acknowledgment and thanks from PNHP for donating to the Maryland Economic Impact Study.

There are two ways to make a contribution for the study:
1. Check: make it out to PNHP (Physicians for a National Health Program) and mail it to PNHP c/o Dr. Eric Naumburg, 6163 Devon Drive, Columbia, MD 21044

2. Credit Card: Click here to donate online.

For questions about and more information about the survey, email enaumburg@hotmail.org or call 443-562-6562.

State Single Payer Strategy Session 9/25/2010 Summary

State Single Payer Strategy Session Update:

On Saturday, September 25^th, dedicated single payer activists gathered from around the state to strategize for the upcoming legislative session and to set a map to victory for the Maryland Health Security Act in Maryland. The morning started with brief updates on the state of single payer at the state and national levels. This was followed by an excellent and informative presentation by Susan Delean-Botkin of the Nurse Practitioner Association of Maryland. Susan and her colleague, Lorraine Diana, successfully passed a piece of legislation this year using a well designed and executed strategy over the past four years. We then heard about grassroots and coalition building from Dr. Eric Naumburg of MD PNHP and Kevin Zeese of ProsperityAgenda.US. The Session was organized by volunteers from Healthcare-Now of Maryland and Maryland chapter of Physicians for a National Health Program.

Participants then gathered in groups to discuss strategies for a legislative approach, for increasing the grassroots membership in Maryland and for building the Maryland Coalition for Health Security into a more functional entity. This report details some of the efforts that were discussed.

Economic Impact Study: Much of the work for single payer in Maryland depends on commissioning an economic impact study for the Maryland Health Security Act. Healthcare-Now of Maryland and Maryland PNHP have an agreement with the Lewin Group to perform this study. We need to raise $40,000 and we currently have $26,000. We are looking for ways to raise the remaining $14,000 before the end of the year. Ideas for fundraising include:

1. House parties – Drs. Carol Paris and Margaret Flowers have resources that can be used to hold a house party. Volunteers who are interested can reach Margaret at mdpnhp@gmail.com.
2. Phonebanking – volunteers can do this from their home or through their organization. Contact Dr. Eric Naumburg at enaumburg@hotmail.com
3. Honoraria for speaking – organizations and community or faith groups that would like to host a speaker on single payer can do so for a low fee. Contact Margaret Flowers at mdpnhp@gmail.com.
4. Contacting coalition member organizations to request donations.
5. Selling single payer items such as grocery bags, bumper stickers, buttons, etc at events. Carol Paris has volunteered to order grocery bags.

Grassroots Organizing and Coalition Building: The Maryland Coalition for Health Security was created in July, 2008 and currently includes 21 organizations in Maryland. Healthcare-Now of Maryland recently improved the website and purchased database tools from Healthcare-Now. Actions to grow our single payer base include:

1. Putting information about our speaker’s bureau on the Maryland Healthcare-Now website.
2. Reaching out to organizations that support health reform such as those who supported the public option during the recent Federal health reform process.
3. Targeting key legislative districts with tabling, leafleting, etc. For those who are interested, these materials  can be downloaded from the Maryland Healthcare-Now website at www.mdsinglepayer.org or contact Eric Naumburg at enaumburg@hotmail.com.

Working with Legislators: In this current economic climate, it is important to emphasize the cost savings of single payer health care and how this would have a positive impact on the state budget. Volunteers are encouraged to:

1. Make ourselves known to legislators by attending their events between now and the November election and make sure they know you are there because you support single payer.
2. Research which people and organizations are important to target legislators.
3. Arrange an Annapolis Night-Out during the legislative session to bring the single payer word to our state legislators.
4. Identify candidates who could improve their chances of being elected by supporting single payer and working with them to educate them about single payer.
5. Encourage our strong supporters in the legislature to participate in events with their colleagues to educate other legislators about single payer. Hold district meetings.
6. Develop talking points about single payer and the federal legislation using data specific to Maryland.
7. Organize a press conference and lobby days.

If you are interested in getting involved with these activities or have ideas to add, please contact us through info@mdsinglepayer.org or look on the website (www.mdsinglepayer.org) for a meeting near you or let us know if you want to join our regular conference calls.

On Medicare’s anniversary: Kucinich, Conyers, Sanders issue “Open Letter of Support to the Single-payer Community”

By Sahil Kapur for the Raw Story –

A trio of progressives in Congress invoked the 45th birthday of Medicare Friday to call for a national single payer health insurance system, predicting it’s “inevitable” if Americans want lower costs.

“It has never been more important to have a strong movement behind Medicare for All,” wrote Sen. Bernie Sanders (I-VT) and Reps. Dennis Kucinich (D-OH) and John Conyers (D-MI) in a letter addressed to “friends of health care for all.”

The trio, all of whom have sponsored single payer bills, argued that cost controls are insufficient in the health reform law enacted March and claimed the growing need to save money would galvanize support for such a system.

“As we honor Medicare’s 45th birthday today, I am proud to say that the movement for Medicare for All remains strong and vibrant,” Kucinich said.

While various lawmakers have endorsed single payer proposals, it remains far out of the reach of Congress due to the prevalence of anti-government public sentiments and the political influence of the private insurance industry, which would be torn down.

The Affordable Care And Patient Protection Act, enacted by President Barack Obama in March, is projected by the Congressional Budget Office to cover nearly all Americans and reduce the deficit. It has no new public insurance programs.

Although Sanders, Kucinich and Conyers all voted for the new law, they said in the letter that it “does not adequately contain costs” for Americans.

“In my view, the single-payer approach is the only way we will ever have a cost-effective, comprehensive health care system in this country,” said Sanders.

A Commonwealth Fund report last month found that Americans spend roughly twice as much on medical costs than residents of other industrialized nations yet the US system lags in areas of quality, efficiency and equity.

Sanders and Kucinich have led on pushing for national or state-based single payer programs in the Senate and House respectively, but have failed to garner the necessary support.

According to reports, Medicare, a single payer system for the elderly in America, has lower overhead costs and higher satisfaction rates than private insurance on average.

The White House and Democratic National Committee on Friday proclaimed their commitment to sustaining and strengthening Medicare.

“We believe Medicare for All is inevitable in the United States,” the lawmakers wrote. “It is up to all of us to determine when the inevitable becomes reality.”

Read the open letter here (.pdf).

The Baucus 8 One Year Later

On May 5, 2009, 8 health advocates stood up to the members of the Senate Finance Committee, chaired by Senator Max Baucus, to expose the exclusion of the health reform favored by the majority of people in America: a single payer/national improved Medicare for All health program. Industry lobbyists were invited to testify before the committee while single payer leaders were excluded despite a request to participate. The advocates, who became known as the Baucus 8, gathered one year later to discuss their motivations for speaking out on that day:

In this longer video, the Baucus 8 reveal what they learned about the health reform process and what we need to do now to achieve true health reform: Single payer/national improved Medicare for All.

Members of the Baucus 8 are represented by the organizations listed below. You can learn more about their work and get involved through their websites.

Join us in building the broad and educated grassroots movement that will create the political will for true health reform!

Guaranteed Health Care for All
Health Care Now
Labor for SP
Mobilization for Health Care
National Nurses United
Physicians for a National Health Program
Prosperity Agenda
Single Payer Action

Brief Report on the Conference: “What Does Health Reform Mean For You, Your Business or Nonprofit”

Hosted by Johns Hopkins Bloomberg School of Public Health
June 25, 2010

Panelists from AARP, Families USA, Maryland Association of NonProfit Organizations, Maryland Health Care for All! and the Small Business Majority

I went to the Friday session. The main presenters were Cheryl Fish-Parcham from Families USA, Lynda Flowers and Lynn Nonnemaker from AARP and Terry Gardiner from Small Business Majority.

The topic was to tell us how the Patient Protection and Affordable Care Act (PPACA) relates to Maryland. In general I thought that the conference skimmed the surface of the complexities in the law; some of this is due to the fact that the Department of Health and Human Services (HHS) needs to create a lot of regulations to interpret the law. But, also there was little analysis of how the law is going to affect Maryland before the main pieces of the PPACA (the Medicaid expansion and setting up the exchange) go into effect in the year 2014, 3 ½ years from now. Near the end of the Q and A, an emergency room nurse stated that there were lots of people coming to her facility without health insurance and asked what could she do to help them get insurance. The representative from Families USA suggested that she call her organization and they would help out. As there are no easy answers, no specific solutions were mentioned. Vinnie Demarco (Healthcare for All) bragged that the Medicaid population in Maryland would increase by 170,000. What he failed to mention is that while some of the increase is due to the Maryland Law that opens up Medicaid to parents and caretakers between 40% and 116% of the federal poverty limit; a lot is also due the expected increase in Medicaid enrollment that occurs during all recessions. DHMH has reported enrollment of 52,000 in the new eligibility category created by the Maryland law from July 2008 to November 2009.

The presenters often avoided salient facts about the effect of the interim programs in Maryland. For example, Terry Gardiner in reviewing the small business landscape failed to mention that the current state small business program that offers insurance subsidies has been a failure with less that 1200 lives covered and the number of participating businesses in decline because of rising premiums and cuts in coverage. In this environment without cost controls on insurers, it is unlikely that the new federal tax deduction for health insurance premiums that is now available to small business will expand the number of small businesses able to cover their employees.

The new temporary federal high-risk insurance pool, which will be run by MHIP (Maryland Health Insurance Program), is going to be small. Maryland gets $85 Million dollars over 3 1/2 years; amounting to less than 10% of MHIP’s budget. While MHIP is open to the uninsured with pre-existing conditions immediately, in order to be eligible for the new federal high-risk pool you must have been uninsured for 6 months first. The conflict between the two programs is clear. MHIP has remained small, 18,000 members, because the premiums are often unaffordable.

Maryland Medical Assistance (Medicaid) has been the pride of incremental reformers because enrollment has increased; for three reasons – tax returns are being used to inform parents that there children are eligible for Medicaid, the Maryland Medicaid expansion (starting July 2008) that I already mentioned and the great recession which nationally has produced the largest increase in Medicaid enrollment of any economic downturn. Because of the American Reinvestment and Recovery Act (the Obama Stimulus) and fortuitous timing, Maryland has financed much of the Medicaid expansion with the additional $1 billion dollars it received from the federal government starting in mid-2008. There is a temporary increase in the federal medicaid match from 50% to 61.65% that runs out 12/31/2010; unless congress extends it. But in spite of this, the North Carolina Institute of Medicine has estimated that even with the Medicaid expansion, the overall number of uninsured in Maryland has increased since the downturn in the economy.

Some irritations of omission at the conference:

One of the questioners asked about the supply crisis of primary care providers, the answer was that things had worked out better than expected in Massachusetts when they set up an exchange because most people could identify a medical home. No mention of the poll showing that people in Massachusetts were still having difficulty actually getting to see a provider.

When discussing the exchange it was mentioned that because of no pre-existing conditions insurers could not base premiums on health status when the exchange goes into effect in 2014; what was not mentioned is that they can increase premiums up to 400% based on age. Further, insurers find other ways to avoid those with pre-existing conditions by limiting networks and covered services.

Hopefully, the Congress will continue the increased Medicaid match or the state could be facing a $380 Million Dollar hole in the budget which will inevitably lead to cut backs in the Medicaid program – this can only be done with a waiver from HHS. If you write your congressman to ask for a continuation of the increase federal Medicaid match; you could also mention that we could save over $300 Million dollars by eliminating Health Choice (the private part of Medicaid) and expanding the publicly administered part of Medicaid; that represents the difference in administrative costs and profits between the two programs.

Eric Naumburg, M.D., M.P.H.
enaumburg@hotmail.com
Howard County Healthcare-Now
Physicians for a National Health Program

Write Congress

Please write to your elected representative in the U.S. House of Representatives to urge them to support two amendments to the health care bill: (1) The Weiner Amendment which would substitute a single payer system based on HR 676 which has 86 co-sponsors. This bill will be submitted on the Floor of the U.S. House of Representatives in September or October. (2) The Kucinich Amendment which would make it easier for state’s to enact their own single payer legislation. This amendment was included in HR 3200 but there are efforts to have it removed.

In order to send the letter go here.

This will bring you to a draft letter which you can send, edit or modify.

Speakers

As dust settles on so-called Healthcare reform in 2009, now more than ever the word about single-payer needs to reach the citizens of Maryland. Healthcare-Now of Maryland provides speakers for groups anywhere within the state—community associations, union locals, religious organizations, etc. Our speakers include activists and doctors and healthcare workers. For more information or to schedule a speaker, email info@mdsinglepayer.org.

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