Exploring Human Potential

How Medicaid Is Socializing and Polularizing Single Payer Approaches To Population Health.

Posted on | July 25, 2017 | 2 Comments

 Mike Magee

As the Republican controlled Senate prepares for a ballot today to vote on a bill yet to be identified, their governor counterparts in 31 of our 50 states are fast at work familiarizing themselves and socializing themselves to a new way of managing the health of populations within their geographic boundaries – single payer systems.

Despite the attempt to brand the term “single payer” the way that Medicare was attacked a half century ago as big government “socialized medicine”, the majority of governors has tacitly acknowledged what Warren Buffett described as a health care status quo that is “the tapeworm of American economic competitiveness”. The decline of state economies reinforced by the burden of weak social systems, challenged and undermined by a raging opioid epidemic, have caused Republican governors like John Kasich to declare independence when it comes to health policy.

Way back in 1965, when Canada endorsed a single payer approach for all Canadians, Americans did the same – but only for those over 65. We called it Medicare, and while it has had issues over the past half century, Americans long ago decided they couldn’t live without it. Of course, until now, they also consented to widening income disparity and health inequality based on a system of “have’s” and “have-not’s” when it comes to the good fortune (or lack of the same) of possessing health insurance.

President Obama’s federal subsidization of an expanded Medicaid with broader eligibilty and more generous coverage and protections hit the sweet spot with all but the reddest of red state governors. Those hold-out’s were literally willing to financially cut off their noses to spite their faces. For others like Kasich who were willing to give President Obama a chance, they liked the way it felt to actually lead and so did the citizens in their communities.

Medicaid celebrated a new approach (within the corridors of defined eligibily) of universality, access, health planning, portability, and integration with other social service programming. Participating governors liked the fact that the program was well funded, that the benefit package was broad (not a sham like the HSA induced high deductible/ empty benefit products proliferating everywhere), and that they preserved the flexibility within bounds to set the priorities on spending and defined how best to advance the overall health of their state populations.

The governors learned that centralized administration of a universally available health insurance offering carried distinct cost savings. Specifically, governor guided single payer health delivery under Medicaid came in 22% less costly than privately insured comparators. Governors like Kasich were left to wonder what might be the economic impact on Buffett’s “tapeworm” were their lessons to be applied across our entire population – single payer back office administration combined with state controlled and planned integrated health delivery. They read the studies that showed a potential immediate 15% savings on our 4 trillion plus annual bill simply by consolidating management of a universal coverage approach in a central systematized fashion.

Governors also could see that the human resource implications of such a move. Our purposefully complex program, which now threatens to break the American economy in much the same manner as reckless military spending collapsed the Soviet Union, has spawned 16 non-clinical jobs in health care for every one clinical role. A shift to single payer, poorly planned and transitioned, could carry with it massive unemployment. But if you look at innovators like Kasich, what you see is active reassignment of jobs by skill in a manner that advances the public good. The governor well understands that the U.S. is the only civilized nation in the world where more is spent on the mechanics of disease fighting than on all social services combined – the very combination of services and supports that help keep a population well. With flexibility, as wildly expensive nursing home use declines, those employees, now mobile, are an immediately useful and experienced mobile home services health corps. Given room for innovation, as they have been under the ACA, governors have applied both innovation and structural remodeling to expand safety, security, and health across multi-generational families.

The Medicaid single payer experiment has been large scale. Under the direction of autonomous state leaders, 77 million have received care of late with extraordinary high satisfaction levels. 34 million of these citizens are children. 2 million new citizens will be ushered into the human race this year through Medicaid prenatal and obstetric coverage. 9 million blind and disabled citizens sleep easier each night thanks to the governors. By 2026, absent Trumpcare regression, the 77 million will grow to 86 million with 35 million children in the ranks. Nearly a third of the states structure offerings through a managed care approach. All integrate physical and mental health, including addiction services.

Governors like Kasich have turned a critical eye toward waste. For example, Medicaid has historically been the primary payer of long term care – specifically nursing homes. Over decades, perverse incentives have created a lawyer and nursing home industry driven cottage industry designed to divest seniors of their assets so that they could reach eligibility requirements to have free nursing home care. Nearly half of all spending  for long term care in the US – over $150 billion a year – comes from Medicaid. Flexibility provided to governors like Kasich could allow the realignment of financial incentives with funds provided for home services to multi-generational families who do right by their seniors rather than abandon or warehouse them.

Innovative programs like Money Follows the Person or The Program of All-Inclusive Care for the Elderly (PACE) should not be confused with the Senate Republicans offerings. Their caps have little if anything to do with innovation and more to do with transferring some $800 billion over the next 10 years from the neediest to the wealthiest Americans in the form of tax cuts.

Trump and his followers may be intent on creating chaos, promoting regressive legislation, and reimagining reality, but governors in most states are laser focused on solutions – and the more they experience single payer efficiency, control, and integrated health planning, the more they and their citizens like it.


Doctor Senators Barrasso and Price – They Are No Royal Copeland.

Posted on | July 14, 2017 | No Comments

Sen. Royal Copeland M.D. (D, NY)

Mike Magee

This week the Republican leadership once again released an unapologetically regressive plan for America’s healthcare that would drive a further wedge between rich and poor and sow despair deep into America’s soul. Sadly, two of the primary leaders of the effort are fellow physicians, Sen. John Barrasso (R,WY) and former Sen. Tom Price (R, GA). This in the same week that we learn that America’s childhood go-to staple, Kraft boxed Mac & Cheese, has been laced with endocrine disrupting phthalates all along and no one seems to have noticed.

Barrasso and Price stand in steep contrast to other historic physician legislators. For example, in 1932, with FDR fully in charge and the New Deal gaining momentum, Walter Campbell, the director of the FDA, and the Assistant Secretary of Agriculture, Rexford Tugwell, put a proposal in front of FDR to strengthen the enforcement powers of the 1906 FDA law. Their ally in Congress was a physician and former New York City Commissioner of Health, now senator from New York, Royal S. Copeland M.D..

Copeland gave it his all, but it was an exercise in futility. To begin with, he was opposed by a wide range of interests from food to drug manufacturers to cosmetic makers. But more importantly, the newspaper and magazine publishers viewed “over-regulation” of this free wielding American sector as an existential threat to them. After all, the advertising dollars spent by every Tom, Dick and Harry with a “miracle cure” were considerable. And that was without counting the food manufacturers whose wallets were wide open as they worked to establish their various national brands. To these publishers, tighter health controls meant tighter marketing budgets. To make matters worse, the Copeland supported legislation would involve itself in regulating the murky area of “false advertising”, and “who knows where that could end”.

But the truth is that at the time the various commercial interests were not too worried about the FDA’s Walter Campbell, or his boss in Agriculture, Rexford Tugwell, or even the Senate’s Royal Copeland. Health legislation was low on the list of priorities in FDR’s New Deal. It was going nowhere fast – that is, until October 11, 1937. That was the day that the American Medical Association was informed by one of its physicians that a number of children in Tulsa, Oklahoma had taken a new sulfanilamide liquid medicine and died.

AMA labs quickly identified the killing agent as diethylene glycol used as a mixing agent in the elixir of sulfanilamide produced by S.E. Massengill and Co. in Bristol, Tennessee. The mix had passed the taste test of the company’s chief chemist, but he had somehow missed that diethylene glycol was a known poison used in anti-freeze. At the time, no safety tests were required before release of medicines on our citizenry.

“Elixir Sulfanilamide” was rushed into production and distributed widely. 240 gallons of the red liquid made it’s way to 31 states, through a web-like network with many small distributors. That was in early September, 1937. In all, over the next 6 weeks 100 children died. And their deaths were not simple. They were proceeded by 7 to 21 days of wrenching painful illness including “stoppage of urine, severe abdominal pain, nausea, vomiting, stupor, and convulsions”.

One young mother spoke for everyone affected in her 1937 letter to FDR:

“The first time I ever had occasion to call in a doctor for [Joan] and she was given Elixir of Sulfanilamide. All that is left to us is the caring for her little grave. Even the memory of her is mixed with sorrow for we can see her little body tossing to and fro and hear that little voice screaming with pain and it seems as though it would drive me insane. … It is my plea that you will take steps to prevent such sales of drugs that will take little lives and leave such suffering behind and such a bleak outlook on the future as I have tonight.”

Doctors, in a manner reminiscent of contemporary physicians who carelessly over-prescribed Oxycontin and ignited the current Opioid Epidemic, were remorseful as well. Consider Dr. Archie Calhoun, of Mount Olive, Mississippi, who wrote on October 22, 1937:

“Nobody but Almighty God and I can know what I have been through these past few days. I have been familiar with death in the years since I received my M.D. from Tulane University School of Medicine with the rest of my class of 1911. Covington County has been my home. I have practiced here for years. Any doctor who has practiced more than a quarter of a century has seen his share of death. But to realize that six human beings, all of them my patients, one of them my best friend, are dead because they took medicine that I prescribed for them innocently, and to realize that that medicine which I had used for years in such cases suddenly had become a deadly poison in its newest and most modern form, as recommended by a great and reputable pharmaceutical firm in Tennessee: well, that realization has given me such days and nights of mental and spiritual agony as I did not believe a human being could undergo and survive. I have known hours when death for me would be a welcome relief from this agony.”

The whole disaster was vigorously reported in the press, including the powerful New York media, home state of FDR, Chief Justice Hughes and Royal Copeland. It was a New York physician, learning of the AMA’s involvement on October 14, 1937, who first had contacted Walter Campbell at the FDA and got the policy ball rolling. As a result of the tragedy, the issue was now a New Deal priority and on everyone’s radar screen. Copeland and Campbell teamed up on legislation.

The AMA, the American Pharmaceutical Association, women’s groups and the national press all closed ranks in support. It didn’t hurt that the main Congressional opponent of Royal Copeland’s legislation was Representative Carroll Reece from Tennessee, home state of the S.E. Massengill Company. Copeland harnessed the power of the media writing an impassioned editorial in Scientific American where he detailed the deficiencies of the 1906 law.

On November 16, 1937, Senator Copeland formally addressed the tragedy on the Senate floor and asked the Department of Agriculture, which had jurisdiction over the FDA, to issue a formal investigative report on the tragedy.  Over the next six months he worked tirelessly on corrective legislation. By June 11, 1938, bills from the Senate and House of Representatives had been reconciled, and on June 25, 1938, FDR signed into law the 1938 Federal Food, Drug, and Cosmetic Act.

A Nation At Risk This 4th of July!

Posted on | July 2, 2017 | No Comments

SOURCE: Decline in State/County GPA from Global Warming

The fact that the US is the only developed nation in the world that spends more on Health Care than all other Social Services combined according to a 2015 Commonwealth Fund study is a remarkably regressive achievement. Besides reflecting our distorted financial and ethical priorities, and the natural end point of a profit-driven free enterprise health care system, it also defines our nation’s vulnerability.

There is growing realization that our inability to come to grips with a decision way back in 1947 to throw our weight behind private profiteering health insurance has the potential to soon crowd out all other US priorities and collapse our economy. A simple shift to consolidate back room insurance functions (not the management or delivery of care) could trim 15% off the US health care bill immediately. But more than this, it would allow us to develop for the first time an integrated plan to assure a more healthy America.

Under such a plan, medical schools would integrate social mission into health professional education as Fitzhugh Mullen recently suggested. Also regressive policies such as those proposed by Trump EPA chief Scott Pruit would be exposed for what they are – economically dangerous and ethically disastrous.

As we wait for the US populace to catch up with this administration (in much the same way as 1970 America’s Nixon supporters took 19 months to finally come to grips with the fact that their President was simply not well enough to manage the duties of Presidency), we all need to continue to expose the truth in words and graphics.

Paul Voosen, Earth and Planetary Science journalist for Science magazine does his part in the June 30, 2017 issue of Science. The graphic above depicts the loss in state and county GDP as a result of the predicted impact of global warming under the current regime. It mirrors in part the human carnage of the opioid epidemic, and the supreme irony that Trump’s loyalest supporters are those most at risk as a result of his regressive policies.

As Frank Rich encourages in this week’s New York magazine cover story, “How A Presidency Ends”, it is highly likely that Trump will come to the same end as Nixon. But only if patriotic Americans continue to doggedly and respectfully pursue, display and share the truth in red, white and blue.

Happy July 4th!

The Secret To Making America Healthy – K.I.S.S.

Posted on | June 26, 2017 | 2 Comments

Mike Magee

As the debate over health care in America rages anew this week, the great lie oft repeated but never defended is that our system is too complex to wrestle to the ground. That is the lie, reinforced over half a century, that has left our citizens and now our entire economy at risk. The truth is, the solution is rather clear, the resources available, and the liability of continued inaction of mounting concern.

How do we make America healthy? Before we address this critical baseline question, let’s first tackle another, “Why should we make America healthy?” The answer to this question could go on for pages but the short-hand response is that healthy citizens maximize human productivity and societal stability. If the idea is to make America as great as it can be, then healthy citizens are the starting point.

So, how do we make America (and Americans) healthy? Whatever we decide to create and provide in pursuit of this fundamental goal, it must be universally available to all citizens. This is because we are an inter-dependent species. We are only as well, or as productive, effective and mutually supportive as the weakest link in our chain. Insecurity breeds insecurity. Fear and dislocation breeds fear and dislocation. Despair undermines our collective futures. So whatever we offer to promote and assure a healthy America must be available at the outset, and with certainty and simplicity, to each and every one of our citizens.

Logic dictates that the execution and management of this offering should be designed to consume as few resources as is humanly possible. The more we consume in the offering and financial management of universal basic health coverage the less will remain for actual services. This simple reality is why most nations have centralized the primary back room functionings of health coverage and financial administration. Where most industrial nations (and our own Medicare) consume 5% to 10% of total health resources on this first step, our complex free-enterprise and employer dependent approach to the offering consumes as much as  25% of total resources while failing to ensure universal coverage.

If all must be covered, and the administration of the offering must be a public and centralized responsibility to assure accountability, uniformity, and cost-effectiveness, that leaves the definition of services and the actual delivery of services. These need not, and some would argue should not, be centralized. A basic package of services should be required of all, and not all services are affordable or even desirable. For example, Canadians universal health plan covers on average 70% of the total cost of health care for Canadians. The plan does not cover pharmaceuticals, optical needs or dentistry. Citizens who wish to can purchase private supplemental plans to cover these costs. Furthermore, plans total offerings vary from province to province, as defined by budgets and priorities set by provincial governments year to year. Hospitals are funded by the provinces, and doctors (who on average make more than American doctors) are largely reimbursed fee-for-service. Ample leeway, state to state, as we see with Medicaid, could be offered to allow a reasonable amount of experimentation and choice.

This combination of central control and management of insurance coverage and local responsibility for budgeting, prioritization, and quality assurance has consistently outperformed America’s purposefully complex free-enterprise health sector free-for-all for over a half century. Our approach underperforms by almost every health measure, costs nearly twice as much, and has patient satisfaction ratings of only 25% in the latest polls. We have paid dearly for our complexity in funding an astonishing array of “non-real work”. For example, we support nearly a half million individuals selling and managing health insurance in the US, and and equal number of hospital and physician office coders and billers on the other side working diligently to get payments out of  the mostly for-profit insurance companies.

Vannevar Bush

But our fundamental error or conceit dates backs to 1947, as we exited WWII and considered how best to manage an enormous chronic burden of disease. Lead by Vannevar Bush, whose military approach to scientific collaboration had provided new blood products, penicillin, and the atomic bomb, our leaders concluded that a similar unencumbered collaborative free-enterprise approach could defeat disease as it had defeated the Nazis. By omission, their definition of health was the absence of disease. Defeat disease and health would be left in its wake. Fund the effort on the backs of employers and unions as a benefit, and ignite collaboration and a collusive integrated career path with federal dollars and enabling patent legislation and victory was assured.

In contrast, Canada took the time to earnestly ask “How do we make Canada (and all Canadians) healthy?” In response, they created universal coverage and continuously refined their answer to this basic question. By 2010, prevention, not intervention, surfaced as mission central. They stated then that “Health promotion is everyone’s business. While it is clear that health services are a determinant of health, they are just one among many. Others include: environmental, social and economic conditions; access to education; the quality of the places where people live, learn, work and play; and community resilience and capacity.”

It really matters little whether Republicans prevail in their regressive efforts to reinforce over a half century of failed health care policy. The die has been cast. As Warren Buffett recently stated,  “Medical costs are the tapeworm of American economic competitiveness.” The cost and inefficiencies have been well documented including:  High administrative costs with 850 health insurance companies selling to millions of employers; high costs passed on to employees in rising contributions and lost wages with the burden weighing more heavily on low income employees; employees of small firms and the unemployed/underemployed left out of coverage; employment based insurance the major contributor to bankruptcies and poor labor relations; and finally a coverage system that discourages worker mobility and advancement. Together, these fatal flaws in a single sector of our society are bringing us to our economic knees.

Whether now or in the future, we will be forced to ask that simple question, “How do we make America (and Americans) healthy?” In responding, we will not be limited by resources. More than ample resources, currently misapplied, have already been dedicated to these services. We need only to recognize that health is not the absence of disease, and mirror Canada’s 2005 proclamation: “As a nation, we aspire to a Canada in which every person is as healthy as they can be—physically, mentally, emotionally and spiritually.”

Do Majority in My State Support Trumpcare? NO!

Posted on | June 16, 2017 | No Comments

State     Oppose AHCA   Support AHCA

DC                  70%                             16%

MA                  59%                             22%

HI                   59%                              23%

WA                 59%                              25%

VT                   57%                              23%

CT                   57%                               24%

MD                 56%                               24%

OR                  56%                              29%

IL                    55%                              25%

CA                  54%                              26%

NY                  54%                              28%

RI                    54%                              23%

WI                  54%                              29%

CO                  53%                              24%

NV                  53%                              28%

IA                   53%                              27%

VA                  52%                              30%

MN                 52%                              27%

KA                  51%                               31%

NJ                   51%                              30%

OH                  51%                              29%

MT                  50%                             26%

MO                 50%                             32%

NC                  50%                             30%

DE                   49%                              27%

AL                   49%                              29%

TX                   49%                              34%

PA                   49%                              30%

MC                  49%                              27%

NH                  49%                               27%

ME                  49%                               30%

NM                  49%                              29%

UT                   48%                               29%

NB                   48%                               34%

SD                    48%                               33%

FL                    48%                               35%

GA                    48%                              30%

ND                    47%                               31%

SC                     47%                               32%

IN                     47%                                31%

MI                    46%                                30%

LA                  46%                                   28%

WY                 46%                                   34%

AZ:                 45%                                   31%

OK:                45%                                   38%

AL:                 43%                                   33%

ID:                 43%                                   30%

KY:                41%                                    33%

AR:                40%                                   32%

TN:                40%                                   35%

WV:               40%                                   36%

Warren Buffett and Charlie Munger: Employer Health Care Not Taxes Is the Problem.

Posted on | June 14, 2017 | No Comments

Buffett and Munger

Mike Magee

This week the Wall Street Journal editorial page couldn’t help itself. They let loose with a snarky piece titled “California Single-Payer Dreaming” and front-ended their conclusion with the words, “This proves the truism that the liberal solution to every government failure is always more government.” For good measure, they added, “This bill reflects the left’s Platonic ideal, with the promise of free care for everyone for everything.”

The editorial cites a California Senate committee price tag of $400 billion, with a Federal contribution of $200 billion as an offset. But an independent University of  Massachusetts/Amherst study released this week pegged the cost at $331 billion and potential Federal offsets of $225 billion. As important the study predicted that moving to single payer simplicity would cut the state’s health care costs by a whopping 18%, and decrease middle class patients cost 9%, and low-income resident costs 5%.

Just about a month ago, the Oracle of Omaha, Democrat Warren Buffett, and his life long sidekick, Republican Charlie Munger, provided a full-throated financial defense of single-payer. Andrew Ross Sorkin who got the scoop summed it up this way when comparing the value of tax reform legislation compared to health care reform: “As Mr. Buffett pointed out, these chief executives are missing the bigger issue — the one that should be their Holy Grail. As a percentage of our gross domestic product, the cost of maintaining our American health care system — hospitals, H.M.O.s, doctor visits, prescription drugs, medical devices, insurance companies, Medicare, Medicaid — is rising at an alarming rate. And Corporate America pays a big (and growing) chunk of the bill.”

Buffett put numbers to his argument. He said, “If you go back to 1960 or thereabouts, corporate taxes were about 4 percent of G.D.P. I mean, they bounced around some. And now, they’re about 2 percent of G.D.P…health care was 5 percent of G.D.P., and now it’s about 17 percent…When American business talks about strangling our competitiveness, or that sort of thing, they’re talking about something that as a percentage of G.D.P. has gone down, while medical costs, which are borne to a great extent by business” are on a steep rise.  “Medical costs are the tapeworm of American economic competitiveness.”

His friend Charlie agrees, pointing out that a corporate tax break won’t change operations in any of the Berkshire Hathaway companies. “We’re not going to change anything at the railroad just for some little tax jiggle.” As for health care politics, Charlie says, “On this issue, both parties hate each other so much that neither one can think rationally, and I don’t think that helps, either.”

Easily lost in the debate are the numerous flaws in employer based health care that were laid out in a Health Affairs article over a decade ago. They include:

1. High administrative costs with 850 health insurance companies selling to millions of employers.

2. These high cost are passed on to employees in rising contributions and lost wages. This burden weighs more heavily on low income employees.

3. Many employees of small firms and the unemployed/underemployed are left out of coverage.

4. Employment based insurance is a major contributor to bankruptcies and poor labor relations. Plus, this system discourages worker mobility and advancement.

5. Many CEO’s know nothing about health care and delegate decisions to consultants and favored local agents who are ripping them off.

Way back in 2006, Stanford’s Alain Enthoven and Victor Fuchs wrote, “In the long term, we think that the likely and most desirable outcome is replacement of job-based insurance with some form of universal health insurance that encompasses choice, competition, and technology assessment to revitalize social insurance while making care more cost-effective.”

Back then then noted the lack of political will to address the status-quo, but also said, “But some external traumatic event…could trigger a political upheaval that would increase support for universal health insurance and force a compromise among alternative proposals.”

Trump may be that event.

How To Defeat Donald Trump in 2018 and 2020.

Posted on | June 7, 2017 | 2 Comments

Mike Magee

It is still early, but I believe Trump may survive immediate impeachment, though a number of his loyal followers may not be so fortunate. This means that those who oppose Trump – both Republicans and Democrats – need to be prepared for elections in 2018 and 2020.

After a recent post on the subject of positive leadership, with Trump as a foil, one of my loyal subscribers commented, Mike, after many years of active involvement in health policy through my professional organizations, I am preparing to take the next step and run for the legislature in my state. Your essay on leadership has provided me with an excellent framework for my campaign platform. I couldn’t agree more that now more than ever we must each choose to lead in whatever way we can.”

If we were to commit from both sides of the aisle to the bipartisan defeat of Trump and his unwavering supporters,  I would suggest that local, state and national leaders embrace and include the following ten points in their election platforms.

1. We have a President who is brazenly and unapologetically regressive.

2. His self-propelled rise advantaged change and magnified fear in a segment of our population.

3. President Trump is a negative leader who embraces fear and uses it as a currency to mobilize and organize populations and achieve short-term regressive goals. 

4. Negative leaders retrench and divide; positive leaders connect across the divide.  Negative leaders segregate; positive leaders aggregate. Negative leaders build walls.  Positive leaders built islands of common stewardship.

5. I am a positive leader. That is why I oppose Donald Trump and his supporters.

6. I believe in pursuing common ground based on openness, inclusiveness, cultural sensitivity, justice, opportunity for all, goodness and fairness.

7. I believe in shared values and a unified vision for the future that includes lifelong learning, new technologies, curiosity, introspection and an active social conscience.

8. As your leader, I will support formative relationships, that is, as I care for you, you will continue to form me as a human being. 

9. I am committed to the success of you, your family, your friends and your community thru cooperative productivity. We will help each other succeed.

10. Together, we will combat Trumpian fear. I commit to:

         a) advancing positive leaders who lead with vision, not fear.

         b) never remaining silent in the face of evil or injustice.

         c) persisting and enduring – I will never give up on you, and hope you will never give up on me.

         d) pursuing balanced success marked by happiness, relationships, and a stubborn adherence to the highest human values.

         e) promoting faith in a higher power, not as a last resort, but as a beacon of goodness, resilience and strength.

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