Archivi delle etichette: million medicare beneficiaries

Interesting US report on healthcare payment reform from UnitedHealth Group @Medici_Manager @helenbevan


A “Real World” Strategy For Health Care Payment Reform

Qualche spunto interessante anche per il SSN italiano?


Brandeis professor traces efforts to reshape health care @Medici_Manager @DonaldsonLiam


When President Nixon wanted to overhaul the health care system to provide universal coverage, his administration turned to Stuart Altman.

Ten years later, when Congress created a commission to improve the Medicare payment system, Altman led the effort. And, in the early ’90s, when newly elected Bill Clinton assembled a team to guide his health care policies, Altman was among the first chosen.

There may be no single person with a longer or deeper history in the health care overhaul efforts of the past 40 years than Altman, a professor of national health policy at Brandeis University in Waltham. He has advised five presidents, both Democratic and Republican; authored countless articles about health policy; and served on a variety of task forces aimed at fixing health care on both the national and state levels.

These four decades as policy maker, adviser, and scholar play a central role in Altman’s new book, “Power, Politics, and Universal Health Care,’’ which traces 100 years of debate and confrontation over one of the nation’s most intractable issues. With President Obama’s health care overhaul under attack from Republicans – and certain to be a defining issue in the November election – Altman and his coauthor, former Brandeis fellow David Shactman, show that today’s controversies have roots in the political and philosophical battles that raged a century ago.

In 1915, for example, the American Association for Labor Legislation, a workers advocacy group, proposed that the US government provide health insurance for low-income workers and their families, similar to programs adopted in Germany and England. Special interests, including the insurance industry and American Medical Association, lined up against the plan. Conservatives, raising alarms about government intervention into the private sector, joined the opposition.

“Opponents claimed that national health insurance was a tool of socialists and communists – rhetoric that still reverberates today in the halls of Congress,’’ Altman and Shactman wrote.

Altman first became involved in health care reform in the early 1970s. He earned his doctorate in economics at the University of California, Los Angeles, where he wrote his dissertation on unemployed married women, then went to teach at Brown University. Former colleagues, working at the US Department of Health, Education, and Welfare during Lyndon B. Johnson’s administration, recruited him to study the supply of registered nurses in the workforce.

When Nixon was elected president, Altman stuck around. Although a Republican, Nixon was eager to propose a universal health care plan to compete with more far-reaching alternatives pushed by liberals such as Massachusetts Senator Edward M. Kennedy. Altman was asked to examine policy options. “I was sort of thrust into it,’’ Altman said.

The challenges he confronted – ballooning health care costs and high numbers of uninsured – were “the exact problems we have today,’’ he said. Watergate intervened before the administration’s proposal got very far, and Altman returned to teaching, at Brandeis, after Nixon resigned. But his involvement in policy making was far from over.

From 1984 to 1996, Altman chaired the congressional Prospective Payment Assessment Commission, an independent panel created to oversee Medicare payments to hospitals to help control health care costs. He worked on Clinton’s transition team, only to see his recommendations to build on the existing system rejected in favor of a more sweeping plan that died in Congress.

Altman later served on the Commission on the Future of Medicare during Clinton’s administration, and advised Obama on health policy during the 2008 campaign. Altman conceived the idea for his book during the early debates over Obama’s health care proposals. Ultimately, Obama got his overhaul passed without a single Republican vote.

Altman wanted to explore why health care has proven such a difficult, divisive issue, and why so many attempts to make it more available and affordable did not succeed. Franklin D. Roosevelt, Harry S. Truman, John F. Kennedy, Nixon, Clinton, and any number of lawmakers all failed to push through major proposals.

In fact, Altman and Shactman began their book assuming that Obama, too, would fall short. The book’s working title: “Failure Again.’’

Health care reform has been so intractable because it provides a lightning rod for long-running political and philosophical conflicts over the role of government, according to Altman. While the left favors a social safety net, the right fears creeping socialism. Conservatives prefer to let market forces meet health care needs, but liberals distrust the motives of private business. Advocacy groups representing special interests such as doctors, hospitals, and senior citizens fight any proposal that may cost them money, jobs, or influence.

With these opposing forces constantly in play, the history of health care reform is replete with attempts at compromise, but short on success stories.

In 1974, in a church basement near the US Capitol, opposing factions met in secret to craft a deal on universal health care. Among the attendees were Altman, representing the Nixon administration, and an aide to Kennedy, then advocating a single-payer system, similar to those in Europe and Canada.

“It would make a good ending to the story if the secret church meetings in June resulted in a successful compromise, but it was not to be,’’ Altman and Shactman wrote. “Neither side felt they could agree to the concessions necessary to make a deal.’’

At 74, Altman remains immersed in health care policy. He advises lawmakers, administration officials, and nonprofit groups about health care economics. Chris Jennings, a consultant in Washington who worked with Altman in the 1980s and ’90s, said Altman “is still incredibly relevant.’’

“He continues to be viewed as a substantive and intellectual health policy reform expert,’’ said Jennings.

Altman said the Patient Protection and Affordable Care Act, aka Obamacare, will reduce the number of uninsured Americans – if it survives court challenges and repeal efforts. If the law is undone, Altman predicted, the nation faces “the worst of all worlds’’: high numbers of uninsured and soaring medical costs.

Altman has donated to Democratic candidates, but he is more pragmatist than partisan. Incremental, rather than revolutionary, change, he said, is the best approach for improving the complex patchwork of government programs and private coverage that has evolved over the past century.

The insurance industry remains important to the US economy and must be included in overhaul efforts, he said. At the same time, the federal government’s involvement is vital to ensuring that all have access to health care.

“The idea that you can do it without the government is pure nonsense,’’ he said. “People have a legitimate concern with ‘too much government,’ but the question is, where is the balance?’’

Romney Narrows Gap With Obama On Voters’ Trust To Manage Medicare @Medici_Manager @KaiserFamFound

By Phil Galewitz

OCTOBER 31ST, 2012, 12:15 AM

As the race for the White House has tightened, President Barack Obama has seen his advantage on several key health issues narrow significantly among likely voters, according to a Kaiser Family Foundation poll released Wednesday. (KHN is an editorially independent program of the foundation).

Most troublesome for Obama is that, among likely voters, GOP candidate Mitt Romney has pulled nearly even with him on which candidate would do a better job with Medicare — an issue that resonates in battleground states with large elderly populations like Florida and Pennsylvania.  Obama’s advantage on that question has shrunk despite the fact that six in 10 likely voters continue to oppose Romney’s idea of changing Medicare to a premium support system, in which the government would guarantee each senior a fixed amount of money to help them purchase coverage.   Overall, about 46 percent of voters said they prefer Obama on Medicare compared to 41 percent  for Romney, a gap that is not statistically significant. In September, Obama held a 16 point lead on the Medicare question.

Senior voters are even more likely to oppose switching to premium support, but they prefer Romney to Obama on Medicare, 48 percent to 43 percent — also not a statistically significant gap.

While the economy remains voters’ most important issue, the poll found over a third of likely voters polled say the Affordable Care Act and Medicare are “extremely important” to their vote. The law appears to be motivating supporters and opponents of the law about equally.

Obama has also seen his lead among likely voters narrow considerably on questions about Medicaid, lowering health costs and determining the future of the 2010 health care law. On each question, Obama’s lead has narrowed from at least 16 percentage points in September to single digits in October.

On the other hand, Obama’s continues to hold a large advantage on women’s reproductive health choices and services, where he is trusted by 51 percent of likely voters compared to 33 percent for Romney.

The survey of 1,215 adults was conducted Oct. 18-23 and has a margin of error of +/- 3 percentage points. The margin of error for the likely voter subgroup is +/- 4 percentage points

Regardless of the Election Outcomes, Much Hard Work Remains to Protect Patients and Make Care Affordable @Medici_Manager

Mark Graban

I wrote this op-ed back in July, but I think it still holds true today… regardless of the results of the November election, there’s still a lot of hard work that needs to be done to improve healthcare quality and reduce costs (these actually go hand in hand). This work needs to be done locally, but the methods and outcomes need to be shared so every hospital and health system can improve as much as possible.

The original piece:

Even with this week’s Supreme Court ruling that upheld most provisions of the 2010 law, hospitals and health systems around the country will have to continue, if not accelerate, their improvement efforts that started well before the passage of the Patient Protection and Affordable Care Act.  These practical changes, driven by proven systems engineering and management principles, often referred to as “Lean thinking,” will continue making care safer and less expensive, regardless of what happens in our nation’s capital.

For example, Denver Health, the city’s public safety net hospital, has used the Lean methodology, based on the famed Toyota Production System, to reduce costs by more than $135 million since 2006. By getting staff members involved in process improvement projects, quality has improved, as Denver Health ranks first in patient survival rates among academic medical centers.

Outside of hospitals, Group Health Cooperative, a Washington-based health insurer and care provider, will continue its “patient centered medical home” (PCMH) efforts that are reducing costs while improving the quality of care. Better coordination and communication, along with increased preventive care, has led to a 29% reduction in emergency room visits and 6% fewer hospitalizations for these patients.

Group Health reports that the quality of care is higher, patients have better experiences, and fewer clinicians are burned out. With Group Health’s efficiency improvements, the average patient visit is actually longer with PCMH, going from 20 to 30 minutes. Using Lean methods to reduce waste in the clinicians’ day means they can dedicate more time to patient care instead of searching for missing information, equipment, and supplies.

ThedaCare, a five-hospital health system in Wisconsin, has radically redesigned many of its emergency care and inpatient processes, for the benefit of patients and payers. For patients with chest pain, the “door to balloon” time (from arrival at the emergency room to the clearing of a heart blockage) fell from 90 minutes to just 37 minutes, meaning less heart damage and faster, less-expensive recoveries.

For patients who are admitted, satisfaction increased from 68% to 90% with ThedaCare’s new “collaborative care” hospital methodology, where physicians, nurses, and pharmacists work as a team with a single integrated plan for a patient’s care. The health system has achieved impressive improvements for cardiac bypass surgery patients – reducing post-operative mortality and length of stay, which leads to about 30% lower costs.

ThedaCare has also reduced the average neonatal intensive care unit stay from 30 day to just 16, through better pre-natal care and the more careful scheduling of cesarean births. These improvements clearly benefit mothers and babies and costs for the healthcare system, broadly defined, are reduced greatly.  However, due to the current structure of our healthcare payment system, the savings generated by the hard work of ThedaCare’s employees and leaders are captured by the payers – both private and public.

Organizations like Group Health are somewhat unique in that they benefit financially by keeping patients healthy and out of the hospital. They are both the payer and provider of care, so savings in one part of the organization benefits the other. Leading healthcare providers, like ThedaCare, often find their revenue is lower as the result of shorter hospital stays and improved patient care. Even non-profits, like all three organizations cited here, need to have a positive financial return to be able to invest in their futures.

Hospitals and health systems are highly motivated by their mission and their patients’ needs. Future reform efforts need to go beyond ensuring coverage. They must focus on ensuring health systems can be rewarded financially, or at least not be harmed, for doing the right thing – including keeping patients healthy and reducing errors and infections.

ABOUT MARK GRABAN Mark Graban is the author of the Shingo Award-winning book Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement and the new book Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements. He is also the founder and Chief Improvement Officer of KaiNexus, a software startup. With a background in engineering and manufacturing, Graban has worked exclusively in healthcare since 2005 where he applies “lean” and Toyota Production System principles to improve quality of care and patient safety, to improve the customer/patient experience, to help the development of medical professionals and employees, and to help build strong organizations for the long term. For more information, please

Candidates Talk Medicaid In Washington Governor’s Race @Medici_Manager

By Ruby de Luna, KUOW

OCT 25, 2012 

This story is part of a reporting partnership that includes KUOWNPR and Kaiser Health News.

Medicaid – and how to expand the program – has become an issue in the competitive governor’s race in Washington State.

In June, the U.S. Supreme Court ruled that the Affordable Care Act went too far by requiring states to expand Medicaid or else lose all federal funding for the program that covers the poor and disabled.

The ruling left it up to states to decide whether or not to open up the program to cover more low-income people without insurance.  In Washington State, Chris Gregoire, the current Democratic governor, chose to continue with plans for expansion.  But Gregoire is not seeking reelection, and whoever is elected governor this fall could change that course.

Inslee (Photo by Ronald Woan via Flickr)

The issue is playing out in an extremely tight racepitting Democrat Jay Inslee, an eight-term congressman from Seattle, against Republican Rob McKenna, the attorney general.Inslee voted for the health law in Congress and he would follow Gregoire’s lead, expanding Medicaid as mandated by the Affordable Care Act. McKenna says he’s for expansion, but with restrictions. For example, he’d like to require current as well as new Medicaid beneficiaries to share costs.

“We’re only one of the few states where there’s not even a $5 co-pay… what we’re saying is that everyone has to have some financial skin in the game, even just a little bit,” McKenna said.

Currently more than 1.2 million Washington residents get health coverage through Medicaid.  Enrollment to the program has gone up since 2008. The state restricts Medicaid to low income children and their parents, people with disabilities, and the elderly.

After expansion, the program will open up to include adults without children.  And eligibility will be based on income. For a single person, that threshold is just under $15,000 in annual income.  For a family of four, it’s $30,657.

McKenna (Photo by KCTS 9 via Flickr)

McKenna’s position is not a standard issue Republican stance. He doesn’t support the reform plan put forward by the Republican presidential ticket of Mitt Romney and Paul Ryan.  As Washington Attorney General, McKenna joined the lawsuit that challenged the Affordable Care Act, but only the part of the lawsuit that opposed the mandate that most individuals must buy insurance.

The Supreme Court rejected that argument, but  McKenna says the Medicaid portion of the ruling gives states some leverage to negotiate with the feds on how to run the program.

Early projections found that about 500,000 Washington residents would qualify under the expanded program, and roughly half of them would enroll.

McKenna wants Medicaid to be maintained as a safety net.  But he fears that many employers will stop providing health insurance for their lower wage employees and those people will end up on Medicaid. He wants more flexibility from the federal government to keep that from happening.

“Our goal needs to be keeping as many people on private coverage as much as possible, and not moving as many people as possible on to Medicaid.”

Inslee says the expansion will help people without insurance, but there are fiscal benefits for the state as a whole, too, because right now everyone bears the cost for those who don’t have health coverage.

“We know that when people do not have insurance, they get their health care in one place, and that’s the emergency room,” Inslee said. “Instead of getting routine treatment for the flu, their asthma, or whatever, from a primary care doctor, they go into the emergency room.  And that costs four to five times more money to have the same treatment in the emergency room.  And you know who it costs—it costs you and me.”

Inslee says those charges are billed to insurance carriers, and the carriers pass on those costs to consumers.  He also argues that expanding Medicaid is one way to make sure that federal taxes paid by Washington residents are used to help Washington.

“Look, we’re going to pay these taxes one way or another.  This money is going to Washington, D.C. one way or another.  The question is where does it go then—does it go just to Florida and California, or does it come back to the state of Washington by hundreds of millions of dollars?”

If Washington continues with Medicaid expansion, the federal government will pick up 100 percent of the tab for the first three years.  Over time, the federal match tapers to 90 percent by 2020.

This story is part of a reporting partnership that includes KUOW, NPR and Kaiser Health News.

We want to hear from you: Contact Kaiser Health News


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L’endorsement per Barack Obama del New York Times. @Medici_Manager

The economy is slowly recovering from the 2008 meltdown, and the country could suffer another recession if the wrong policies take hold. The United States is embroiled in unstable regions that could easily explode into full-blown disaster. An ideological assault from the right has started to undermine the vital health reform law passed in 2010. Those forces are eroding women’s access to health care, and their right to control their lives. Nearly 50 years after passage of the Civil Rights Act, all Americans’ rights are cheapened by the right wing’s determination to deny marriage benefits to a selected group of us. Astonishingly, even the very right to vote is being challenged.

That is the context for the Nov. 6 election, and as stark as it is, the choice is just as clear.

President Obama has shown a firm commitment to using government to help foster growth. He has formed sensible budget policies that are not dedicated to protecting the powerful, and has worked to save the social safety net to protect the powerless. Mr. Obama has impressive achievements despite the implacable wall of refusal erected by Congressional Republicans so intent on stopping him that they risked pushing the nation into depression, held its credit rating hostage, and hobbled economic recovery.

Mitt Romney, the former governor of Massachusetts, has gotten this far with a guile that allows him to say whatever he thinks an audience wants to hear. But he has tied himself to the ultraconservative forces that control the Republican Party and embraced their policies, including reckless budget cuts and 30-year-old, discredited trickle-down ideas. Voters may still be confused about Mr. Romney’s true identity, but they know the Republican Party, and a Romney administration would reflect its agenda. Mr. Romney’s choice of Representative Paul Ryan as his running mate says volumes about that.

We have criticized individual policy choices that Mr. Obama has made over the last four years, and have been impatient with his unwillingness to throw himself into the political fight. But he has shaken off the hesitancy that cost him the first debate, and he approaches the election clearly ready for the partisan battles that would follow his victory.

We are confident he would challenge the Republicans in the “fiscal cliff” battle even if it meant calling their bluff, letting the Bush tax cuts expire and forcing them to confront the budget sequester they created. Electing Mr. Romney would eliminate any hope of deficit reduction that included increased revenues.

In the poisonous atmosphere of this campaign, it may be easy to overlook Mr. Obama’s many important achievements, including carrying out the economic stimulus, saving the auto industry, improving fuel efficiency standards, and making two very fine Supreme Court appointments.

Health Care

Mr. Obama has achieved the most sweeping health care reforms since the passage of Medicare and Medicaid in 1965. The reform law takes a big step toward universal health coverage, a final piece in the social contract.

It was astonishing that Mr. Obama and the Democrats in Congress were able to get a bill past the Republican opposition. But the Republicans’ propagandistic distortions of the new law helped them wrest back control of the House, and they are determined now to repeal the law.

That would eliminate the many benefits the reform has already brought: allowing children under 26 to stay on their parents’ policies; lower drug costs for people on Medicare who are heavy users of prescription drugs; free immunizations, mammograms and contraceptives; a ban on lifetime limits on insurance payments. Insurance companies cannot deny coverage to children with pre-existing conditions. Starting in 2014, insurers must accept all applicants. Once fully in effect, the new law would start to control health care costs.

Mr. Romney has no plan for covering the uninsured beyond his callous assumption that they will use emergency rooms. He wants to use voucher programs to shift more Medicare costs to beneficiaries and block grants to shift more Medicaid costs to the states.

The Economy

Mr. Obama prevented another Great Depression. The economy was cratering when he took office in January 2009. By that June it was growing, and it has been ever since (although at a rate that disappoints everyone), thanks in large part to interventions Mr. Obama championed, like the $840 billion stimulus bill. Republicans say it failed, but it created and preserved 2.5 million jobs and prevented unemployment from reaching 12 percent. Poverty would have been much worse without the billions spent on Medicaid, food stamps and jobless benefits.

Last year, Mr. Obama introduced a jobs plan that included spending on school renovations, repair projects for roads and bridges, aid to states, and more. It was stymied by Republicans. Contrary to Mr. Romney’s claims, Mr. Obama has done good things for small businesses — like pushing through more tax write-offs for new equipment and temporary tax cuts for hiring the unemployed.The Dodd-Frank financial regulation was an important milestone. It is still a work in progress, but it established the Consumer Financial Protection Bureau, initiated reform of the derivatives market, and imposed higher capital requirements for banks. Mr. Romney wants to repeal it.If re-elected, Mr. Obama would be in position to shape the “grand bargain” that could finally combine stimulus like the jobs bill with long-term deficit reduction that includes letting the high-end Bush-era tax cuts expire. Stimulus should come first, and deficit reduction as the economy strengthens. Mr. Obama has not been as aggressive as we would have liked in addressing the housing crisis, but he has increased efforts in refinancing and loan modifications.Mr. Romney’s economic plan, as much as we know about it, is regressive, relying on big tax cuts and deregulation. That kind of plan was not the answer after the financial crisis, and it will not create broad prosperity.
Foreign Affairs
Mr. Obama and his administration have been resolute in attacking Al Qaeda’s leadership, including the killing of Osama bin Laden. He has ended the war in Iraq. Mr. Romney, however, has said he would have insisted on leaving thousands of American soldiers there. He has surrounded himself with Bush administration neocons who helped to engineer the Iraq war, and adopted their militaristic talk in a way that makes a Romney administration’s foreign policies a frightening prospect.Mr. Obama negotiated a much tougher regime of multilateral economic sanctions on Iran. Mr. Romney likes to say the president was ineffective on Iran, but at the final debate he agreed with Mr. Obama’s policies. Mr. Obama deserves credit for his handling of the Arab Spring. The killing goes on in Syria, but the administration is working to identify and support moderate insurgent forces there. At the last debate, Mr. Romney talked about funneling arms through Saudi Arabia and Qatar, which are funneling arms to jihadist groups.Mr. Obama gathered international backing for airstrikes during the Libyan uprising, and kept American military forces in a background role. It was smart policy.In the broadest terms, he introduced a measure of military restraint after the Bush years and helped repair America’s badly damaged reputation in many countries from the low levels to which it had sunk by 2008.The Supreme CourtThe future of the nation’s highest court hangs in the balance in this election — and along with it, reproductive freedom for American women and voting rights for all, to name just two issues. Whoever is president after the election will make at least one appointment to the court, and many more to federal appeals courts and district courts.Mr. Obama, who appointed the impressive Justices Elena Kagan and Sonia Sotomayor, understands how severely damaging conservative activism has been in areas like campaign spending. He would appoint justices and judges who understand that landmarks of equality like the Voting Rights Act must be defended against the steady attack from the right.

Mr. Romney’s campaign Web site says he will “nominate judges in the mold of Chief Justice Roberts and Justices Scalia, Thomas and Alito,” among the most conservative justices in the past 75 years. There is no doubt that he would appoint justices who would seek to overturn Roe v. Wade.
Civil Rights
The extraordinary fact of Mr. Obama’s 2008 election did not usher in a new post-racial era. In fact, the steady undercurrent of racism in national politics is truly disturbing. Mr. Obama, however, has reversed Bush administration policies that chipped away at minorities’ voting rights and has fought laws, like the ones in Arizona, that seek to turn undocumented immigrants into a class of criminals.The military’s odious “don’t ask, don’t tell” rule was finally legislated out of existence, under the Obama administration’s leadership. There are still big hurdles to equality to be brought down, including the Defense of Marriage Act, the outrageous federal law that undermines the rights of gay men and lesbians, even in states that recognize those rights.Though it took Mr. Obama some time to do it, he overcame his hesitation about same-sex marriage and declared his support. That support has helped spur marriage-equality movements around the country. His Justice Department has also stopped defending the Defense of Marriage Act against constitutional challenges.Mr. Romney opposes same-sex marriage and supports the federal act, which not only denies federal benefits and recognition to same-sex couples but allows states to ignore marriages made in other states. His campaign declared that Mr. Romney would not object if states also banned adoption by same-sex couples and restricted their rights to hospital visitation and other privileges.Mr. Romney has been careful to avoid the efforts of some Republicans to criminalize abortion even in the case of women who had been raped, including by family members. He says he is not opposed to contraception, but he has promised to deny federal money to Planned Parenthood, on which millions of women depend for family planning.For these and many other reasons, we enthusiastically endorse President Barack Obama for a second term, and express the hope that his victory will be accompanied by a new Congress willing to work for policies that Americans need.

Fact and fiction in the US election healthcare debate @Medici_Manager

Interessante puntualizzazione di Michael McCarthy sul BMJ!

Why Romney or Obama might deliver the opposite of what you’d expect @HarvardBiz @Medici_Manager

Ecco come funziona l’informazione e la discussione su grandi temi politici nei paesi civili!

Possiamo chiedere ai nostri candidati alle prossime elezioni politiche, e ai giornalisti che li intervistano,  di farci sapere che cosa si impegnano a fare per il nostro Servizio Sanitario Nazionale?

Vote for the Guy You Disagree With

by Justin Fox  |  11:00 AM September 6, 2012

There’s a case to be made (and, in fact, it has been made) that, if what you think the U.S. economy needs is more fiscal and monetary stimulus, you should vote for Mitt Romney and Paul Ryan in November (or, if you’re not a U.S. citizen, pray for a Romney/Ryan victory). This is despite the fact that Romney and Ryan say they’re against fiscal stimulus, and the Republican Party platform calls for a return to the gold standard (the opposite of monetary stimulus). The reasoning is pretty simple: the likely Republican majority in the House and the possible Republican majority in the Senate will work against any attempt by President Obama to stimulate the economy — or do much of anything else, for that matter. Whereas if Romney moves into the White House, Republican lawmakers will cut him slack and the Democrats will too if he pushes policies that they wanted in the first place. A similar if less-stark dynamic could play out on the monetary-policy Federal Open Market Committee, where inflation hawks with Republican leanings would discover they weren’t so hawkish after all.

What I hadn’t really thought of, until I read conservative scholar Nicholas Eberstadt’s epic essay on entitlements, “A Nation of Takers” (it was excerpted in the Wall Street Journal on Saturday, but you want to read the whole thing) is that you could just as easily make the opposite argument. If you think what the nation needs above all is austerity and entitlement reform — meaning entitlement cutbacks — you’re likelier to get your way in a second Obama administration than under Romney/Ryan. Here’s Eberstadt:

[T]he growth of entitlement spending over the past half century has been distinctly greater under Republican administrations than Democratic ones. Between 1960 and 2010, to be sure, the growth of entitlement spending was exponential — but in any given calendar year, it was on the whole roughly 8 percent higher if the president happened to be a Republican rather than a Democrat.

What’s more, federal budget deficits have over the past century generally grown under Republican administrations and shrunk under Democrats. And for whatever it’s worth, the stock market usually does better under Democrats than Republicans.

What is one to make of all this?

It could be random chance. As I’ve written before, presidents’ impact on short-term economic performance is probably much less than it’s usually made out to be.

It could also be the result of the strange political equations that the U.S. system of separating executive from legislative power sets up. Winning the presidency doesn’t mean you get to set the agenda for your entire time in office; you may never have a legislative majority, and midterm elections often revitalize your opposition. So knowing which party occupies the White House often doesn’t tell us all that much about where the power to make economic policy lies.

In the case of entitlement spending, there’s also the interesting development that entitlement recipients in the U.S. now skew old and rural, and so does the Republican base. The convoluted campaign debate over who’s going to cut Medicare, the medical-insurance program for the elderly, and who’s going to save it, should give some indication that’s there’s no clear divide between Democrats supporting entitlements and Republicans opposing them.

Finally, there’s the basic psychological and philosophical truth that, as economist John Kay puts it, “complex goals are best achieved indirectly.” People have no idea what will actually make them happy, city planners build dull cities, and companies that focus on maximizing shareholder returnunderperform those with different goals. So voting for the candidate whose campaign statements you agree with may get you the opposite outcome of what you want.

I shouldn’t overstate my case here. Sometimes presidents deliver what they promise on the campaign trail. Ronald Reagan said he’d cut taxes, and he did. Barack Obama said he’d expand health insurance coverage to all, and he’s getting pretty close. Presidents, while often hamstrung on the domestic front, have a lot of leeway to arrange foreign policy as they choose.

Then again, in a big, complex world, the results of presidents’ foreign policy choices are often wildly different from what they predicted and intended. Presidents don’t always accomplish the opposite of what they commit to on the campaign trail — it would make voting much easier if they did. But the link between avowed priorities and eventual outcomes is a lot more tenuous than is generally acknowledged in our political discourse. And I’m not sure if that’s a bad thing or a good thing.

More blog posts by Justin Fox
Justin Fox


Justin Fox is editorial director of the Harvard Business Review Group and author of The Myth of the Rational Market: A History of Risk, Reward, and Delusion on Wall Street.

Where the Candidates Stand on Medicare and Medicaid @ProPublica @Medici_Manager

Ecco come funziona l’informazione e la discussione su grandi temi politici nei paesi civili!

Possiamo chiedere ai nostri candidati alle prossime elezioni politiche, e ai giornalisti che li intervistano,  di farci sapere che cosa si impegnano a fare per il nostro Servizio Sanitario Nazionale?

by Suevon Lee ProPublica, Sept. 14, 2012

Medicare and Medicaid, which provide medical coverage for seniors, the poor and the disabled, together make up nearly a quarter of all federal spending. With total Medicare spending projected to cost $7.7 trillion over the next 10 years, there is consensus that changes are in order. But what those changes should entail has, of course, been one of the hot-button issues of the campaign.

With the candidates slinging charges, we thought we’d lay out the facts. Here’s a rundown of where the two candidates stand on Medicare and Medicaid:


Big Picture

Earlier this year, the Medicare Board of Trustees estimated that the Medicare hospital trust fund would remain fully funded only until 2024. Medicare would not go bankrupt or disappear, but it wouldn’t have enough money to cover all hospital costs.

Under traditional government-run Medicare, seniors 65 and over and people with disabilities are given health insurance for a fixed set of benefits, in what’s known as fee-for-service coverage. Medicare also offers a subset of private health plans known as Medicare Advantage, in which roughly one-quarter of Medicare beneficiaries are currently enrolled. Obama retains this structure.

The Obama administration has also made moves that it says would keep Medicare afloat. It says the Affordable Care Act would extend solvency by eight years, mainly by imposing tighter spending controls on Medicare payments to private insurers and hospitals.

In contrast, Rep. Paul Ryan, Mitt Romney’s running mate, has proposed a more fundamental overhaul of Medicare, which he says is on an “unsustainable path.” On hiscampaign website, Romney says that Ryan’s proposals “almost precisely mirrors” his ideas on Medicare. But he’s been fuzzy on other aspects of the plan.

A Romney-Ryan administration would replace a defined benefits system with a defined contribution system in which seniors are given federal vouchers to purchase health insurance in a newly created private marketplace known as Medicare Exchange. In this marketplace, private health plans, along with traditional Medicare, would compete for enrollees’ business. These changes wouldn’t start until 2023, meaning current beneficiaries aren’t affected – just those under 55.

Under the Romney-Ryan, the vouchers would be valued at the second-cheapest private plan or traditional Medicare, whichever costs less. Seniors who opt for a more expensive plan would pay the difference. If they choose a cheaper plan, they keep the savings.

Who’s covered

In the current system, people 65 and over are eligible for Medicare, which Obama has said he would keep for now.

Romney has proposed raising the eligibility age for Medicare beneficiaries from 65 to 67 in 2022, then increasing it by a month each year after that. In the long run, he wouldindex eligibility levels to “longevity.” Ryan’s budget plan proposesraising Medicare eligibility age by two months a year starting in 2023, until it reaches 67 by 2034.

Many others looking to keep Medicare solvent have also proposedraising the age of eligibility.

The Congressional Budget Office estimates that raising the minimum age from 65 to 67 would reduce annual federal spending by 5 percentBut it would also result in higher premiums and out-of-pocket costs for seniors who would lose access to Medicare.

Obama’s health care law also adds some benefits for seniors, such as annual wellness visits without co-pays, preventive services like free cancer screenings and prescription drug savings.

Proposed Savings

The Affordable Care Act is projected to reduce Medicare spending by $716 billion over the next 10 years. These reductions, as detailed by Washington Post’s Wonkblog, will come mostly from reducing payments to hospitals, nursing homes and private health care providers.

While Ryan criticized such spending cuts in his speech at the Republican National Convention, his own budget proposed keeping these reductions.

“The ACA grows the trust fund by giving more general revenue to the Treasury, which then gives the trust fund bonds. But it then uses the money from those bonds to expand coverage for low- and middle-income people,” explains Dylan Matthews on Washington Post’s Wonkblog.

Romney hasn’t really come up with a solid answer: he previously said he would restorethe $716 billion savings that the health care law imposes. Per this New York Timesstory, the American Institutes for Research calculates this would increase premiums and co-payments for Medicare beneficiaries by $342 a year on average over the next 10 years.

For more on where the candidates stand on the $716 billion, the private health policy Commonwealth Fund offers this helpful explanation.

Caps on Spending

Both Obama and Ryan have set an identical target rate that would cap Medicare spending at one-half a percentage point above the nation’s gross domestic product.

But they have different ideas on mechanisms to achieve it.

The Affordable Care Act establishes a 15-member Independent Payment Advisory Boardthat, starting in 2015, would make binding recommendations to reduce spending rates. As Jonathan Cohn points out in the New Republic, the commission is prohibited from making any changes that would affect beneficiaries.

Ryan has proposed hard caps on spending and derided this panel of appointed members as “unelected, unaccountable bureaucrats.” When laying out his plan in a 2011 memo, Ryan wrote that to control spending, “Congress would be required to intervene and could implement policies that change provider reimbursements, program overhead, and means-tested premiums.”

Romney hasn’t stated clear proposals for imposing a cap on spending.


Big Picture

Though, it’s far less discussed on the campaign trail, Medicaid actually covers more people than Medicare. The joint federal-state insurance program for the poor, the disabled, and elderly individuals in long-term nursing home care currently covers about 60 million Americans.  The Affordable Care Act has expanded Medicaid coverage further. Beginning 2014, Medicaid will include people under 65 with income below 133 percent of the federal poverty level (roughly $15,000 for an individual, $30,000 for a family of four). This was estimated to cover an additional 17 million Americans as eligible beneficiaries.

In June, however, the U.S. Supreme Court ruled that states could opt out of the Medicaid expansion. A ProPublica analysis estimated that the 26 states that challenged the health care law, and thus may possibly opt out, would account for up to 8.5 million of those new beneficiaries.

Romney and Ryan would overhaul this current system by turning Medicaid into a system of block grants: the federal government would issue lump sum payments to the states, who would determine eligibility criteria and benefits for enrollees. These grants would begin in 2013.

Effects on spending

The Congressional Budget Office estimates that Medicaid expansion under the new health care law would cost an additional $642 billion over the next 10 years.

Under the Ryan plan, federal Medicaid grants would be adjusted only for inflation, but not health care costs, which grow at a much higher rate. The CBO estimates Ryan’s plan would save the federal government $800 billion over the next 10 years. Another study conducted by Bloomberg News shows that the block-grants could decrease Medicaid funding by as much as $1.26 trillion over the next nine years.

Actual Impact                                                                                                     

The New York Times points out that more than half of Medicaid spending goes toward the elderly and disabled. An Urban Institute analysis estimates the Ryan plan would result in 14 million to 27 million fewer people receiving Medicaid coverage by 2021.

Though rarely mentioned by any of the candidates, Medicaid costs are soaring to cover the elderly who require long-term nursing care. As the Times’ details how, states saddled by high Medicaid costs have begun turning to private managed care plans to blunt the cost.

RomneyCare vs. ObamaCare – which is better? @Medici_Manager @HarvardHSPH

Possiamo chiedere ai nostri candidati alle prossime elezioni politiche, e ai giornalisti che li intervistano,  di farci sapere che cosa si impegnano a fare per il nostro Servizio Sanitario Nazionale?

Posted by John McDonough  August 27, 2012

Mitt Romney has ended his self-imposed silence on his signature achievement as Massachusetts Governor — declaring himself “very proud” of his signing of the Massachusetts Health Reform law (aka: RomneyCare, Chapter 58) in April 2006.

Appearing on Fox News and other outlets, Romney also declared that the Massachusetts Health Reform law is “better” than the Affordable Care Act (aka: ObamaCare).

Reasonable question: which is better? Personally, I am delighted that the two presidential contenders might debate which government-engineered scheme to expand affordable health insurance is better. Let me try and offer my own answer.

There is no simple answer. On some things, RomneyCare wins, on others, it’s hands-down ObamaCare. And on some, it’s more complicated. Let’s look at some details:

Ways that RomneyCare (RC) is better than ObamaCare (OC):

1. RC provides deeper premium support and cost sharing subsidies to make health insurance more affordable to those receiving public subsidies.

2. RC established an insurance exchange (Connector) with a directive to be an advocate to keep consumers’ health insurance premiums more affordable.

Ways that ObamaCare is better than RomneyCare:

1. OC premium support and cost sharing subsidies help families with incomes up to 400% of the federal poverty line, vs. 300% FPL under RC.

2. OC bans lifetime and annual benefit caps and RC does not.

3. OC eliminates medical underwriting and pre-existing condition exclusions for all health insurance policies. Massachusetts did this in the 1990s and so there was no need for this to be addressed in RC.

4. OC requires health insurance companies to spend at least 80-85 cents of every premium dollar on medical costs as opposed to profits, marketing and overhead.  RC includes no such provisions.

5. OC allows young adults to stay on their parents’ health insurance policies until they reach age 26. RC allows young adults to stay on their parents’ plan for up to two years after they are no longer dependent, and no older than age 25.

6. OC requires that all health insurance policies cover preventive care services (ie: contraception) with no co-pays or other cost sharing. RC has no such protections.

7. OC requires that all Members of Congress and their staffs can receive federal health insurance coverage via the new state health insurance exchanges. RC did not make any similar requirement on Massachusetts state legislators.

8. OC improves Medicare for its beneficiaries by: closing the prescription drug “donut hole;” providing an annual wellness checkup with no cost sharing; lowering beneficiary premiums; and extending the life of the Hospital Insurance/Part A Trust Fund by about 8 years. RC does not address or improve Medicare at all.

9. OC instigates a significant effort to lower the health care system’s administrative costs. RC has no such provisions at all.

10. OC instigates a series of reforms in the delivery of medical care services, including the establishment of accountable care organizations, medical homes, value-based insurance designs, penalties for excessive rates of hospital acquired infections and readmissions, and more. RC does not address delivery system improvements at all.

11. OC establishes a series of programs and initiatives to improve public health, prevention and wellness, including the creation of the first-ever national prevention strategy. RC provides funding for some existing public health programs, though no new public health or prevention initiatives.

12. OC requires every chain restaurant with at least 20 outlets to post on menus and menu boards the calories of every item on its menu. RC has no such public information requirement.

13. OC includes major new funding for community health centers and the National Health Service Corps to improve the nation’s supply of primary care services. RC has no such provisions.

14. OC requires the establishment of a National Health Workforce Commission — appointed, though blocked from convening by House Republicans. RC does not address health care workforce needs at all.

15. OC establishes major new provisions to combat health care fraud and abuse in Medicare, Medicaid, and private insurance. RC includes no provisions addressing fraud and abuse in any sector.

16. OC establishes new standards and a national framework to combat elder abuse, including violence, neglect, and financial exploitation. RC includes no such provisions.

17. OC requires that drug, medical device, and medical supply companies publicly report all gifts, honoraria, and other gratuities to physicians and other licensed medical professionals. RC includes no such provisions.

18. OC directs the Food & Drug Administration to create a pathway for the approval of so-called “bio-similars” or generic-like versions of biopharmaceutical drugs, provisions strongly supported by the pharmaceutical and biotechnology industries. RC has no such provisions.

19. OC includes provisions to ensure that nursing patients and their families are able to obtain transparent information about the ownership and corporate responsibility of nursing homes. RC includes no such protections.

20. OC establishes a new 10% tax on indoor tanning services, which have been linked to the explosion in serious skin cancers, especially melanomas, among young women ages 15-35. RC does not address this epidemic.

OK — 20 versus 2. You may have others which will add or subtract from either column. My verdict — as a BIG fan of MA health reform — ObamaCare wins easily.

Now, one other BIG difference: financing. Here’s Mitt:

“My health care plan I put in place in my state has everyone insured, but we didn’t go out and raise taxes on people and have a unelected board tell people what kind of health care they can have,” Romney said in an interview with CBS’ Denver affiliate, KCNC.

So which plan is better when it comes to financing? Again, fair question.

It’s true, there were no tax increases (unless you count individual and employer tax penalties for non-coverage) associated with MA health reform. But there’s a big difference — Massachusetts got the federal government to pick up the lion’s share of the cost. MA health reform would have been impossible without the Administration of President George W. Bush playing Sugar Daddy.

I would propose — the appropriate comparison is how ObamaCare was financed in comparison with the major health achievement of Obama’s predecessor, George W. Bush.

In 2003, with Bush’s strong support, a Republican-controlled House and Senate approved the Medicare Modernization Act (MMA) that created the Medicare Part D prescription drug benefit, a big advance sought by senior citizen groups for many years. How was that law financed? 25% was financed by Medicare enrollee premiums and 75% was financed by lathering the costs onto the federal deficit. The Congressional Budget Office estimates that between 2010 and 2019, the MMA would increase the federal debt by about one trillion dollars.

In 2010, with Obama’s strong support, a Democratic-controlled House and Senate approved the Affordable Care Act (ACA). White House and Congressional leaders decided that the law needed to be entirely self-financed so that it would not increase the federal debt at all. The CBO estimated in 2010 that the ACA would reduce the federal debt by about $140 billion 2010-2019.

Mitt Romney and the Republican Party support the Part D drug program and indicate no desire to eliminate it. They also indicate no desire, retrospectively, to develop a plan to pay for it beyond allowing the Chinese (and other purchasers of U.S. debt) to finance it. Barack Obama and the Democrats support the ACA and made the most difficult decision to pay for it. You can easily disagree with how they chose to pay for it — and still respect their integrity in taking the political hits to pay for it.

Advantage — Obama and ObamaCare.

JAMA Forum: Mitt Romney, Paul Ryan, and the Magic Asterisk @Medici_Manager

Possiamo chiedere ai nostri candidati alle prossime elezioni politiche, e ai giornalisti che li intervistano,  di farci sapere che cosa si impegnano a fare per il nostro Servizio Sanitario Nazionale?

By David Cutler, PhD

The press has focused a lot on the similarities between Mitt Romney and Paul Ryan. They are both technocratic, they espouse tax cuts, and they believe in a balanced budget. But there is a deeper similarity as well: they both believe deeply in the “magic asterisk.”

The magic asterisk was the invention of David Stockman, budget director to Ronald Reagan. Stockman, who needed to show a more favorable budget than the Reagan tax cuts would justify, put in an asterisk and noted “future savings to be identified.” (He also invented the magic asterisk’s cousin, Rosy Scenario. She seems to be making a comeback as well.) Since then, the magic asterisk has become a staple of budgets that don’t add up and wishful economic thinking. What Stockman invented, however, Romney and Ryan have perfected.

Example 1: The Romney-Ryan team wants to cut federal Medicaid spending by a third in the next decade and by half over the next 17 years. This is after causing the loss of health insurance coverage for 30 million people (by repealing the Affordable Care Act) and adding hundreds of thousands of 65- and 66-year-olds to the ranks of the uninsured by raising the eligibility age for Medicare. A nonpartisan research organization projects that this will lead to 14 million to 27 million people losing Medicaid coverage as a result. How will we cope with this? The magic asterisk rides to the rescue. (It opines that state governments will figure out how to reduce costs by 50% while covering 30 million more people.)

Example 2: Romney and Ryan propose a voucher for Medicare. According to a recent study that I coauthored, a person turning 65 years old in 2023 could expect to pay $60 000 more for Medicare over his lifetime as a result of the voucher plan. Today, a typical household headed by someone 65 to 69 years old has less than $25 000 in financial assets. How will they afford more than twice that amount in lifetime costs? Cue the magic asterisk. (“By replacing the inefficiency of the current system with a competitive, market-oriented system…, the plan puts the future of Medicare on a sound footing.”)

The irony is that any actual proposed reductions in Medicare spending are seen by Romney as a vital threat to the health of the elderly, but fairy-tale savings are okay. The Affordable Care Act reduced Medicare spending by about $700 billion over the next decade, largely by reducing spending to hospitals, home health agencies, and Medicare Advantage plans. According to Mitt Romney, this is damaging Medicare. Alas, Ryan’s budget plan kept those savings in it, and when Ryan joined the Romney ticket, he had to disavow those spending reductions. So far, Ryan has replaced these proposed cost reductions with… the magic asterisk.

Example 3: As most physicians know, Medicare payments to physicians are to decrease by nearly 30% unless Congress takes action to prevent the sustainable growth rate (the reimbursement formula based on economic growth that was intended to help curb health care spending) from going into effect. Ryan’s budget proposes a “doc fix” but then has no funding to prevent it. Rather, there is a “reserve fund” to pay for it, with the money for the reserve fund coming from the magic asterisk. It’s a good thing the asterisk will provide the money. Without it, the payment cuts take effect.

The magic asterisk is useful even beyond health care. Paul Ryan’s budget proposes to cut taxes deeply and balance the federal budget. What spending is cut to do this? In addition to reducing Medicare and Medicaid, Ryan proposes that nondefense, discretionary spending (such as support for national parks, the environment, cancer research, and the Food and Drug Administration) essentially disappear from the federal budget. Of course, he doesn’t say this. It’s buried in the magic asterisk. You can only realize that he wants to get rid of the government’s role in these areas by seeing that he has no money for it.

The magic asterisk is so essential to Romney and Ryan’s plans that I think it deserves more attention. How about a Romney-Ryan campaign symbol that is an asterisk in red, white, and blue with a picture of David Stockman in the middle? (Actually, hold that thought. David Stockman recently blasted Paul Ryan’s “Fairy-Tale Budget” as “devoid of credible math or hard policy choices.”) Or maybe the magic asterisk could debut in a campaign slogan: Romney-Ryan: A New Deal for America* (*New Deal to be identified).

Jesting aside, federal budgets are not something to be taken lightly. Barack Obama laid out exactly what he wanted to do on health care, and he has taken heat for it. How about the same from Romney and Ryan? Tell us exactly what you want to do and leave out the magic asterisks. Then, doctors and patients can see which plan they like better. Is a little candor too much to ask for?


About the author: David M. Cutler, PhD, is the Otto Eckstein Professor of Applied Economics in the Department of Economics and Kennedy School of Government at Harvard University and a member of the Institute of Medicine. He served on the Council of Economic Advisers and the National Economic Council during the Clinton Administration and was senior health care advisor to Barack Obama’s presidential campaign.

About The JAMA Forum: To provide ongoing coverage throughout this election year, JAMAhas assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide insight about the political aspects of health care. Each JAMAForum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

$765 billion wasted by medical industry in 2009 could pay for health care reform @ProPublica @Medici_Manager

A Costly Equation: Medical Dollars Wasted Are Greater Than the U.S. Defense Budget

by Marshall Allen ProPublica, Sept. 18, 2012

I’ve heard a lot of reports about the staggering amount of fraud, overtreatment and unnecessary health care in the United States. But the recent “Best Care at Lower Cost” report by the Institute of Medicine included this stunner: In 2009, the health care system wasted an estimated $765 billion– more than the entire budget of the Department of Defense.

I’ve got to hand it to the IOM committee for finding an interesting way to give those numbers a punch.
The report outlined the varieties of waste: Care is provided that’s not based on evidence; discretionary care is used too much; high cost options are chosen rather than avoided; care is fragmented; insurance administration and paperwork are inefficient; and fraud is at every level. The estimates of money poorly spent included:

  • $210 billion on overuse and unnecessary care.
  • $130 billion in inefficiency, including mistakes and harm.
  • $190 billion in excess administrative costs.

Whose money is being wasted? Yours and mine. Medical inflation increases health insurance premiums. In 2010, Medicare spent anestimated $48 billion– our tax dollars – on overpayment and waste. But the most tragic victims are people who need medical care but don’t have the money to pay for it. The cost of care is a major barrierto many patients, and its driven higher by waste.
Who’s profiting from the status quo? Members of the health care industry – though certainly not everyone is feeding at the trough.When I wrote recentlyabout unnecessary stents, Dr. David Brown, an interventional cardiologist and professor of medicine at SUNY-Stony Brook School of Medicine, told me unnecessary treatment persists because “the medical system is addicted to the revenues that it generates.”
And here’s the kicker: The debates about health care reform might be moot if we eliminated the waste. The net cost of healthcare reform (i.e., President Obama’s Affordable Care Act) is estimated to be $1.1 trillion over a 10 year period. That’s less than two years of the estimated waste in health care.
So what do you think? The system is hemorrhaging money. What can be done to stop it? Have you had experiences with any medical facilities working in innovative ways to cut costs?

The Supreme Court on health reform: Everybody wins! @kevinmd

by  | in PHO | 31 responses

The Supreme Court upheld the Affordable Care Act.

I’ll leave the detailed legal analysis  to other commentators that you’ll no doubt find elsewhere.

Although some may not feel this way, this is an outcome everybody should be happy with.

Most important, patients should be happy.  As I wrote in the New York Times Room for Debaterecently, the ACA has already provided benefits not to only the uninsured, but one of the most vulnerable segments of the population — seniors:

One of the unsung benefits of the Affordable Care Act is Medicare’s Annual Well Visit exam, which has been offered since 2011. Thanks to these visits, which I perform everyday in my primary care clinic, I have the opportunity to evaluate seniors for their risk of falling, screen for depression and ensure preventive services like vaccines and cancer screening are adhered to.

Furthermore, health reform has already helped seniors save money. In 2011 alone, nearly 3.6 million Medicare beneficiaries saved $2.1 billion in prescription drug costs.

Primary care doctors should be happy as well. As the ACP’s Bob Doherty has written, they had much to lose, including billions of dollars in higher Medicare and Medicaid reimbursements.

Of course, progressives will be happy with the outcome. The President’s signature accomplishment is allowed to stand. 32 million previously uninsured Americans will have access to affordable health insurance in 2014, which will certainly help the scores of millions who live everyday without that safety net. Those with pre-existing conditions will have access to insurance at reasonable prices. And although not optimal, various cost control initiatives, like bundling care and the formation of Accountable Care Orgnaizations, will proceed.

Conventional wisdom dictates that it would be those on the political right who would be most disappointed with this outcome. Although they may be stinging now, here’s why they should be happy as well. It will prevent, or significantly delay, the prospect of a single payer system.

The Affordable Care Act entrenches the current system of private insurers. In fact, they should expect tens of millions of new patients because of Obamacare. And concerning the individual mandate, remember it’s actually a conservative idea born from the Heritage Foundation, and implemented by Republican presidential candidate Mitt Romney in Massachusetts.

Had the ACA been struck down, we would have been back to the drawing board. No one would touch health care again for years, while costs continue to spiral out of control, and the number of uninsured continue to rise. Progressives would have introduced a Constitutionally compliant way to expand coverage that could be passed via budget reconciliation, bypassing the need for a Senate supermajority. That solution would have been a gradual expansion of Medicare: effectively, steps to a single payer system.

In fact, had the Supreme Court ruled the other way, some states couldn’t wait to go the single payer route.

And that is a true government takeover of health care.

Now, I’m aware that scenario may happen whether the ACA was held up or not. If the ACA’s cost control measures fail, for instance.  But at least this gives the private insurance system a chance to fix our system before resorting to a draconian single payer route.

Obamacare is far from perfect. It doesn’t do anything to fix our broken medical malpractice system, its most glaring flaw. It doesn’t provide enough incentive for medical students to choose primary care. It doesn’t address the crushing burden of medical school education.

But it’s a start.

The Supreme Court’s ruling is an obvious victory for primary care doctors, patients, and progressives. Considering what the alternative could have been, those on the political right should take comfort in the decision as well.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of, also on FacebookTwitterGoogle+, and LinkedIn.