Category Archives: Federal Government

Immigrants and Health – Two Studies

The following two articles come from Dr. Don McCanne’s Quote of the Day blog.

International Journal of Health Services
August 8, 2018
Medical Expenditures on and by Immigrant Populations in the United States: A Systematic Review
By Lila Flavin, Leah Zallman, Danny McCormick, and J. Wesley Boyd

Abstract

In health care policy debates, discussion centers around the often-misperceived costs of providing medical care to immigrants. This review seeks to compare health care expenditures of U.S. immigrants to those of U.S.-born individuals and evaluate the role which immigrants play in the rising cost of health care. We systematically examined all post-2000, peer-reviewed studies in PubMed related to health care expenditures by immigrants written in English in the United States. The reviewers extracted data independently using a standardized approach. Immigrants’ overall expenditures were one-half to two-thirds those of U.S.-born individuals, across all assessed age groups, regardless of immigration status. Per capita expenditures from private and public insurance sources were lower for immigrants, particularly expenditures for undocumented immigrants. Immigrant individuals made larger out-of-pocket health care payments compared to U.S.-born individuals. Overall, immigrants almost certainly paid more toward medical expenses than they withdrew, providing a low-risk pool that subsidized the public and private health insurance markets. We conclude that insurance and medical
care should be made more available to immigrants rather than less so.

From the Discussion

Many Americans, including some in the health care sector, mistakenly believe that immigrants are a financial drain on the U.S. health care system, costing society disproportionately more than the U.S.-born population, i.e., themselves. Our review of the literature overwhelmingly showed that immigrants spend less on health care, including publicly funded health care, compared to their U.S.-born counterparts. Moreover, immigrants contributed more towards Medicare than they withdrew; they are net contributors to Medicare’s trust fund.

Our research categorized immigrants into different groups, but in all categories, these studies found that immigrants accrued fewer health care expenditures than U.S.-born individuals. Among the different payment sources – public, private, or out-of-pocket – public and private expenditures were lower for immigrants, with immigrants spending more out-of-pocket. Differences decreased the longer immigrants resided in the United States.

While annual U.S. medical spending in 2016 was a staggering $3.3 trillion, immigrants accounted for less than 10% of the overall spending – and recent immigrants were responsible for only 1% of total spending. Given these figures, it is unlikely that restrictions on immigration into the United States would result in a meaningful decrease in health care spending. To the contrary, restricting immigration would financially destabilize some parts of the health care economy, as suggested by Zallman and colleagues, who found that immigrants contributed $14 billion more to the Medicare trust fund than they withdrew.

Fiscal responsibility is an important reason for the United States to provide insurance for newly arrived immigrants, as they could continue to enlarge the low-risk pool of healthy individuals that helps offset the cost of insuring high-risk individuals. Currently, under the ACA, undocumented immigrants cannot enroll in the state health care exchanges. If we are seeking to minimize costs, which would seem a major factor in the reasoning of policymakers who would deny immigrants care, then it makes financial sense to enroll individuals who will (on average) contribute more to the health care system than they withdraw. Healthy, young immigrants are precisely whom we should target for Medicaid enrollment, state exchanges, or private health insurance.

http://journals.sagepub.com/doi/full/10.1177/0020731418791963

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The New England Journal of Medicine
August 1, 2018
A New Threat to Immigrants’ Health — The Public-Charge Rule
By Krista M. Perreira, Ph.D., Hirokazu Yoshikawa, Ph.D., and Jonathan Oberlander, Ph.D.

The United States is making major changes to its immigration policies that are spilling over into health policy. In one such change, the Trump administration is drafting a rule on “public charges” that could have important consequences for access to medical care and the health of millions of immigrants and their families. The concept of a public charge dates back to 19th-century immigration law. Under current guidelines, persons labeled as potential public charges can be denied legal entry to the United States. They can also be prevented from adjusting their status from a nonimmigrant visa category (e.g., a student or work visa) to legal permanent resident status. In addition, if they become public charges within the first 5 years after their admission to the United States, for reasons that existed before they came to the country, in rare cases they can be arrested and deported. Immigrants and their families consequently have strong incentives to avoid being deemed public charges.

In evaluating whether a person is likely to become a public charge, immigration officials take account of factors such as age, health, financial status, education, and skills. The use of cash assistance for income maintenance (e.g., Supplemental Security Income or Temporary Assistance for Needy Families) and government-funded long-term care are considered in making these determinations. Other noncash benefits such as health and nutrition programs are specifically excluded from consideration, and use of cash-assistance benefits by the immigrant’s dependents is not currently factored in.

The Trump administration is proposing sweeping changes to these guidelines. A draft rule from the Department of Homeland Security (DHS) would substantially expand the definition of a public charge to include any immigrant who “uses or receives one or more public benefits.” Not just cash assistance but nearly all public benefits from federal, state, or local governments would be considered in public-charge determinations, including nonemergency Medicaid, the Children’s Health Insurance Program (CHIP), and subsidized health insurance through the marketplaces created by the Affordable Care Act (ACA); Medicare would be excluded. The DHS draft notes that in making these determinations, “having subsidized insurance will generally be considered a heavily weighted negative factor.” The broadened definition of public charge would also encompass food assistance (the Supplemental Nutrition Assistance Program [SNAP] and the Women, Infants, and Children Program [WIC]), programs designed to assist low-income workers (e.g., the Earned Income Tax Credit [EITC]), housing assistance (Section 8 vouchers), and the Low Income Home Energy Assistance Program. Moreover, not only immigrants’ use of public assistance but use of these programs by any dependents, including U.S.-born citizen spouses and children, would also be considered.

The potential impact of these changes is enormous. In 2016, about 43.7 million immigrants lived in the United States. If enacted, the new regulations would affect people seeking to move to the United States to be reunified with family members and to work, as well as lawfully present immigrants who hope to become legal permanent residents (green-card holders). One estimate suggests that nearly one third of U.S.-born persons could have their use of public benefits considered in the public-charge determination of a family member. This includes “10.4 million citizen children with at least one noncitizen parent.” Notably, unauthorized immigrants are not the primary target of the draft rule, since they are already ineligible for most federally funded public assistance. Instead, lawfully present immigrants would bear the brunt, as well as persons living in “mixed-status” families (those in which some members are citizens and others are not) and persons living abroad who wish to immigrate to the United States.

We believe that the draft public-charge regulation represents a substantial threat to lawfully present immigrants’ access to public programs and health care services. What modifications may be made is uncertain — after the rule is formally proposed, there will be a public comment period, and revisions could be made before it is finalized. But if this rule takes effect, it will most likely harm the health of millions of people and undo decades of work by providers nationwide to increase access to medical care for immigrants and their families.

https://www.nejm.org/doi/full/10.1056/NEJMp1808020?query=featured_secondary

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Medicaid Work Requirements Worsen Health

Back in May, I posted a link to a Health Affairs blog article, Social Determinants Of Health: A Public Health Concept In Conflict in which it was reported that the current regime was seeking to impose work requirements for people on Medicaid.

As reported then, and on Monday in a follow-up article, CMS approved the first waiver to implement a work requirement for Medicaid beneficiaries in Kentucky on January 12th.

The article stated that a couple of weeks ago, a district court found the approval of these work requirements to be “arbitrary and capricious”, and in direct violation of the Administrative Procedures Act of 1996.

According to the article, CMS failed to consider whether the waiver’s estimated removal of 95,000 Kentuckians was in line with the program’s goals of furnishing medical assistance, and the judge ordered the waiver to be returned to CMS.

It was the government’s argument, the article states, that new research into the social determinants of health demonstrate that income and employment are associated with improved health, and so a work requirement thereby fits within the goals of the program.

The case in Kentucky hinged on the fact that work requirements worsened financial assistance, which the judge pointed out is a main tenet of the program.

The author then writes that if CMS wants to use research within the social determinants of health, then he will analyze Medicaid work requirements through this lens. A recent post in Health Affairs focused on the perversion of social determinants of health as a concept, and the current post builds off that one, to demonstrate that this regime’s justification for Medicaid work requirements is misguided at best.

To illustrate this, he follows a theoretical low-income worker, a 50-year-old from Louisville, who could no longer work in his job as a longshoreman due to cardiovascular disease and suffered chest pain whenever he exerted himself. He is uninsured, has a wife and three adult children. And is also trying to find a job.

The author continues by examining the following issues: Unemployment and Health, Medicaid Improves Health, Medicaid Work Requirements Harm Those With Jobs, and concludes by stating that Medicaid Work Requirements Worsen Health.

The theoretical case of the 50-year-old longshoreman is not so theoretical, as each of the 16 Kentucky plaintiffs in the case demonstrated. One is a graduating student with endometriosis, another is a mother of four with congenital hip dysplasia, and another is a partly blind mortician (no jokes, please) with chronic lung disease. All would have risked losing their coverage as a result of work requirements.

And to make the case more clearly, your humble blogger, while not currently on Medicaid, but eventually will be, has end-stage renal disease, and does peritoneal dialysis every night at home, and goes to the clinic twice a month for blood work and to see the nephrologist. In addition, every two weeks on a Monday, as will happen this coming Monday, I have to be home to receive my supplies, and this Friday must call in another order. Working a full-time job, if one were available that matched my experience, would prevent me from doing so.

This is another reason why our health care system is broken and needs to be replaced by a single payer system that does not separate out older beneficiaries, as Medicare does, poorer ones as Medicaid does, and children and military personnel, as the other programs do.

One system for all Americans.

The Cry of the Children

Taking a break from writing about health care, workers’ comp, and medical travel, I want to talk about something I saw, or rather heard yesterday afternoon on MSNBC.

It was an audio (furnished by ProPublica) of children crying at a detention center (more like Concentration Camp) that broke my heart. I was in tears, and very seldom do so. But those cries went right to me.

If they did to you, then you are a good human being. If not, then you have no soul. And please, don’t quote me that that’s the law, or it is in the Bible, or they are illegal and have no rights.

EVERY HUMAN BEING HAS RIGHTS.

And as for whether or not they are “illegal”, I guess you forgot that when your ancestors arrived on the Mayflower or whatever ship they sailed on, the landlords here for thousands of years knew you were “illegal” too.

The ancestors of all of these people now streaming to our border came to this hemisphere some 20,000 years ago, so by those standards, you, me, and all the rest of us are undocumented aliens. But no one tells us to leave. Or yanks our kids from our arms.

That we do this and many other things to minorities is a symptom of our greed, ignorance, and stupidity that never seems to die out. Take for example, our Confederate-era Attorney General, Jeff “Foghorn Leghorn” Sessions. That refugee from the set of “Gone With the Wind” is not only a religious zealot, but a full-out bigot and racist from a region of the nation that still has not given up its racism and hatred of non-whites, and non-Christians. In this case, non-Protestants from Catholic Latin America.

Too many of our fellow Americans have been poisoned by talk radio, Fox News, and local politicians to see that we are all immigrants and that at times in the long history of the human species, we were migrants too. Our prehistoric ancestors migrated, as did many more recent peoples. But none ever subjected to such cruelty, except during the 1930’s and 1940’s.

We were all taught in school to believe in the ideals of America as a shining city on a hill (incidentally, an idea the Puritans created), and was more about a religious view than a secular one. We were all taught about why we fought a revolution, why we have a Declaration of Independence, and why we have a Constitution that secures our rights and liberties.

And now we are throwing all that away because of a clique of neo-fascist, racist bullies and bigots, headed by a pathological liar and con man, who has conned a large segment of the American people (by which I mean White people) that he can make America great again, all the while cozying up to dictators and dissing our friends.

Folks, this is how Hitler and the Nazis began. And it ended with 6 million dead (my maternal great-uncle, aunt and their six children among them), so don’t tell me it is legal or biblical. You know where you can put that.

And those of you who say they have stolen our jobs or they are criminals and rapists, I have news for you…next time you are in a restaurant, or a family member is in a hospital, bus your own table, and clean up your family member’s dirty linen. Because if Herr Miller (Stephen) gets his way, there won’t be any bus boys, nurses’ aides, home health aides, janitors, and other occupations Americans won’t be filling begging for workers. Oh, and you can come to Florida and pick your own fruits and vegetables, because there won’t be anyone to do it for you.

AMERICA IS A NATION OF IMMIGRANTS, SO WE NEED THESE PEOPLE.

 

Mad Dog Attacks Public Transport

Tom Lynch of LynchRyan’s Workers’ Comp Insider blog, wrote an article this morning that follows on the heels of my post from yesterday about the Justice Department not defending portion of the Affordable Care Act (ACA).

According to Tom, the GOP finally figured out how to fight the ACA, and he discusses three events beginning with February of last year in which the GOP-led Congress attacked the ACA. The three events are:

February 2017 – tax cut law that zeroed out the penalty for not having insurance.

February 2018 – getting 20 states to sue the federal government and contend that repeal of the penalty obviates the individual mandate making the entirety of the ACA unconstitutional.

And just last month, as I wrote yesterday, got the Justice Department to not defend the government in the suit.

Tom continues to say that if the 20 states win, pre-existing conditions, which the ACA protects, goes out the window. There are about 133 million Americans under the age of 65 who fall into that category. I am one of them.

Insurance companies are not happy either, Tom reports, and the trade association for the health insurance companies, America’s Health Insurance Plans, supports the provision under the ACA, and is quoted thus: “Removing those provisions will result in renewed uncertainty in the individual market, create a patchwork of requirements in the states, cause rates to go even higher for older Americans and sicker patients, and make it challenging to introduce products and rates for 2019,” according to a statement released by AHIP.

Finally, Tom asks the question — what happens if the 20 states win their suit? His answer, the 1.25 million Americans with Type 1 diabetes are waiting for an answer.

Yet, they and others don’t really have to wait for an answer, because the answer is staring us right in the face, but we refuse to see it, or even acknowledge its presence. Instead, we keep doing the same things over and over again, thinking the free market has the answer.

That is patently not true. A real, comprehensive, universal single payer system or an improved Medicare for All system that does not force those who are ill and don’t have a lot of money to pay for parts of the coverage, either the medical portion, or the 20% not now covered by Medicare, is the answer. Anything less is just a dog chasing a bus, catching that bus, and the dog and bus getting hurt.

Social Determinants Of Health: A Public Health Concept In Conflict

Source: Social Determinants Of Health: A Public Health Concept In Conflict

Vermont becomes first state to permit drug imports from Canada – POLITICO

In a rebuff to the current neo-liberal regime and its recent plan to tackle drug prices, the State of Vermont became the first in the nation to allow cross-border purchasing of drugs from Canada. Makes sense because the border is not that far away.

Years ago, my late mother worked for a company here in Florida that facilitated drugs to come to patients from Canada, the UK and Israel.

But thanks to successful lobbying by a former Democratic Congressman from Louisiana who after leaving Congress became a lobbyist for the pharmaceutical industry, the government forbade the importation of Canadian drugs.

The measure is one of the most aggressive attempts by a state to tackle rising drug prices that critics say are crippling state finances.

Source: Vermont becomes first state to permit drug imports from Canada – POLITICO

Obamacare: The Last Stage of Neoliberal Health Reform

In my recent review of the Introduction to Health Care under the Knife, the term “neoliberalism” was discussed as one of the themes the authors explored in diagnosing the root causes of the failure of the American health care system.

For review, the term neoliberalism refers to a modern politico-economic theory favoring free trade, privatization, minimal government intervention in business, reduced public expenditure on social services, etc. (Source: Collins English Dictionary – Complete and Unabridged, 12th Edition 2014)

As defined in Wikipedia, and as I wrote in my review, neoliberalism refers primarily to the 20th-century resurgence of 19th-century ideas associated with laissez-faire economic liberalism. Those ideas include economic liberalization policies such as privatization, austerity, deregulation, free trade and reductions in government spending in order to increase the role of the private sector in the economy and society. These market-based ideas and the policies they inspired constitute a paradigm shift away from the post-war Keynesian consensus which lasted from 1945 to 1980.

This recrudescence or resurgence gained momentum with the election of Ronald Reagan to the presidency, and with the Republican takeover of the House of Representatives in the 1994 midterm election, which made Newt Gingrich Speaker of the House, and implemented the Contract with America. (I’ve called it the Contract on America, for obvious reasons)

Yet, the full impact of neoliberalism was not felt until the rise of the TEA Party in the run-up to the passage of the Affordable Care Act, or Obamacare, and that led to the Freedom Caucus in the House that has tried unsuccessfully multiple times to repeal and replace Obamacare with basically nothing.

Economist Said E. Dawlabani, in his book, MEMEnomics, describes the period from 1932 to 1980, which includes the post-war Keynesian consensus, as the second MEMEnomic cycle, or “Patriotic Prosperity” MEME. The current period, from 1980 to the present, represents the third MEMEnomic cycle, or the “Only Money Matters” MEME.

It is in this period that the American health care system underwent a radical transformation from what some used to call a “calling profession” to a full-fledged capitalist enterprise no different from any other industry. This recrudescence of 19th century economic policies did not spring forth in 1980 fully formed, but rather had existed sub-rosa in the consciousness of many American conservatives.

In the early 1970’s, Richard Nixon’s administration came up with the concept of the Managed Care Organizations, or MCOs, as the first real attempt to apply neoliberalism to health care. As we shall see, this would not be the first time that neoliberal ideas would be implemented into health care reform.

In Chapter Seven, of their book, Health Care under the Knife, authors Howard Waitzkin and Ida Hellander, discuss the origins of Obamacare and the beginnings of neoliberal health care reform. They point to the year 1994 as a significant one for reform worldwide, as Colombia enacted a national program of “managed competition” that was mandated and partially funded by the World Bank. This reform replaced their prior health system and was based mostly on public hospitals and clinics.

1994 was also the year when then First Lady, Hillary Clinton spearheaded a proposal like the one Colombia enacted that was designed by the insurance industry. I am sure you all remember the Harry and Sally commercials that ran on television that sank her proposal before it ever saw the light of day?

What ultimately became Obamacare was the plan implemented in 2006 in Massachusetts by Mitt Romney, but that was later disavowed when he ran for President in 2012. Waitzkin and Hellander write that even though these programs were framed to improve access for the poor and underserved, these initiatives facilitated the efforts of for-profit insurance companies providing “managed care.”

Insurance companies, they also said, profited by denying or delaying necessary care through strategies such as utilization review and preauthorization requirements; cost-sharing such as co-payments, deductibles, co-insurance, and pharmacy tiers; limiting access to only certain physicians; and frequent redesign of benefits.

These proposals, the authors state, fostered neoliberalism. They promoted competing for-profit private insurance corporations, programs and institutions based in the public sector were cut back, and possibly privatized. Government budgets for public-sector health care were cut, private corporations gained access to public trust funds, and public hospitals and clinics entered competition with private institutions, with budgets determined by demand rather than supply. Finally, prior global budgets for safety-net institutions were not guaranteed, and insurance executives made operational decisions about services, superseding the authority of physicians and other clinicians.

The roots of neoliberal health reform emerged from the Cold War military policy, and the authors cite economist Alain Enthoven providing much of the intellectual framework for those efforts. Enthoven was the Assistant Secretary of Defense under Robert S. McNamara during both the Kennedy and Johnson administrations. While he was at the Pentagon, between 1961 and 1969, he led a group of analysts who developed the “planning-programming-budgeting-system” (PPBS) and cost-benefit analysis, that intended to promote more cost-effective spending decisions for military expenditures. Enthoven became the principal architect, the authors indicate, of “managed competition”, which became the prevailing model for the Clinton, Romney, and Obama health care reforms, as well as the neoliberal reforms around the world.

The following table highlights the complementary themes in the military PPBS and managed competition in health care.

_____________________________________

Sources: See note 11, page 273.

Enthoven continued to campaign for his idea throughout the 1970s and 1980s and collaborated with managed care and insurance executives to refine the proposal after being rejected by the Carter administration. The group that met in Jackson Hole, Wyoming, which included Enthoven and Paul Ellwood, was funded by the five largest insurance corporations, as well as the 1992 Clinton presidential campaign, and wife Hillary’s Health Security Act.

The authors state that Barack Obama, while a state legislator in Illinois, favored a single payer approach, but changed his position as a presidential candidate. In 2008, he received the largest financial contributions in history from the insurance industry, that was three times more the contributions of his rival, John McCain.

The neoliberal health agenda, the authors write, including Obamacare, emerged as one component of a worldwide agenda developed by the World Bank, the International Monetary Fund, and other international financial institutions. The agenda to promote market-driven health care, facilitated access to public-sector health and social security trust funds by multinational corporations, according to Waitzkin and Hellander. The various attempts in the US by the Republican Party to privatize Social Security is an example of this agenda.

An underlying ideology claimed that corporate executives could achieve superior quality and efficiency by “managing” medical services in the marketplace, but without any evidence to support it, the authors contend. Health reform proposals from different countries have resembled one another closely and conform to a cookie-cutter template. Table 2 describes the six features of nearly all neoliberal reform initiatives.

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† Sources: patients, employers, public sector trust (“solidarity”) funds (the latter being “contributory” for employed workers, and “subsidized” for low income and unemployed).
‡ Sources: patients, public sector trust funds – Medicaid, Medicare.

The six features of neoliberal health reform are as follows:

  1. Organizations of providers – large, privately controlled organizations of health care providers, operate under direct control or strong influence of private insurance corporations, in collaboration with hospitals and health systems, may employ health care providers directly, or may contract with providers in a preferred network. In Obamacare, they are called Accountable Care Organizations (ACOs), supported only in Medicare, but Obamacare accelerated organizational consolidation in anticipation of broader implementation.

In this model, for-profit managed care organizations (MCOs) offer health plans competitively. In reality, competition is restrained by the small number of organizations large enough to meet the new laws’ financial and infrastructure requirements, as well as by the consolidation in the private insurance industry. They contract with or employ large numbers of health practitioners. Instead, physicians and hospitals are absorbed into MCOs.

  1. Organizations of purchasers – large organizations purchasing or facilitating the purchase of private health insurance, usually through MCOs. Under Obamacare, the federal and state health insurance “exchanges”—later renamed “marketplaces” to reflect reality of private, government-subsidized corporations—fulfill a similar role.
  2. Constriction of public hospitals and safety net providers – public hospitals at the state, county, or municipal levels compete for patients covered under public programs like Medicaid or Medicare with private, for-profit hospitals participating as subsidiaries or contractors of insurance companies or MCOs. With less public-sector funding, public hospitals reduce services and programs, and many eventually close. Under Obamacare, multiple public hospitals have closed or have remained on the brink of closure. Note: This is a subject I have written about in prior posts about Medicaid expansion.
  3. Tiered benefits packages – defined in hierarchical terms, minimum package of benefits viewed as essential, individuals and employers can buy additional coverage, poor and near poor in Medicaid eligible for benefits that used to be free of cost-sharing, but since Obamacare passed, states have imposed premiums and co-payments. Under Obamacare, various metal names—bronze, silver, gold, platinum, identify tiers of coverage, where bronze represents the lowest tier and platinum the highest.
  4. Complex multi-payer and multi-payment financing – financial flows under neoliberal health policies are complex (see Chart 7.1). There are four sources of these various financial flows.
    1. Outflow of payments – each insured person considered a “head” for whom a “capitation” must be paid to an insurance company or MCO.
    2. Inflow of funds – funds for capitation payments come from several sources. Premiums paid by workers and their families, contributions from employers is a second source. Public-sector trust funds are a third source, co-payments and deductibles constitute a fourth source, and taxes are a fifth source.
  5. Changes in the tax code – neoliberal reforms usually lead to higher taxes because they increase administrative costs and profits, Obamacare reduces tax deductions and imposes a tax for so-called Cadillac insurance plans. In addition, it calls for penalties for those who do not purchase mandatory coverage, administered by the IRS. I was unable to get on the ACA because I had not filed a return in several years due to long-term unemployment because of the financial collapse of 2007/2008, and the subsequent jobless recovery.

Chart 7.1 Financial Flows under Neoliberal Health Reform

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*Purchase of insurance policies for employers and patients mediated by large organizations of health care purchasers.

What is the outlook for single payer in the US, the authors ask?

They cite national polls that show that about two-thirds of people in the US favor single payer. See Joe Paduda’s post here.

If the US were to adopt single payer, the PNHP proposal would provide coverage for all needed services universally, including medications and long-term care, no out-of-pocket premiums, co-payments, or deductibles; costs would be controlled by “monopsony” financing from a single, public source, would not permit competing private insurance and would eliminate multiple tiers of care for different income groups; practitioners and clinics would be paid predetermined fees for services without and need for costly billing procedures; hospitals would negotiate an annual global budget for all operating costs, for-profit, investor-owned facilities would be prohibited from participating; most nonprofit hospitals would remain privately owned, capital purchases and expansion would be budgeted separately, based on regional health-planning goals.

Funding sources would include, they add, would include current federal spending for Medicare and Medicaid, a payroll tax on private businesses less than what businesses currently pay for coverage, an income tax on households, with a surtax on high incomes and capital gains, a small tax of stock transactions, while state and local taxes for health care would be eliminated.

From the viewpoint of corporations, the insurance and financial sectors would lose a major source of capital accumulation, other large and small businesses would experience a stabilization or reduction in health care costs. Years ago, when I first considered single payer, I realized that if employers no longer had to pay for health care for their employees, they could use those funds to employ more workers and thus limit the impact of recessions and jobless recoveries.

So how do we move to single payer and beyond?

According to the authors, and to this reporter, the coming failure of Obamacare will become a moment of transition in the US, where neoliberalism has come home to roost. This transition is not just limited to health care. The theory of Spiral Dynamics, of which I have written about in the past, predicts that at the final stage of the first tier, or Existence tier, the US currently occupies, there will be a leap to the next stage or tier, that being the Being tier, where all the previous value systems have been transcended and included into the value systems of the Being tier.

We will need to address, the authors contend, with the shifting social class position of health professionals and to the increasingly oligopolistic and financialized character of the health insurance industry. The transition beyond Obamacare, they point out, will need to address also the consolidation of large health systems. Obamacare has increased the flow of capitated public and private funds into the insurance industry and extended the overall financialization of the global economy.

The authors conclude the chapter by declaring that as neoliberalism draws to a close, and as Obamacare fails, a much more fundamental transformation needs to reshape not just health care, but also the capitalist state and society.

To sum it all up, all the attempts cure the ills of health care by treating the symptoms and not the cause of the disease will not only fail, but is only making the disease worse, and the patient getting sicker. We need radical intervention before the patient succumbs to the greed and avarice of Wall Street, big business, and those whose stake in the status quo is to blame for the condition the patient is in in the first place.

Therefore, Obamacare is the last stage of neoliberal health care reform.