Billing and insurance-related waste in an academic medical center

Posted by on Wednesday, Feb 21, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Administrative Costs Associated With Physician Billing and Insurance-Related Activities at an Academic Health Care System

By Phillip Tseng, MEd; Robert S. Kaplan, PhD; Barak D. Richman, JD, PhD; Mahek A. Shah, MD; Kevin A. Schulman, MD
JAMA, February 20, 2018


Importance: Administrative costs in the US health care system are an important component of total health care spending, and a substantial proportion of these costs are attributable to billing and insurance-related activities.

Objective: To examine and estimate the administrative costs associated with physician billing activities in a large academic health care system with a certified electronic health record system.

Design, Setting, and Participants: This study used time-driven activity-based costing. Interviews were conducted with 27 health system administrators and 34 physicians in 2016 and 2017 to construct a process map charting the path of an insurance claim through the revenue cycle management process. These data were used to calculate the cost for each major billing and insurance-related activity and were aggregated to estimate the health system’s total cost of processing an insurance claim.

Exposures: Estimated time required to perform billing and insurance-related activities, based on interviews with management personnel and physicians.

Main Outcomes and Measures: Estimated billing and insurance-related costs for 5 types of patient encounters: primary care visits, discharged emergency department visits, general medicine inpatient stays, ambulatory surgical procedures, and inpatient surgical procedures.

Results: Estimated processing time and total costs for billing and insurance-related activities were 13 minutes and $20.49 for a primary care visit, 32 minutes and $61.54 for a discharged emergency department visit, 73 minutes and $124.26 for a general inpatient stay, 75 minutes and $170.40 for an ambulatory surgical procedure, and 100 minutes and $215.10 for an inpatient surgical procedure. Of these totals, time and costs for activities carried out by physicians were estimated at a median of 3 minutes or $6.36 for a primary care visit, 3 minutes or $10.97 for an emergency department visit, 5 minutes or $13.29 for a general inpatient stay, 15 minutes or $51.20 for an ambulatory surgical procedure, and 15 minutes or $51.20 for an inpatient surgical procedure. Of professional revenue, professional billing costs were estimated to represent 14.5% for primary care visits, 25.2% for emergency department visits, 8.0% for general medicine inpatient stays, 13.4% for ambulatory surgical procedures, and 3.1% for inpatient surgical procedures.

Conclusions and Relevance: In a time-driven activity-based costing study in a large academic health care system with a certified electronic health record system, the estimated costs of billing and insurance-related activities ranged from $20 for a primary care visit to $215 for an inpatient surgical procedure. Knowledge of how specific billing and insurance-related activities contribute to administrative costs may help inform policy solutions to reduce these expenses.

From the Introduction

Administrative costs have been estimated to represent 25% to 31% of total health care expenditures in the United States, a proportion twice that found in Canada and significantly greater than in all other Organization for Economic Co-operation and Development member nations for which such costs have been studied. The rate of growth in administrative costs in the United States has outpaced that of overall health care expenditures1 and is projected to continue to increase without reforms to reduce administrative complexity.

Most of the administrative costs in the US health care system (at least 62% based on prior studies) has been attributed to billing and insurance-related activities (described as billing hereafter). Billing costs are disproportionately high in the United States: for instance, in primary care practice, performing these activities in the United States costs nearly 4 times more than performing the corresponding activities in Canada.

From the Discussion

This study used a state-of-the-art cost accounting method to derive the costs associated with billing for physician activities at an encounter level. Across the 5 services examined in this study, billing costs for professional services ranged from 3.1% to 25.3% of professional revenue, which represented $20 to $215 in absolute costs per visit.

Previous studies of billing costs were developed before adoption of certified EHR systems. These studies used a variety of methods to estimate costs, including existing aggregate data, cost reports and departmental budgets, case studies, and interviews and surveys. They reported that physician billing costs represented 10% to 14% of revenue. This study, using a more accurate cost-tracing approach, estimated these costs to be 14.5% of primary care physician annual revenue, which is at the upper end reported in previous studies.

Billing activities were associated with these high costs despite specific efforts to streamline billing operations. Examination of the billing process did not reveal any significantly wasteful or inefficient efforts, such as overt duplication of tasks or the performance of low-skill tasks by high-wage personnel.

Certified EHR systems were implemented, in part, to address concerns about the significant administrative cost burden in the US health care system. The Office of the National Coordinator for Health Information Technology has suggested that adoption of certified EHR systems could have economic benefits for physicians and health systems by directly addressing these costs. However, the results of the current study suggest that administrative costs remain high even in the setting of a certified EHR. Although the EHR system can automatically generate bills for clinical visits, these systems require the time of high-cost physicians to perform coding and documentation activities that are unrelated to clinical services. In addition, the process maps revealed that despite the electronic system, the billing process still required multiple steps by many types of personnel. Full allocation of certified EHRs to billing activities significantly increased billing costs from the base-case estimate.

These findings suggest that significant investments in certified health information technology have not reduced high billing costs in the United States. To a large degree, the significant administrative costs measured in this study are the consequences of heterogeneous payment requirements across the multiple payers and health plans contracting with the academic health center. The lack of standardized contracts and price schedules within and across markets might explain why administrative costs in the United States are significantly higher than those in other nations that also make fee-for-service payments to private hospitals and physicians. Adoption of certified EHR systems by hospitals appears to have been unable to cope with the complexity of multiple payer contracts or to catalyze significant transformation of the administrative business processes in US health care.…


Disentangling Health Care Billing For Patients’ Physical and Financial Health

By Vivian S. Lee, MD, PhD, MBA; Bonnie B. Blanchfield, CPA, ScD
JAMA, Editorial, February 20, 2018

In this issue of JAMA, Tseng and colleagues1 estimated the administrative costs associated with physician billing and insurance-related activities in one large academic medical center with a fully implemented electronic health record (EHR) system. Based on a time-driven activity-based costing method and interviews with health system administrators and physicians, the authors estimated that the costs associated with billing activities performed by physicians represented, as a proportion of professional revenue, 14.5% for primary care visits, 25.2% for emergency department visits, 8.0% for general medicine inpatient stays, 13.4% for ambulatory surgical procedures, and 3.1% for inpatient surgical procedures. For primary care visits, this translated to an estimated more than $99,000 of billing and insurance-related expenses annually for each primary care physician working in the system just to get paid.

As high as these figures are, they likely underestimate the true financial burden of billing for physicians in most health systems. For one, the hospital and physicians of this academic system share a single billing organization, an unusual efficiency for an industry in which hospitals and physicians are typically separate business entities. In addition, billing costs in this study did not include costs within clinical departments for credentialing and other billing-related functions or charge integrity costs (ie, the costs associated with ensuring that all health care delivery charges are accounted for and properly accrued to each patient visit or discharge). While annual operating costs of the EHR were included in this estimate of billing costs, the capital costs of the EHR were not. When the full costs of EHR installation and implementation were fully amortized and attributed to billing, the calculated costs of billing increased by another 44% to 68%.

Despite the preimplementation assumption that EHRs would streamline coding and reduce clinical documentation requirements, this study suggests that, if anything, administrative time needed for billing has increased for physicians and other staff as EHRs have become more widespread. In the health care system the authors studied, each primary care visit necessitated 3 minutes of physician time for billing, which amounts to about 5 hours per week for a typical primary care physician. These figures exceed previous estimates of 3 to 4 hours per week.

The results from the analyses by Tseng et al1 are consistent with previous reports and again highlight how much health care is an outlier compared with other industries. The unnecessarily complex, fragmented, and inefficient system of billing, coding, and claims negotiations in the US health care system employs enough people to populate small nations just to ensure that health care organizations and clinicians are reimbursed for their services. While non–health care industries typically might employ 100 full-time-equivalents to collect payment for $1 billion in services, health care employs an astounding 770 full-time-equivalents per $1 billion of physician services. The process of moving money from payer to hospitals and physicians in the United States consumes an estimated $500 billion per year, and 80% of that amount may be waste. Evidence of that waste includes the high rate of errors in remittances (3-fold higher than other industries) and the high rate of billed charges that are initially denied by insurance companies (12.6% in one study) but that are later paid (81%).

Increasing Payer and Hospital or Health System Mergers

Increasing market consolidation bringing insurers and health systems (including hospitals and physicians) under the same corporate umbrella could help simplify what could then be considered “internal” transactions. Along the same lines, discussions of a national single payer system suggest that such a model could reduce administrative costs substantially, although the political viability of this strategy is uncertain.

Rising Consumer Payments

These changes may be accelerated by the mounting pressure from consumers as payment obligations shift increasingly to them. Whether it is direct payment for noncovered services, a higher share of premium expenses, or increasing copays and deductibles, consumers now pay a larger share of health care costs than employers.

As the report by Tseng et al demonstrates, now is an opportune time to start unraveling the Gordian knot of health care billing and administration, ultimately, for the sake of the health—both physical and financial—of patients. Alternative payment models and EHRs may just be the 2 ends of the cord that the health care system has needed to find to help begin the disentangling.…

This report further validates previous studies demonstrating administrative excesses in our health care system, especially in billing and insurance related activities. If anything, this new study shows that the administrative costs in time and funds may be even greater than previous studies suggest. It further shows that the promise of greater efficiency through certified electronic health record systems was not fulfilled, and EHRs have even compounded the administrative waste.

To understand the magnitude of the problem, you should read the excerpts above. Also prior studies, several of which were done by some members of the academic leadership at PNHP can be found on the PNHP website (

An accompanying editorial states, “discussions of a national single payer system suggest that such a model could reduce administrative costs substantially, although the political viability of this strategy is uncertain.” Yet they conclude, “Alternative payment models and EHRs may just be the two ends of the cord that the health care system has needed to find to help begin the disentangling.”

It is ironic that the editorialists suggest that that the ineffective alternative payment models and disappointing EHR technology somehow hold the solutions to this egregiously expensive and wasteful problem of administrative excesses. Yet the mechanism that has been proven in other nations to be highly effective – a single payer national health program – seems to be dismissed because of uncertain political viability.

From a policy perspective, single payer is the right way to go whereas APMs and EHRs will never get us there. When the policy is right and the politics are wrong, you don’t change the policy, you change the politics. This study shows once again that we have only one clear policy choice – an improved Medicare for all. Let’s fix the politics so we can get there.

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New federal rule expanding short-term, limited-duration pauper plans

Posted by on Tuesday, Feb 20, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Trump Administration works to give relief to Americans facing high premiums, fewer choices

U.S. Department of Health & Human Services, February 20, 2018

In direct response to President Trump’s October 2017 Executive Order, the Departments of Health and Human Services (HHS), Labor, and the Treasury (the Departments) issued a proposed rule today that is intended to increase competition, choice, and access to lower-cost healthcare options for Americans. The rule proposes to expand the availability of short-term, limited-duration health insurance by allowing consumers to buy plans providing coverage for any period of less than 12 months, rather than the current maximum period of less than three months. The proposed rule, if finalized, will provide additional options to Americans who cannot afford to pay the costs of soaring healthcare premiums or do not have access to healthcare choices that meet their needs under current law

“Americans need more choices in health insurance so they can find coverage that meets their needs,” said Health and Human Services Secretary Alex Azar. “The status quo is failing too many Americans who face skyrocketing costs and fewer and fewer choices. The Trump Administration is taking action so individuals and families have access to quality, affordable healthcare that works for them.”

“Americans who find themselves between jobs or simply can’t afford coverage because prices are too high will be helped by President Trump’s Healthcare for All Executive Order,” said Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma. “In a market that is experiencing double-digit rate increases, allowing short-term, limited-duration insurance to cover longer periods gives Americans options and could be the difference between someone getting coverage or going without coverage at all.”…

CMS Fact Sheet: Short-Term, Limited-Duration Insurance Proposed Rule…


Proposed Rule: Short-Term, Limited-Duration Insurance (Department of the Treasury; Department of Labor; Department of Health and Human Services)

Federal Register, to be published February 21, 2018


This rule contains proposals amending the definition of short-term, limited- duration insurance for purposes of its exclusion from the definition of individual health insurance coverage. This action is being taken to lengthen the maximum period of short-term, limited- duration insurance, which will provide more affordable consumer choice for health coverage.

Short-Term, Limited-Duration Insurance

Short-term, limited-duration insurance is a type of health insurance coverage that was
designed to fill temporary gaps in coverage that may occur when an individual is transitioning from one plan or coverage to another plan or coverage. Although short-term, limited-duration insurance is not an excepted benefit, it is exempt from the PHS Act’s individual-market requirements because it is not individual health insurance coverage. Section 2791(b)(5) of the PHS Act provides “[t]he term ‘individual health insurance coverage’ means health insurance coverage offered to individuals in the individual market, but does not include short-term limited duration insurance.”


Consumers who would be likely to purchase short-term, limited-duration insurance for longer periods would benefit from increased insurance options at lower premiums, as the average monthly premium in the fourth quarter of 2016 for a short-term, limited-duration policy was approximately $124 compared to $393 for an unsubsidized PPACA-compliant plan. This proposed rule would also benefit individuals who need coverage for longer periods for reasons previously discussed in the preamble, such as needing more than 3 months to find new employment, or finding PPACA-compliant plans to be unaffordable. Individuals who purchase short-term, limited-duration insurance as opposed to being uninsured would potentially experience improved health outcomes and have greater protection from catastrophic health care expenses. Individuals purchasing short-term, limited-duration policies could obtain broader access to health care providers compared to those PPACA-compliant plans that have narrow provider networks.

Issuers of short-term, limited-duration insurance would benefit from higher enrollment. They are likely to experience an increase in premium revenues and profits because such policies can be priced in an actuarially fair manner (by which the Departments mean that it is priced so that the premium paid by an individual reflects the risks associated with insuring the particular individual or individuals covered by that policy) and are not required to comply with PPACA medical loss ratio requirements for group and individual health insurance coverage.

Costs and Transfers

Short-term, limited-duration insurance policies would be unlikely to include all the elements of PPACA-compliant plans, such as the preexisting condition exclusion prohibition, coverage of essential health benefits without annual or lifetime dollar limits, preventive care, maternity and prescription drug coverage, rating restrictions, and guaranteed renewability. Therefore, consumers who switch to such policies from PPACA-compliant plans would experience loss of access to some services and providers and an increase in out-of-pocket expenditures related to such excluded services, benefits that in many cases consumers do not believe are worth their cost (which could be one reason why many consumers, even those receiving subsidies for PPACA-compliant plans, may switch to short-term, limited-duration policies rather than remain in PPACA-compliant plans). Depending on plan design, consumers who purchase short-term, limited-duration insurance policies and then develop chronic conditions could face financial hardship as a result, until they are able to enroll in PPACA-compliant plans that would provide coverage for such conditions.

Because short-term, limited-duration insurance policies can be priced in an actuarially fair manner, subject to State law, individuals who are likely to purchase such coverage are likely to be relatively young or healthy. Allowing such individuals to purchase policies that do not comply with PPACA, but with term lengths that may be similar to those of PPACA-compliant plans with 12-month terms, could potentially weaken States’ individual market single risk pools. As a result, individual market issuers could experience higher than expected costs of care and suffer financial losses, which might prompt them to leave the individual market. Although choices of plans available in the individual market have already been reduced to plans from a single insurer in roughly half of all counties, this proposed rule may further reduce choices for individuals remaining in those individual market single risk pools.

The Departments anticipate that most of the individuals who switch from individual market plans to short-term, limited-duration insurance would be relatively young or healthy and would also not be eligible to receive APTC (Advance Premium Tax Credit). If individual market single risk pools change as a result, it would result in an increase in premiums for the individuals remaining in those risk pools. An increase in premiums for individual market single risk pool coverage would result in an increase in Federal outlays for APTC.

The Congressional Budget Office estimates that 3 million people will drop coverage in 2019 from the individual market and premiums will increase 10 percent on average, as a result of the change to the individual shared responsibility payment.…

The Trump administration has released a rule that will allow individuals to purchase a short-term, limited-duration insurance plan for a period less than twelve months, extending the current limit which is less than three months. What are these plans, and why does the administration believe that they should be made more readily available?

In 2016 the average monthly premium for a short-term, limited-duration plan was $124 compared to $393 for an unsubsidized PPACA-compliant plan. The very low premium should give you a hint that you are not buying very much protection. In fact, “short-term, limited-duration insurance policies would be unlikely to include all the elements of PPACA-compliant plans, such as the preexisting condition exclusion prohibition, coverage of essential health benefits without annual or lifetime dollar limits, preventive care, maternity and prescription drug coverage, rating restrictions, and guaranteed renewability.” People who need health care would likely face financial hardship under these plans. Also, younger, healthier individuals would likely be attracted by the low premiums and leave the PPACA-compliant plans, concentrating risk in the compliant plans resulting in higher premiums for those who remain. The coverage is so poor that the rule states, “it is exempt from the PHS Act’s individual-market requirements because it is not individual health insurance coverage.” These are pauper plans. They provide neither guaranteed health care access nor financial security in the face of medical need.

HHS Secretary Alex Azar says, “The status quo is failing too many Americans who face skyrocketing costs and fewer and fewer choices,” so they are making available an additional choice of very cheap pauper plans.

CMS Administrator Seema Verma says, “In a market that is experiencing double-digit rate increases, allowing short-term, limited-duration insurance to cover longer periods gives Americans options and could be the difference between someone getting coverage or going without coverage at all,” a choice for some between a pauper plan or nothing at all.

The goal was affordable health care for all, not affordable private health plans no matter how worthless they are. We need to replace Congress and the administration with people who understand and care about the difference.

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Robert Reich on ‘the common good’ – appropriate for Presidents day

Posted by on Monday, Feb 19, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

The Meaning of America

By Robert Reich, February 17, 2018

When Trump and his followers refer to “America,” what do they mean?

Some see a country of white English-speaking Christians.

Others want a land inhabited by self-seeking individuals free to accumulate as much money and power as possible, who pay taxes only to protect their assets from criminals and foreign aggressors.

Others think mainly about flags, national anthems, pledges of allegiance, military parades, and secure borders.

Trump encourages a combination of all three – tribalism, libertarianism, and loyalty.

But the core of our national identity has not been any of this. It has been found in the ideals we share – political equality, equal opportunity, freedom of speech and of the press, a dedication to open inquiry and truth, and to democracy and the rule of law.

We are not a race. We are not a creed. We are a conviction – that all people are created equal, that people should be judged by the content of their character rather than the color of their skin, and that government should be of the people, by the people, and for the people.

That idealism led Lincoln to proclaim that America might yet be the “last best hope” for humankind. It prompted Emma Lazarus, some two decades later, to welcome to American the world’s “tired, your poor/ Your huddled masses yearning to breathe free.”

That idealism sought to preserve and protect our democracy – not inundate it with big money, or allow one party or candidate to suppress votes from rivals, or permit a foreign power to intrude on our elections.

It spawned a patriotism that once required all of us take on a fair share of the burdens of keeping America going – paying taxes in full rather than seeking loopholes or squirreling money away in foreign tax shelters, serving in the armed forces or volunteering in our communities rather than relying on others to do the work.

These ideals compelled us to join together for the common good – not pander to bigotry or divisiveness, or fuel racist or religious or ethnic divisions.

The idea of a common good was once widely understood and accepted in America. After all, the U.S. Constitution was designed for “We the people” seeking to “promote the general welfare” – not for “me the narcissist seeking as much wealth and power as possible.”

Yet the common good seems to have disappeared. The phrase is rarely uttered today, not even by commencement speakers and politicians.

There’s growing evidence of its loss – in CEOs who gouge their customers and loot their corporations; Wall Street bankers who defraud their investors; athletes involved in doping scandals; doctors who do unnecessary procedures to collect fatter fees; and film producers and publicists who choose not to see that a powerful movie mogul they depend on is sexually harassing and abusing women.

We see its loss in politicians who take donations from wealthy donors and corporations and then enact laws their patrons want, or shutter the government when they don’t get the partisan results they seek.

And in a president of the United States who has repeatedly lied about important issues, refuses to put his financial holdings into a blind trust and personally profits from his office, and foments racial and ethnic conflict.

This unbridled selfishness, this contempt for the public, this win-at-any-cost mentality, is eroding America.

Without binding notions about right and wrong, only the most unscrupulous get ahead. When it’s all about winning, only the most unprincipled succeed. This is not a society. It’s not even a civilization, because there’s no civility at its core.

If we’re losing our national identity it’s not because we now come in more colors, practice more religions, and speak more languages than we once did.

It is because we are forgetting the real meaning of America – the ideals on which our nation was built. We are losing our sense of the common good.…

The Common Good, by Robert B. Reich (Publication date February 20, 2018)…

Crisis in U.S. Health Care: Corporate Power vs. The Common Good, by John Geyman, M.D.…

Contrasting our presidents, past and present, it is easy to see why Robert Reich says that we are losing our sense of the common good. He writes, “Yet the common good seems to have disappeared. The phrase is rarely uttered today, not even by commencement speakers and politicians.”

Well, that doesn’t apply to all of us. If you type “common good” into the search window at the PNHP website ( you will find many references to the common good. Even one of our own, John Geyman, has written a book, “Crisis in U.S. Health Care: Corporate Power vs. The Common Good.”

Tomorrow is the publication date of Robert Reich’s new book, “The Common Good.” It is liberally excerpted at the Amazon website (link above).

Presidents Washington and Lincoln helped us to understand the common good. Now President Trump, in his own style, unintentionally reminds us of the importance of this concept. We should use this Presidents Day as a starting point on our renewed quest for the common good.

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David Cutler: What is the health spending problem?

Posted by on Friday, Feb 16, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

What Is The U.S. Health Spending Problem?

By David M. Cutler
Health Affairs, Published Ahead of Print February 14, 2018


Is increased spending on medical care harmful to the US economy? The overall share of the gross domestic product spent on medical care is not a problem, provided that the services bought are worth more than their cost. However, high and rising costs expose two often-overlooked problems. First, spending is too high because many dollars are wasted. Estimates suggest that unnecessary medical spending costs the typical American family thousands of dollars each year. Second, high medical costs combined with stagnant incomes for a large share of the population and the inability of governments at all levels to raise tax dollars leads to increased health and economic disparities: fewer people covered by private insurance, the rationing of care in public health programs, and the lack of funds for other social programs. These distribution issues, coupled with the large waste, imply that efforts to address medical spending need to be among our highest priorities.

A Large Part of Spending Is Wasteful

A large number of studies have estimated the waste in health care. Estimates suggest that between one-quarter and one-half of medical spending is not associated with improved health, although this view is not without controversy.

High prices are a second form of wasteful spending.

Excessive administrative costs are a third form of wasteful spending.

The fact that there is so much waste in medical care does not mean that spending more is necessarily bad.

But neither should we assume that all spending increases reflect value, as indicated by the rising prices of established drugs or of services from newly merged hospitals. Most fundamentally, the presence of significant waste argues that we ought to pay at least as much attention to ways of improving efficiency as we do to whether and how people should get covered.

Rising Spending Worsens Inequality

The second problem with medical spending is that it feeds into the already severe harms caused by growing income inequality. The most important fact about the income distribution in the United States is that it is becoming increasingly unequal: Real incomes have soared at the very high end, risen modestly in the next few deciles, and been stagnant or falling at the bottom.

Rising medical costs combined with stagnant incomes for a large share of the population mean that more people will need help paying for medical care. A family at the median income level, whose income is relatively constant, has had no easy way to pay the roughly $10,000 rise in the cost of a family health insurance policy between 1999 and 2017.

At the same time that needs are increasing, however, government resources are being cut. Governments at all levels are loath to raise taxes, and some are even cutting them. Total government revenue as a share of GDP has been relatively constant for several decades and is projected to fall with enactment of the federal tax bill in December 2017.

This combination of increased need for help and fewer resources to spend inevitably creates problems. Three problems are particularly apparent.

Fewer People Are Covered by Private Insurance

Public Programs Turn to Rationing

Other Social Programs Are Crowded Out

Even with both explicit and implicit rationing, rising costs for medical care translate into higher overall government spending. Given the constraint on raising money, this necessarily means that less money is available for other government services—for example, spending on early childhood education or income subsidies for low-income workers.


Additional medical spending brings both benefits and costs to society. For this reason, the question about how much money a country such as the United States can afford to spend on medical care is not well formulated. But that ambiguity does not mean that additional medical spending is innocuous. The United States is being pulled apart as a country, separating into rich and poor. Every dollar that is spent on medical care is one less dollar available for addressing the problems of an unequal society, and one more dollar that is difficult for much of the population to pay. One of the goals for health policy must be to reduce social and economic disparities, not increase them.…

In this article David Cutler reminds us of two problems with health care spending that demand our attention: Wasted dollars on health care could be better spent on the typical American family, and high medical costs along with stagnant incomes and limits on government funding lead to increased health and economic disparities.

Reducing waste is relatively straightforward under a single payer national health program. Cutler calls for improving efficiency and two of the ways that single payer would do that include a tremendous reduction in administrative waste by converting to a well designed single financing system, and a reduction in services of negligible value by improving allocation of our resources such that services of greater value displace those of little value.

But look at the potential single payer would have at helping to address our social and economic disparities. Although David Cutler remains silent on single payer, it is obvious to us that the problems he discusses cry out for single payer reform.

The publishers have granted free access to this article. You should take advantage of that to read the full article.

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How should we use the CMS National Health Expenditures projection?

Posted by on Thursday, Feb 15, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

CMS Office of the Actuary releases 2017-2026 Projections of National Health Expenditures

Centers for Medicare & Medicaid Services (CMS), February 14, 2018

Today the independent CMS Office of the Actuary released the projected national health expenditures for 2017-2026.

National health expenditure growth is expected to average 5.5 percent annually over 2017-2026, according to a report published today as an “Ahead Of Print” by Health Affairs and authored by the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS).

Growth in national health spending is projected to be faster than projected growth in Gross Domestic Product (GDP) by 1.0 percentage point over 2017-2026. As a result, the report projects the health share of GDP to rise from 17.9 percent in 2016 to 19.7 percent by 2026.

The outlook for national health spending and enrollment over the next decade is expected to be driven primarily by fundamental economic and demographic factors: trends in disposable personal income, increases in prices for medical goods and services, and shifts in enrollment from private health insurance to Medicare that result from the continued aging of the baby-boom generation into Medicare eligibility.

“Personal healthcare spending” measures spending for medical goods and services provided directly to patients. Over the projection period, growth in personal healthcare prices and growth in the use and intensity of care provided collectively explain about three quarters of the growth in personal healthcare spending.

The report also found that by 2026, federal, state and local governments are projected to finance 47 percent of national health spending, up from 45 percent in 2016.

“Today’s report from the independent CMS Office of the Actuary shows that healthcare spending is expected to continue growing more quickly than the rest of the economy,” said CMS Administrator Seema Verma. “This is yet another call to action for CMS to increase market competition and consumer choice within our programs to help control costs and ensure that our programs are available for future generations.”…


National Health Expenditure Projections 2017-2026; Forecast Summary; Major Findings for National Health Expenditures: 2017-2026

Centers for Medicare & Medicaid Services (CMS), Office of the Actuary

* Under current law, national health spending is projected to grow at an average rate of 5.5 percent per year for 2017-26 and to reach $5.7 trillion by 2026. While this projected average annual growth rate is more modest than that of 7.3 percent observed over the longer-term history prior to the recession (1990-2007), it is more rapid than has been experienced 2008-16 (4.2 percent).

* Health spending is projected to grow 1.0 percentage point faster than Gross Domestic Product (GDP) per year over the 2017-26 period; as a result, the health share of GDP is expected to rise from 17.9 percent in 2016 to 19.7 percent by 2026.

* Projected national health spending and enrollment growth over the next decade is largely driven by fundamental economic and demographic factors: changes in projected income growth, increases in prices for medical goods and services, and enrollment shifts from private health insurance to Medicare related to the aging of the population.

* Among the major payers for health care, growth in spending for Medicare (7.4 percent per year) and Medicaid (5.8 percent per year) are both substantial contributors to the rate of national health expenditure growth for the projection period. Both trends reflect the impact of an aging population, but in different ways. For Medicare, projected enrollment growth is a primary driver; for Medicaid, it is an increasing projected share of aged and disabled enrollees.

* The recent enactment of tax legislation that eliminated the individual mandate is expected to lead to a reduction in the insured rates. Economic factors, such as projected GDP growth and employment trends, are the primary factors contributing to a slight projected decline in the insured share of the population from 91.1 percent in 2016 to 89.3 percent in 2026.…


National Health Expenditure Projections, 2017–26: Despite Uncertainty, Fundamentals Primarily Drive Spending Growth

Health Affairs, February 14, 2018


National Health Expenditures (NHE)
2018 – $3,675.3 billion
2026 – $5,696.2 billion

NHE per capita
2018 – $11,193.2
2026 – $16,167.6

NHE as percent of GDP
2018 – 18.2%
2026 – 19.7%…

The Office of the Actuary of CMS remains the best source of predictions for the future of our health care spending. Reasonable economic and demographic analyses indicate that growth of spending will continue to be driven especially by price increases and by growth in use and intensity of care related to demographic changes. By 2026, national health expenditures as a share of GDP are expected to rise to 19.7 percent – almost one-fifth of our GDP.

Although we continue to have a national discourse on the amount of our health care spending, other important variables include the accessibility of health care and the financial barriers which influence that access. The design of the nation’s health care financing system is even more crucial than the amount we are spending.

Because of the high costs of health care, the great variability in individual health care needs, and and the unequal distribution of income and wealth, a health care system that takes care of everyone requires an egalitarian transfer from the healthy and wealthy to the sick and poor. A well designed single payer national health program does precisely that, but it requires the implementation of an effective public (government) program.

Can the private sector accomplish the transfer in an effective and equitable manner? Absolutely not, and we have a century of experience with the private sector to prove this. Even with the high level of government involvement that we now have (the government funds about two-thirds of our health care) the design of our health care financing system has failed to implement the tools that would increase the effectiveness and efficiency in allocation of our health care funds and resources.

What does this have to do with the report on our national health expenditures? The press release quotes CMS Administrator Seema Verma: “Today’s report from the independent CMS Office of the Actuary shows that healthcare spending is expected to continue growing more quickly than the rest of the economy. This is yet another call to action for CMS to increase market competition and consumer choice within our programs to help control costs and ensure that our programs are available for future generations.” Get the government out and turn it over to the private sector – a recipe for disaster – as the policies already put into place by the current administration and previous administrations are now demonstrating, and they promise much more.

Using standard economic and demographic analyses can predict a certain amount of stability in health care financing, but the political variables can greatly distort the future. Depending on who we select to lead our nation, we could have comprehensive, affordable health care for absolutely everyone, or we could have a system designed primarily to enrich the medical-industrial complex while threatening the health and financial security of the majority of us.

Don’t let a sterile report on national health expenditures lull you into complacency.

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Copayments can kill

Posted by on Wednesday, Feb 14, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Weatherford teacher dies from flu effects

By Christin Coyne and Jelani Gibson
Weatherford Democrat, February 5, 2018

A second grade teacher at Ikard Elementary School, 38-year-old Heather Holland, died Sunday due to complications of the flu.

In addition to a classroom of second graders, Holland left behind husband Frank Holland, a 10-year-old daughter, and a 7-year-old son.

Holland fell ill about a week ago and planned to pick up flu medication but felt the $116 copay was too high, her husband said.

Frank Holland bought the prescription himself when he found out, but things worsened.

“Friday night, things escalated and she ended up in the ICU,” Holland said. “The doctors got the blood cultures back and they had to put her on dialysis early Saturday.”

Heather Holland died Sunday morning.

“I have to be strong for the kids but it’s still surreal, it hasn’t all set in,” Holland said. “We’ve been together a long time, over half my life. She’s my best friend, my soulmate, my everything.”…

It is difficult to discuss policy issues in the face of tragedies such as this. Heather Holland’s husband, children and students come first. A moment of silent contemplation seems appropriate here.


We will never know whether earlier initiation of her flu medication could have improved her outcome. Evidence suggests that the medication shortens duration of symptoms, but reduction of complications is not quite so clear.

What we do know is that treatment was available, but it was delayed because of a $116 copayment. We do know that erecting financial barriers to care such as cost sharing through deductibles, copayments and coinsurance reduces access to care and can result in adverse outcomes – suffering and sometimes even death.

In this case we would have much preferred to have never heard about this tragedy because taking medication, getting well, and going back to work is not a newsworthy story. Again, we will never know for sure.

One of the most fundamental principles of a national health program such as the model supported by PNHP is that the financing of health care and the delivery of health care are totally separated. People should have health care when they need it without a need to arrange personal finances as a condition of accessing that care. Instead, the entire health care system should be financed in advance of need through equitable taxes based on ability to pay.

This concept is so simple, yet across the political spectrum voices tell us that patients need to fulfill their personal financial responsibilities before they access care. In a well designed single payer national health program they have already done that by paying their taxes. All of our policies should be oriented to helping people get the care they need when they need it. Why do we make that so complicated?

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Stephen Miller has to go

Posted by on Tuesday, Feb 13, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Letter to the White House: Stephen Miller must be removed

National Council of Jewish Women

On February 8, 17 Jewish organizations sent a letter authored and organized by NCJW to White House Chief of Staff General John Kelly expressing our deep concern that Senior Policy Advisor Stephen Miller does not belong in national leadership due to his extreme viewpoints and advocacy of racist policies.

February 8, 2018

General John F. Kelly
White House Chief of Staff
The White House
1600 Pennsylvania Avenue
Washington, DC 20500

Dear General Kelly:

We, the undersigned Jewish agencies and organizations, are writing to share our deep concern that Senior Policy Advisor Stephen Miller does not belong in national leadership due to his extreme viewpoints and advocacy of racist policies.

As Jews, we are in solidarity with immigrants and refugees and believe that our nation must be a refuge and welcoming home for new Americans. Our people have been persecuted too many times in history for us to do otherwise. Not only our history but our holy texts teach us this: we are commanded by the Torah to welcome the stranger, for we were once strangers in the land of Egypt. We believe that we are all made b’tzelem Elohim, or “in the image of God.” Every person is deserving of a dignified and safe life, regardless of race, religion, nationality or any other identity.

Stephen Miller’s views on immigration are extreme and dangerous, and he has been an obstacle to passing widely-supported, bipartisan, popular, badly-needed immigration policy changes throughout his time in the administration. There will be no forward motion for immigrants and refugees while he advises the president, despite bipartisan support, to the detriment of all who live and work in this country. Immigrants are a vital part of American society and crucial to our country’s businesses. They are also human beings deserving of a decent life, out of the shadows.

Miller’s views are anathema to our Jewish and American values. They’re outside the mainstream, and they have no place in the White House. Throughout his professional career, Miller has made no secret of his belief that immigration should be restricted and that immigrants are bad for our country. With then-Senator Sessions, Miller helped orchestrate the defeat of comprehensive immigration reform in 2014. He worked closely with Breitbart Media, a platform for the alt-right and white supremacist movements, and was a reliable media presence to comment on anti-immigrant and nativist policies. During the 2016 election, Miller was a frequent warm-up act at Trump’s campaign rallies, revving up the crowd by invoking the image of immigrants as criminals, telling rally attendees “We’re going to build [the wall] out of love for every family who wants to raise their kids in safety and peace.”

During his time in the White House, Miller’s hard line stance against immigrants has informed and even directed the administration’s policies. Miller was the architect of the first and second Muslim and Refugee bans, which blocked people from seven Muslim-majority countries from entering the US. He orchestrated cuts to the refugee program, resulting in the lowest admissions number in modern history during the worst refugee crisis since World War II. Miller helped author the now infamous list of the administration’s immigration priorities, which include building a border wall, defunding sanctuary cities, eliminating the diversity visa program, and changing the nation’s entire immigration system from one based on family unification to one based on speaking English and being light-skinned. These priorities have been cited as a prerequisite to any immigration negotiations. They are grotesquely anti-immigrant, and against the values of most Americans and certainly the Jewish community which our organizations represent.

Miller’s racist views should be enough to disqualify him from the White House, and his sway over President Trump has made it nearly impossible for Congress to move forward on a bipartisan deal to protect Dreamers — which 70-80% of Americans support. Senator Lindsey Graham held up Miller as an outlier even within their own party, and other Members of Congress point to Miller as a barrier to any type of agreement on immigration.

Our organizations, and the millions of Jews we represent, are in solidarity with immigrants and refugees as a reflection of our Jewish values and our American values. When our nation opens its doors, our families, communities, schools, and congregations thrive. Unlike Miller, we believe that the Statue of Liberty, by which so many of our own families passed during their journeys to the United States, is a potent symbol of the best our country has to offer — welcome and hope.

Stephen Miller opposes the beliefs we hold dear, and while he advises President Trump there will be no forward movement on immigration — to the detriment of this great nation founded by immigrants. We urge you to remove Miller from your team and the White House as soon as possible.


American Jewish World Service
Americans for Peace Now
Bend the Arc Jewish Action
Habonim Dror North America
J Street
Jewish Community Action
Jewish Council on Urban Affairs
Jewish Labor Committee
Jews for Racial & Economic Justice (JFREJ)
Jews United for Justice
National Council of Jewish Women
Open Hillel
T’ruah: The Rabbinic Call for Human Rights
The Workmen’s Circle…


The National Council of Jewish Women (NCJW) is a grassroots organization of volunteers and advocates who turn progressive ideals into action. Inspired by Jewish values, NCJW strives for social justice by improving the quality of life for women, children, and families and by safeguarding individual rights and freedoms.

NCJW believes that the moral test of a nation is how it treats its most vulnerable members. In recent years, the United States has failed that test, cutting the budgets of human needs programs and diverting critical federal dollars to military spending. Federal investments must ensure that human needs programs are fully funded including health care, lifelong education, opportunities to work, income supplements when work is not possible, and affordable necessities, including food, housing, and caregiving for children, seniors, and people with disabilities.


Trump takes immigration cues from ‘Pres. Stephen Miller’

By Paul Begala
CNN, January 23, 2018

In a remarkable bipartisan meeting on January 9, the President said he would sign what Sen. Dianne Feinstein, D-California, called “a clean DACA bill,” which would allow the Dreamers to stay with no strings attached. After that, he said, we would move to “Phase Two, which would be comprehensive immigration reform. … But I think we need to do DACA first.”

In that January 9 meeting, President Trump promised to take the heat and sign a bipartisan immigration reform bill. Acting on his urging, Senators Graham and Dick Durbin, D-Illinois, hammered out a compromise. At 10:15 a.m. on January 11, Durbin phoned the President and said they had a deal. He was receptive and invited the senators to brief him.

By the time Durbin and Graham came to the White House at noon, the President’s tone had changed radically. Surrounded by hardline staffers like Mr. Miller, and bolstered by anti-immigration Republicans like Senator Tom Cotton, R-Arkansas, and Rep. Bob Goodlatte, R-Virginia, the President launched into a racist tirade, saying he wanted more immigrants from overwhelmingly white Norway, rather than black and brown immigrants from “shithole countries” in Africa, the Caribbean and Central America.

“Every time we have a proposal, it is only yanked back by staff members,” Graham said. How can it be that the President, who ran as a deal-maker, is being overruled by a young man who seems to want to upend every deal?…


This two and one-half minute video from BBC reveals Stephen Miller’s character…

Although this is an unusual selection for a blog on single payer it is very apropos since Stephen Miller is one of the most influential advisors to President Trump and is a primary source of his speeches and some of his inflammatory rhetoric. Although the NCJW letter targets Miller’s “extreme viewpoints and advocacy of racist policies,” in a larger sense it represents a protest against the warped mores he brings to the White House that negatively impact other issues of social justice, including our issue of health care justice.

Our president needs help in making this a better nation. Stephen Miller “opposes the beliefs we hold dear.” He has to go.

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Events during the 2016 presidential campaigns and the first year of the Trump presidency have called into serious question his character, ethical behavior, mental health, and fitness for the office he now holds. As E. J. Dionne, Norman J. Ornstein and Thomas E. Mann observe in their 2017 book:

We have never had a president who aroused such grave and widespread doubts about his commitment to the institutions of self-government, to the norms democracy requires, to the legitimacy of opposition in a free republic, and to the need for basic knowledge about major policy questions and about how the government works. We have never had a president who daily raises profound questions about his basic competence and his psychological capacity to take on the most powerful and challenging political office in the world. We have never had a president who spoke more warmly of dictators than of democratic allies, and whose victory came with the assistance of a foreign power that meddled in our election. (Dionne, EJ, Jr, Ornstein, NJ, Mann, TE. One Nation After Trump: A Guide for the Perplexed, the Disillusioned, the Desperate, and the Not-Yet Deported. New York. St. Martin’s Press, 2017, pp. 1-2.)

Over the last two years, Trump has indicted himself in so many ways, ranging from pathologic and almost daily lying and his lack of knowledge or concern about policy issues to his impulsive and unpredictable behavior to his denial of alleged violations of the law and his constant attacks on our institutions, including the news media and our intelligence agencies. He shamelessly brags about his sexual prowess and ability to get away with anything (“When you’re a star they let you do it. You can do anything. Grab ‘em by the pussy.” (Donald Trump’s Lewd Comments About Women, 2016.)

He turns out to be a narcissist who believes he can do no wrong, is paranoid about those opposing him, and whose behavior puts himself above the rule of law. These traits have led to widespread fear and concern across this country and abroad.

Trump’s behavior has provided such demonstrable evidence of mental aberrances to lead the American Psychoanalytic Association to renounce their long-held policy of not commenting about an individual’s mental state without having first seen the person as a patient. (Begley, S. Psychiatry group tells members they can ignore ‘Goldwater rule’ and comment on Trump’s mental health. STAT, July 25, 2017.)

His well-reported behaviors led a group of 27 psychiatrists, psychologists, and other mental health experts to publish their 2017 book, The Dangerous Case of Donald Trump, edited by Bandy X. Lee, M.D. Their diagnostic assessments vary from sociopath and narcissism to paranoia, lack of impulse control, and vengeful retaliation. Whatever the diagnostic terms, however, this disturbing assessment is made by one of the authors:

What we do know is that he can’t be relied upon to recognize having been wrong; nor does he seem to be able to learn from experience such that he could avoid repeating the same untruth or another the next day, possessed as he appears to be of the same absolute conviction that characterized his previous error. (Glass, LL. In Lee, B.X. Editor, The Dangerous Case of Donald Trump, p. 158).

Two of the above 27 authors call on Congress to act now, under the Twenty-Fifth Amendment to the U. S. Constitution, to create an independent, impartial panel of investigators to evaluate Trump’s fitness to fulfill the duties of the presidency.

Whatever his mental health diagnoses, Trump is a danger to our democracy, and his presidency appears to be unsustainable given the corruption from the top down in the White House and Cabinet appointees. How can he survive the Mueller investigation, revelations about his own sexual misconduct, the $130,000 hush money, and the scandals surrounding his presidency that many now agree are far worse than Watergate?

Hopefully, our democracy will survive this acute illness as the democratic process moves forward, but what can we do to prevent future challenges of this kind? Two lessons seem apparent to me:

  1. Reporting of tax returns should be required of all candidates for the White House early in their campaigns. In this instance, it is likely that Trump’s reporting would have drawn attention to his shady business practices and ties to Russia that could lead to his potential blackmail; and
  2. Requiring background checks and applications for security clearances for all candidates for the presidency and vice presidency would seem to be in order.
    It seems obvious that Trump wouldn’t be president today if these kinds of vetting were done early in the 2016 election campaigns. Jennifer Rubin, Op-Ed columnist for The Washington Post, is spot-on with this observation:

Trump’s emotional and mental limitations should debunk a number of rationalizations from his devoted cultists, who insisted he was the best choice in 2016, cheered his first year in office and continue to pretend he’s fit for office. He’s sounding presidential. No, he’s reading off a teleprompter, likely with very little comprehension. He’s playing four-dimensional chess with Kim Jong Un. No, he’s impulsively lashing out, with the risk of provoking a deadly clash. He’s a master manipulator when he shifts from position to position, sometimes in the same sentence. No, he likely doesn’t even realize what contradicts what or remember what he originally said. His use of alternative facts is a brilliant scheme to control the press narrative. No, he’s incapable of processing real information and driven by an insatiable need for praise and reaffirmation.  . . . We’re playing with fire, counting on the ability of others to restrain him from, say, launching a nuclear war and, nearly as bad, jettisoning our representative democracy. Vice President Pence, the Cabinet and Congress have a moral and constitutional obligation to bring this to a stop. (Rubin, J. The ‘stable genius’ isn’t even functioning as president.”  The Washington Post, January 6, 2018.)

Are Medicaid work requirements legal?

Posted by on Monday, Feb 12, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Experimenting On The Health Of The Poor: Inside Stewart v. Azar

By Sara Rosenbaum
Health Affairs Blog, February 5, 2018

As the complaint in Stewart v. Hargan (now Stewart v. Azar), filed on January 24 in federal district court in Washington D.C. makes abundantly clear, both the work experiment solicitation and the approval of Kentucky’s 1115 waiver in its wake are remarkable for the clarity of their intent to use punishment—in the form of denial or loss of health insurance coverage—to promote work. It doesn’t take a wealth of empirical research to conclude that people who are healthy probably are more likely to hold jobs and work more. Furthermore, there is actual empirical research that suggests that the very act of providing access to health care under the ACA expansion has had a positive effect on health and work. There simply is no evidence to support any reasonable hypothesis that health can be promoted by threatening the future and stability of health care for people whose health is worse to begin with and who—owing to the concentrated nature of poverty in the U.S.—tend to live in communities with higher unemployment and reduced job prospects.

Every dimension of the Kentucky demonstration is in play, with no hypothesis other than the assumption that people are healthier when they work. The evidence regarding how Medicaid actually promotes work is not even acknowledged.

This design combines work requirements with new program features that, according to the state, reflect the far less forgiving world of commercial health insurance. In this version of Medicaid, its core objective becomes the inverse of its statutory aim: to limit access as much as possible so that people will stop relying on it.

These hoops are multiple: Work requirements with few, poorly defined exemptions; lengthy loss of coverage for failure to follow additional reporting requirements; stripping away essential benefits with little hope of regaining them; using Medicaid to expose people to the limits of commercial insurance through escalating premiums, delayed enrollment, and elevated cost-sharing; and selectively withholding benefits from people considered undeserving.

(To better understand the lawsuit, an explanation of the plaintiffs’ legal arguments, omitted here, can be accessed at the link below.)

The Limits Of 1115

Medicaid’s core features, essential structure, and express prohibitions on certain types of experiments essentially put the brakes on how far 1115 experiments can go. Furthermore, as the complaint notes, 1115 as an experimental statute has its own brakes. Its agency powers can be invoked only for experiments that further program objectives.

Kentucky’s Aim: Selectively Culling The Eligible Population

Given the fact that federal law bars states from selecting winners and losers among the eligibility groups they cover, what is so striking about the Kentucky experiment is the lengths to which the state and its federal partner have gone to come up with a strategy, under the guise of experimentation, for selectively culling the Medicaid population.

Final Thoughts

Despite its historic role in shaping Medicaid policy, however, 1115 is a statute that grants limited powers. At its heart, 1115 is designed to fulfill a specific purpose: to enable Medicaid to better achieve its objectives. What makes the January 11 Medicaid work solicitation and the Kentucky approval such outliers is the singular absence of an experiment that promotes Medicaid’s core objectives. The relationship between work and health is axiomatic but this axiom alone cannot serve as the basis for threatening insurance coverage for people who cannot fulfill work requirements.

Indeed, so far afield from Medicaid’s objectives are the Administration’s work experiments that, in its solicitation, the Administration makes clear that it will permit no federal funds to be claimed for costs associated with work supports, nor will it permit states to keep savings attributable to the loss of eligibility for reinvestment in other Medicaid activities. These two fundamental caveats drive home the degree to which the Trump Administration has essentially admitted that, rather than advancing policy goals involving health care for the poor, Medicaid work experiments undermine them.…

For another opinion on the legality of Medicaid work requirements, by Nicholas Bagley, JD:…

Nicolas Bagley writes, “But the courts have not been moved by the argument—true though it may be—that Congress never meant for section 1115 to be a vehicle for the adoption of sweeping, controversial, and partisan reforms to Medicaid. Instead of winning in court, the opponents of work requirements may need to win some elections.”

Medicaid was established to help low-income individuals receive the health care that they need. Section 1115 waivers were established to allow states to make modifications within the Medicaid program to better achieve that goal. The Trump administration is now undermining that goal by using the waivers to punish Medicaid beneficiaries by denying health care if unemployed. The legality is being challenged.

In her full article Sara Rosenbaum describes the legal principles and how HHS/CMS is undermining them. Nicholas Bagley also discusses the legal issues while making the very important point that the moral foundation ultimately is determined by our action as voters. We get what we choose.

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BMJ: Failing health of the United States

Posted by on Friday, Feb 9, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

The role of challenging life conditions and the policies behind them

By Steven H Woolf, Laudan Aron
BMJ, Editorial, February 7, 2018

Life expectancy in the US has fallen for the second year in a row. This is alarming because life expectancy has risen for much of the past century in developed countries, including the US. The decline in US health relative to other countries, however, is not new; it has been unfolding for decades. In 1960, Americans had the highest life expectancy, 2.4 years higher than the average for countries in the Organisation for Economic Cooperation and Development (OECD). But the US started losing ground in the 1980s. US life expectancy fell below the OECD average in 1998, plateaued in 2012, and is now 1.5 years lower than the OECD average.

A joint panel of the National Research Council and Institute of Medicine investigated the US health disadvantage in 2013. It found that Americans had poorer health in many domains, including birth outcomes, injuries, homicides, adolescent pregnancy, HIV/AIDS, obesity, diabetes, and heart disease. It also found that many factors contribute to the health disadvantage; for example, Americans are more likely to engage in unhealthy behaviors (such as heavy caloric intake, drug abuse, and firearm ownership), live in cities designed for cars rather than pedestrians or cyclists, have weaker social welfare supports, and lack universal health insurance.

The panel reported high death rates in the US from drugs, a problem that has grown over time. Between 2000 and 2014, the rate of fatal drug overdoses rose by 137%, a crisis fueled by the growing use of highly addictive opioid drugs. In 2015 alone, more than 64 000 Americans died from drug overdoses, exceeding the number of US casualties in the Vietnam war. Drug addiction is devastating families and the social fabric of communities. The country is belatedly scrambling to reduce access (with, for example, prescription drug monitoring and drug take back programs), improve emergency responses to reverse overdoses (such as naloxone programs), and enhance access to effective addiction treatment (such as medication assisted treatment).

But the opioid epidemic is the tip of an iceberg, part of an even larger public health crisis in the US: death rates from alcohol abuse and suicides have also been rising. Between 1999 and 2014, the suicide rate rose by 24%. These “deaths of despair,” as some have called them, are disproportionately affecting white Americans, especially adults aged 25-59 years, those with limited education, and women. The sharpest increases are occurring in rural counties, often in regions with longstanding social and economic challenges.

Why white Americans are dying at higher rates from drugs, alcohol, and suicides is unclear, complex, and not explained by opioids alone. The answer—likely some combination of factors in American life—must explain why the rise in mortality is greatest in white, middle aged adults and certain rural communities. Possibilities include the collapse of industries and the local economies they supported, the erosion of social cohesion and greater social isolation, economic hardship, and distress among white workers over losing the security their parents once enjoyed. By contrast, greater resilience might explain why black Americans—who have contended with longstanding structural disadvantages, discrimination, and higher all cause mortality—have not experienced a surge in drug deaths or suicides.

Other data are also enlightening. Over the three decades in which survival advances slowed in the US, educational performance weakened, social divides (including income inequality) widened, middle class incomes stagnated, and poverty rates exceeded those of most rich countries. The US is rich, but its wealth is not inclusive. Its social contract is weaker than in other countries—those in need have less access to social services, healthcare, or the prevention and treatment of mental illness and addiction. The “American dream” is increasingly out of reach, as social mobility declines and fewer children face a better future than their parents.

In theory, policy makers jolted by the shortening lifespan of Americans would hasten to correct these conditions. They would promote education, boost support for children and families, increase wages and economic opportunity for the working class, invest in distressed communities, and strengthen healthcare and behavioral health systems. But the pro-business policy agenda favored by elected officials rarely prioritizes these needs. On the contrary, recent legislation and regulations may prolong or intensify the economic burden on the middle class and weaken access to healthcare and safety net programs.

Ironically, leaders are outspoken about ending the opioid epidemic and bemoan spiraling and unsustainable healthcare costs. Solutions to both problems—which involve investment to support struggling families and communities and thereby improve public health—are often rejected, usually by leaders with competing self interests or ideological objections. The consequences of these choices are dire: not only more deaths and illness but also escalating healthcare costs, a sicker workforce, and a less competitive economy. Future generations may pay the greatest price.…

This editorial states that lack of universal health insurance is one cause of declining health and life expectancy in the United States, especially when contrasted with the superior performance of other OECD nations. But it is only one cause. We have much more that we need to do to reverse the increasing disparities and their unwelcome outcomes.

The people of the United States need an epiphany – the realization that we need to join together to improve understanding of our deficiencies and then to resolve to work together to fix them. The solutions lie primarily in the public arena. That means we need national political leadership that is dedicated to this cause. But that also means that the people will have to fire the obstructionist partisans. That would be easy except for the plethora of obstructionist partisan voters who are immune to epiphanies.

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Physicians for a National Health Program's blog serves to facilitate communication among physicians and the public. The views presented on this blog are those of the individual authors and do not necessarily represent the views of PNHP.

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