Future physicians ask if the AMA is ready for single payer

Posted by on Friday, Jun 8, 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.

Is this the year the AMA finally joins the single-payer movement?

By Jonathan Michels, Robertha Barnes, and Sydney Russell Leed
STAT, June 8, 2018

Fifty years ago this month, at the 1968 meeting of the American Medical Association, a fourth-year medical student named Peter Schnall seized the microphone and scolded several hundred of the most prestigious, highly educated white men in America.

“Organized medicine has never felt responsible and accountable to the American people for its actions and continues to deny them any significant voice in determining the nature of services offered to them,” Schnall chastised the group.

Today, in the midst of a revived Poor People’s Campaign, physicians and medical students are again pressuring the AMA to be more responsive to the needs of the nation’s uninsured and underinsured. At the AMA’s House of Delegates annual meeting in Chicago this weekend, its Medical Student Section will ask the AMA to end its decades-long opposition to a single-payer health insurance program, a system better known as Medicare for All that would be publicly financed but privately delivered. Why bother? For better or for worse, the AMA sets the agenda for American health policy.

Our wildly inefficient system is currently dominated by private insurance companies, a health care model spearheaded by the AMA. It produces some of the worst health outcomes in the industrialized world — the U.S. has the highest infant mortality rate and the highest number of avoidable deaths — and devours an ever-increasing share of our economy, with health spending accounting for a whopping 17.9 percent of our gross domestic product. Despite the improvements of the Affordable Care Act, 28 million Americans remain uninsured, without access to primary care that could prevent costly and life-threatening diseases. Those fortunate enough to have insurance face prohibitively expensive co-pays, premiums, and deductibles that limit access to care, and medical expenses are a leading cause of bankruptcy.

Contrary to the AMA’s assertions, a single-payer system would give health care providers more autonomy because their clinical decisions wouldn’t be second-guessed by insurance companies. Patients would have free choice of any doctor, allowing providers to compete based on quality of care. Physicians would spend less time on administrative responsibilities like paperwork and billing, and more time seeing patients, which boosts both their work satisfaction and income.

Will the AMA choose to move toward guaranteeing health care as a human right or continue down the wrong side of history by linking patients’ health to the vagaries of the private insurance market?

The activists who staged the protest at the AMA meeting in 1968 hoped that the organization would finally recognize health as a human right. It didn’t. A lot has changed in the ensuing 50 years. It’s time the AMA does, too.

Jonathan Michels is a premedical student at the University of North Carolina at Greensboro. Robertha Barnes is an MS/MD student at SUNY Upstate Medical University. Sydney Russell Leed is an MD/MPH student at SUNY Upstate Medical University. All are board members of Physicians for a National Health Program, an organization that advocates for an improved and expanded Medicare for All health system.


The destiny of health care lies in the hands of our nation’s present and future medical students. We are very proud of the student members of the board of Physicians for a National Health Program who authored this inspiring article. They represent the values that health care needs.

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Again, medical bankruptcy is not a myth

Posted by on Thursday, Jun 7, 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.

On March 22, 2018, The New England Journal of Medicine (NEJM) published a Perspective article by Carlos Dobkin, Amy Finkelstein, Raymond Kluender, and Matthew J Notowidigdo titled “Myth and measurement — the case of medical bankruptcies” concluding, “our findings suggest that medical factors play a much smaller role in causing U.S. bankruptcies than has previously been claimed.”

Along with other background material, this was covered in the Quote of the Day for March 22, 2018:


Today, June 7, 2018, the NEJM has published a response by David Himmelstein, Steffie Woolhandler and Elizabeth Warren:


Re: Myth and Measurement — The Case of Medical Bankruptcies

The New England Journal of Medicine, Correspondence, June 7, 2018


Dobkin et al. have made an important contribution in clarifying the relationship between health shocks and economic risk; like us, they have shown that health crises have major economic consequences for families and that even the insured are not adequately protected. However, in their Perspective article (March 22 issue), they mischaracterize our studies implicating medical problems as contributors to approximately 60% of personal bankruptcies, and their claim that medical bankruptcies are uncommon rests on methodologic choices that do not capture all medical causes of bankruptcy.

Contrary to their claim that our inferences about the causal relationship between medical bills and bankruptcy did not align with our respondents’ experiences, almost everyone we labeled “medically bankrupt” explicitly told us that medical problems caused their bankruptcy. For example, 41.8% of debtors interviewed specifically cited illness as a cause of their bankruptcy, 37.8% cited illness-related income loss, and 54.9% cited medical costs.

Dobkin et al. estimate the share of bankruptcies attributable to hospitalization from the change in slope of bankruptcy-filing trends after an index hospitalization. Yet, their data show that the rate began rising before hospitalization. Since the rate of bankruptcy does not increase with age, the increasing rate of bankruptcy before hospitalization could well be due to previous medical costs. Estimated bankruptcy rates based only on a change in filings after an index hospitalization are probably underestimates. In addition, they excluded anyone hospitalized in the 3 years before the study period, thus omitting many people with frequent hospitalizations — a group likely to be at high risk for medical bankruptcy.

The authors assume that hospitalization is the sole indicator of a medical problem that could lead to financial distress. But families can drown in medical debts without a hospitalization — they may spend hours in an emergency department after an accident, followed by months of physical therapy, or have chronic conditions requiring drugs costing tens of thousands of dollars. The authors explain that most people who incur high total medical expenditures have been hospitalized. Yet out-of-pocket — not total — expenditures are most salient to bankruptcy risk; an analysis of 2015 Medical Expenditure Panel Survey data reveals that only 18.2% of out-of-pocket spending was incurred by people hospitalized during the year. In effect, the authors excluded the people who incurred 81.8% of out-of-pocket costs.

Finally, the analysis by Dobkin et al. is not designed to measure bankruptcy associated with a child’s or spouse’s illness. However, a child’s terminal illness or a spouse’s long-term care can bankrupt a family.

Although they acknowledge the limitations of their analysis, the authors assert that their results “suggest that medical factors play a much smaller role in causing U.S. bankruptcies than has previously been claimed.” Yet medical bills account for a majority of unpaid debts sent to collection, and many other studies confirm that illness often inflicts financial suffering.

Debtors’ self-reports do have limitations. But hospitalization is only part of the story, and understanding medical bankruptcy requires multiple forms of empirical investigation, including asking debtors about their histories. Characterizing debtors’ self-reports as “myth” is demeaning to people struggling with health care costs, and artificially narrowing the definition of medical bankruptcy does not improve understanding of its causes.

David U. Himmelstein, M.D.
Steffie Woolhandler, M.D., M.P.H.
City University of New York at Hunter College, New York, NY

Elizabeth Warren, J.D.
U.S. Senate, Washington, DC


The authors reply: Himmelstein et al. argue that if bankruptcy filers are asked what caused their bankruptcy, a large share will say medical expenses. But their approach is not a credible way to estimate the causes of bankruptcy. It is akin to asking patients with cardiac disease what caused their heart attack; they probably do not know whether it was poor genes, poor diet, stress, or other factors. A related problem is social desirability bias, which makes it hard to take at face value explanations reported by the bankruptcy filers.

Causal estimates require isolating a potential cause and its effect on the outcome of interest. This is why we examined the effect of hospitalizations on bankruptcy and why other, similar studies have examined the effect of automobile accidents or cancer diagnoses on bankruptcies. These studies corroborate our conclusion that medical bankruptcies are a very small share of personal bankruptcies.

Continuing to focus on medical bankruptcies distracts from the actual considerable economic costs of illness and injury. Our research highlights that for Americans — even those with health insurance — hospitalizations substantially decrease employment and income; by contrast, in Denmark, people are heavily insured against reduced earnings due to illness and injury. It is here that research and policy need to focus.

Amy Finkelstein, Ph.D.
Raymond Kluender, B.S.
Massachusetts Institute of Technology, Cambridge, MA

Matthew J. Notowidigdo, Ph.D.
Northwestern University, Evanston, IL


It is difficult to understand why Amy Finkelstein and her colleagues are fixated on discrediting the landmark study on medical bankruptcy when they concede the “considerable economic costs of illness and injury.” There are a plethora of studies confirming the magnitude of medical debt and that our current health care financing system leaves far too many exposed to financial hardship.

Finkelstein et al make the very valid point that we we need to be insured against reduced earnings due to illness and injury – a point also made in the classic medical bankruptcy study by Himmelstein et al: “improved programs are needed to replace breadwinners’ incomes when they are disabled or must care for a loved one.” In focusing narrowly on income loss, it would be wrong to neglect the profound consequences of debt due to medical bills, even for those who are insured.

Suggesting that medical bankruptcy is a myth risks reducing the political support needed to revise our health care financing system so that it does not add financial hardship as an additional consequence of illness or injury. We emphatically do need a well designed, single payer national health program – an improved Medicare for all.

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The myth of Medicare’s projected insolvency

Posted by on Wednesday, Jun 6, 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.

Headlines, June 5, 2018

The New York Times: Medicare’s Trust Fund Is Set To Run Out In 8 Years. Social Security, 16.

The Washington Post: A Crucial Medicare Trust Fund Will Run Out Three Years Earlier Than Predicted, New Report Says

The Wall Street Journal: Social Security Expected To Dip Into Its Reserves This Year

The Associated Press: Trustees Report Warns Medicare Finances Worsening

USA Today: Medicare, Social Security Face Money Challenges, Affordable Care Act

Modern Healthcare: Medicare Funds Drying Up Faster Than Estimated

Bloomberg: Medicare Fund Falls Short In 2026, Sooner Than Last Forecast

Politico: Medicare To Go Broke Three Years Earlier Than Expected, Trustees Say



Medicare Financial Outlook Worsens

By Phil Galewitz
Kaiser Health News, June 5, 2018

Medicare’s financial condition has taken a turn for the worse because of predicted higher hospital spending and lower tax revenues that fund the program, the federal government reported Tuesday.

In its annual report to Congress, the Medicare board of trustees said the program’s hospital insurance trust fund could run out of money by 2026 — three years earlier than projected last year.

Juliette Cubanksi, associate director of Kaiser Family Foundation’s Medicare Policy Program, cautioned that the report doesn’t mean Medicare is going bankrupt in the next decade but Part A will only be able to pay 91 percent of covered benefits starting in 2026.

She noted that Congress has never let the trust fund go bankrupt. In the early 1970s, the program came within two years of insolvency. But the 2026 estimate marks the closest the program has come to insolvency since 2009, the year before the Affordable Care Act was approved.

Joe Baker, president of the Medicare Rights Center, said Congress still has plenty of time to act without making changes that harm beneficiaries.

“I worry about fear mongering and the need to do something radical to the program,” he said.


Every year the Medicare trustees project the year in which the funds for Part A of Medicare will be inadequate to pay the full costs for that year, based on anticipated revenue and spending. Each year the media then report the pending insolvency of Medicare. This is nonsense.

Although revenues and demographics may change, adjustments are made to keep the program fully funded. Only if Congress were to decide to destroy Medicare would funding be reduced below sustainable levels. This is particularly ironic since this year the Republicans in their budget have already made a statement that we do not have to have adequate revenues to pay our bills – producing a budget with a trillion dollar deficit.

Our job is to elect representatives who support Medicare – not just for current beneficiaries but for everyone, in an improved version. The inevitable political support would ensure full funding forever.

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Guns and Suicide

Posted by on Tuesday, Jun 5, 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.

Violence Policy Center, May 2018

Guns claimed more than 38,000 lives in the United States in 2016. Yet unknown to most people is the fact that the most common type of gun death in our nation is suicide, not homicide. Equally unknown, and just as misunderstood, is the fact that the vast majority of suicides are preventable. People who use a gun to kill themselves aren’t necessarily more suicidal than those who use other means, they just have the tragic misfortune of having the most lethal means available to them in their time of depression and turmoil. Below are key facts regarding suicide and firearms.

In 2016 (the latest year for which complete national data is available) there were 44,965 suicides in the United States: 123 suicides per day; one suicide every 11.7 minutes. Of these 44,965 deaths, more than half (51.0 percent) used a firearm to take their own lives.

* Suicide is the 10th leading cause of death in the United States. Homicide is the 16th.

* Nearly three out of five people who die from gunshot wounds take their own lives.

* In 2016, the number of gun deaths by suicide in the United States was 22,938, whereas suicide by suffocation resulted in 11,642 deaths and suicide by poisoning resulted in 6,698 deaths.

A common argument is that a suicidal person will find a way to kill himself or herself no matter what — and a gun just happened to be available. However, the Harvard School of Public Health notes that “virtually every other method is less lethal than a firearm so there’s greater chance the person won’t die in their attempt…With a firearm, once the trigger is pulled, there’s no turning back.”

* Approximately 85 percent of suicide attempts with a firearm are fatal. Many of the other most widely used suicide attempt methods have case fatality rates below five percent.

* Guns, unlike other methods, require less preparation and planning. Nearly half (48 percent) of suicide attempt patients reported less than 20 minutes elapsed from first thought of suicide to actual attempt.

* “Attempters who take pills or inhale car exhaust or use razors have some time to reconsider mid-attempt and summon help or be rescued. The method itself often fails, even in the absence of a rescue.”

Every study that has examined the issue to date has found that within the United States, access to firearms is associated with increased suicide risk.

* “Merely having a gun in one’s home increases the likelihood that someone living there will commit suicide by a factor of 2 to 10.”

* States with higher rates of gun ownership tend to have higher rates of suicide than states with less gun ownership.

* One analysis found that, in total, there were almost twice as many suicides among people living in high- gun states as there were in low-gun states even though non-firearm suicides were about equal.

The Harvard School of Public Health created the Means Matter Campaign because “means reduction” has been proven to reduce suicide rates.

* When lethal means are made less available or less deadly (“means reduction”), suicide rates by that method decline, and frequently suicide rates overall decline. This has been demonstrated in a number of areas in the context of suicide: bridge barriers, detoxification of domestic gas, pesticides, medication packaging, and others.

* Firearm owners are not more suicidal than non-firearm owners; rather, their suicide attempts are more likely to be fatal because of guns’ heightened lethality.

* Nine out of 10 people who attempt suicide and survive will not go on to die by suicide at a later date.

* A lethal weapon available to a person in the depths of despair can end a life in an instant. Firearms are used in five out of 10 suicides in the U.S. Removing lethal means from a vulnerable person, especially a youth, can save a life.


Although we desperately need to improve our health care financing system because of its high costs and mediocre performance, leaving too many out, we need to intensify efforts at improving public health and prevention. It would be great to have an improved Medicare for everyone, but that is of little help when presented with someone who just died from a self-inflicted gunshot wound. For that problem, prevention is an imperative.

Guns are a public health hazard. In 2016, guns claimed more than 38,000 lives, and almost 23,000 were by suicide. Understanding the facts, as listed in this report from the Violence Policy Center, lead to some obvious conclusions as to interventions that would help. Some can be accomplished in the private sector, but others clearly require public policies and regulations.

What do gun regulations and a single payer national health program have in common? We’ve known for decades the public policies in both of these realms that we need to enact in order to improve the protection and preservation of our health, and yet we have failed to act. Yes, we have many regulations for both health care and guns, but they are so feeble that they have failed us.

Are we going to continue to let America’s Health Insurance Plans (AHIP) and the National Rifle Association (NRA) obstruct the reforms that we need? Or are we finally going to let our elected representatives know that we are serious about wanting action now?

Today is election day in California. I’m about to vote, and these issues will certainly influence my selections. I hope that they will influence yours as well.

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Higher spending on brand-name drugs in spite of lower use in Medicare Part D

Posted by on Monday, Jun 4, 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.

Increases in Reimbursement for Brand-Name Drugs in Part D

U.S. Department of Health & Human Services, Office of Inspector General, June 2018

What OIG Found

* Total reimbursement for all brand-name drugs in Part D increased 77 percent from 2011 to 2015, despite a 17-percent decrease in the number of prescriptions for these drugs.

* After accounting for manufacturer rebates, reimbursement for brand-name drugs in Part D still increased 62 percent from 2011 to 2015.

* Part D unit costs for brand-name drugs rose nearly 6 times faster than inflation from 2011 to 2015.

* The percentage of beneficiaries responsible for out-of-pocket costs of at least $2,000 per year for brand-name drugs nearly doubled across the 5-year span.


We found that, over a 5-year period, increases in Part D reimbursement for brand-name drugs outpaced inflation. Despite a decrease in utilization of brand-name drugs, these substantial increases in reimbursement led to greater Medicare spending and higher beneficiary out-of-pocket costs for these drugs. Specifically, total Part D reimbursement for all brand-name drugs increased 77 percent, from $58 billion in 2011 to $102 billion in 2015. To control for the possibilities that (1) increases in utilization or (2) newer, more expensive brand-name drugs may have affected total Part D reimbursement, we analyzed the number of prescriptions and unit costs for brand-name drugs that were reimbursed in every year from 2011 to 2015. Overall, we found that utilization decreased for the majority of these brand-name drugs, while the average Part D unit cost increased 29 percent from 2011 to 2015.

Increases in Part D unit costs significantly outpaced inflation; in fact, the average unit cost for brand-name drugs in Part D rose nearly 6 times faster than inflation from 2011 to 2015. We also found that Part D unit costs closely followed the upward trend in benchmark prices, which are typically reflective of manufacturer prices. Therefore—like the 2016 ASPE report, which suggested that increases in drug prices contributed to the growth in total prescription drug spending—we conclude that increases in unit prices for brand-name drugs resulted in Medicare and its beneficiaries’ paying more for these drugs.

We also found that the percentage of beneficiaries who were responsible for out-of-pocket costs of at least $2,000 per year for brand-name drugs nearly doubled across the 5 years. These trends are consistent with those described in the previous OIG report, which found increases in the number of beneficiaries who reached the catastrophic-coverage phase of their Part D benefits. In addition, we found that total beneficiary out-of-pocket costs were highest for brand-name drugs in three therapeutic classes of maintenance drugs (insulins, cholesterol reducers, and respiratory tract corticosteroids). Because maintenance drugs are typically used to treat chronic, long-term conditions, increasing reimbursement for these drugs will continue to affect Part D and its beneficiaries for years to come. OIG remains committed to examining these issues and working with CMS to ensure the integrity of the Part D program.


Probably the most significant finding in this OIG study is that the unit costs (prices paid) for brand-name drugs in Medicare Part D rose six times faster than the rate of inflation. Although the use of brand-name drugs has declined 17 percent, the total reimbursement has increased 77 percent because of these unit cost increases.

These escalating unit costs are borne by both the taxpayers who fund Medicare and the patients who are paying higher out-of-pocket costs. The spending increases have been particularly burdensome for patients requiring maintenance drugs for chronic conditions.

We do not have to continue to put up with this. Last month, a group associated with Physicians for a National Health Program released a proposal that would ensure universal access to safer, more innovative, and more affordable drugs. The report can be accessed at the following link:


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Instilling personal responsibility into prisoners through co-pays – another nutty idea

Posted by on Friday, Jun 1, 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 $580 Co-pay

By Beth Schwartzapfel
The Marshall Project, May 30, 2018

For those in the outside world accustomed to paying $25 or more at every doctor’s visit, the idea of prisoners paying $2 to $8 to see a doctor seems nominal. Forty-two states plus the federal Bureau of Prisons charge a co-pay, according to the Prison Policy Initiative, a criminal justice think tank.

When you’re making pennies an hour, or nothing at all, a small co-pay can be the equivalent of hundreds of dollars.

Prisons charge co-pays for similar reasons as free-world health insurers: to cut down on unnecessary medical visits by requiring patients to share in the cost of their care. U.S. prisons spend between $3,000 and $10,000 per inmate per year on medical care — about 20 percent of total prison spending—according to a 2014 analysis by the Pew Charitable Trusts.

“We want a real-world environment for the prisoners because in the real world you and I would be required to have a copay,” Mark Myers, spokesman for the Oklahoma Department of Corrections, told the news site the Frontier. Prisoners in Oklahoma earn 5 cents per hour at the bottom of the wage scale, so the state’s $4 co-pay is roughly equivalent to $580 for a minimum wage worker on the outside, the Frontier reported.

Most states charge a fee for each visit, with a $3.47 national average, according to the Prison Policy Initiative’s 2017 analysis. At $8 per visit, Nevada’s prison co-pay is the highest in the nation. “Charging a co-pay encourages the inmates to develop personal responsibility for their health care, it helps manage the volume of unnecessary doctor appointments in the clinics and assists with a small portion of the medical costs,” said Brooke Santina, spokeswoman for the Nevada Department of Corrections.

Despite their toll on inmates’ individual finances, the fees don’t add up to much on prisons’ balance sheets. In Illinois, the $5 co-pay brings in about $400,000 per year — not enough to recoup the administrative costs of running the program, according to Department of Corrections spokeswoman Lindsey Hess.

Illinois lawmakers want to change that in their state. They voted last week to eliminate the $5 co-pay the state’s prisons have been charging for years. “When you’re denied your liberty, medical care is part of the deal. If you need it, you should get it,” said Jennifer Vollen-Katz, executive director of the John Howard Association, a state prison watchdog group that pushed the legislation. In letters and surveys, co-pays consistently emerged as one of prisoners’ biggest concerns, Vollen-Katz said, with more than half saying they avoid health care to avoid the co-pay.


The insistence on charging prisoners who have essentially no income a co-pay for health care services is an example of how fixated our policymakers are on designing health care financing systems based on existing policies, no matter how flawed.

Who in their right mind really believes that a prisoner earning maybe a nickel an hour is  developing “personal responsibility” for health care by paying a four dollar co-pay for a medical visit? Yet this personal responsibility meme has permeated nearly our entire health care financing system resulting in adverse outcomes because of the financial disincentives to obtaining appropriate health care.

Although co-pays for prisoners are ridiculous on the face of it and should be eliminated, as you go up the scale of income and levels of cost sharing, the negative impact might lessen, but it is not eliminated except perhaps for the very wealthy. Numerous studies have confirmed that cost sharing for working families with good incomes can still result in financial insecurity and impaired access to care.

Our personal responsibility should be to obtain care for our family members or ourselves when it seems appropriate for preventive or therapeutic purposes. The burden of cost sharing conflicts with such personal responsibility – the opposite of what our policy goals should be.

A well designed, single payer improved Medicare for all gets the personal responsibility concept right so that everyone can receive appropriate health care when needed.

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Trump administration’s false rhetoric on the social determinants of health

Posted by on Thursday, May 31, 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.

Social Determinants Of Health: A Public Health Concept In Conflict

By Danielle Garrett, Ann Hwang, Clare Pierce-Wrobel
Health Affairs Blog, May 30, 2018

The new battlefront over health programs for the poor is taking place over what has historically been a progressive concept: social determinants of health. The new battlefront over health programs for the poor is taking place over what has historically been a progressive concept: social determinants of health.

This approach builds off of extensive public health research that shows changing health behaviors is most effective when paired with changes to the broader environment that enable those behaviors. In practice, this often involves removing barriers to services and increasing access to successful interventions.

Same Words, New Meaning

In January 2018, when the Centers for Medicare and Medicaid Services (CMS) announced that it would allow states to implement work requirements as a condition of receiving Medicaid coverage, the letter from CMS to state Medicaid directors employed language with seemingly familiar tones as it noted the many “determinants of health.” It went on to state that, “CMS recognizes that a broad range of social, economic, and behavioral factors can have a major impact on an individual’s health and wellness, and a growing body of evidence suggests that targeting certain health determinants, including productive work and community engagement, may improve health outcomes.”

Secretary of Health and Human Services Alex Azar echoed the letter from CMS when he noted that many state officials were discussing requests for work requirements. “It seems to be getting a great deal of excitement to deal with the social determinants of health,” Secretary Azar shared during a February press conference in Indianapolis announcing the federal government’s approval of a Medicaid work requirement waiver for the state of Indiana.

While described as being about social determinants of health, the proposed policy from CMS actually takes an antithetical approach. If a beneficiary doesn’t meet the work requirements, this policy imposes a barrier to health care access by locking that individual out of Medicaid coverage. Rather than addressing the underlying factors that might contribute to lack of employment, such as need for education, training, transportation, the availability of jobs in the community, and poor health itself, the policy utilizes a punitive approach.

All Sticks And No Carrots

Punishing people for not engaging in a desired behavior by removing their access to care has very real consequences for people’s health and might actually exacerbate undesired health behaviors. It is nonsensical for a policy that is pitched by policymakers as improving health to actually do the opposite, as people will lose access to health care. Such an approach will likely make it even more difficult for individuals to find employment in addition to impacting their health.

The history of safety net programs has shown work requirement policies to be unsuccessful in improving employment or health status. For example, when Wisconsin implemented a work requirement for their food support program, more than three people lost coverage for every individual who gained employment. Lack of health insurance coverage is associated with a variety of poor health outcomes and a lack of access to care.

Creating A New Barrier To Health

While truly addressing the social determinants of health involves removing barriers that prevent people from making healthy decisions, punitive policies such as work requirements create an environment where people face more barriers to making healthy decisions. Medicaid work requirement waivers currently under development also demonstrate how these policies can inequitably distribute these barriers. A proposal under consideration in Michigan, for example, would disproportionately enforce the requirements for urban centers and communities of color that are facing major health and employment crises—like Flint—while exempting mostly white, rural communities.

An agenda that attempts to change health behaviors by making it harder to make healthy choices runs the risk of actually worsening health outcomes, increasing disparities, and diverting investments away from evidence-based interventions that improve health. We should not be fooled by the contorted language from CMS about “social determinants” that is being used to promote policies that only make it harder for people to make the healthy choice.



After Years of Trying, Virginia Finally Will Expand Medicaid

By Abby Goodnough
The New York Times, May 30, 2018

Virginia’s Republican-controlled Senate voted on Wednesday to open Medicaid to an additional 400,000 low-income adults next year, making it all but certain that the state will join 32 others that have already expanded the public health insurance program under the Affordable Care Act.

Republican lawmakers in the state had blocked Medicaid expansion for four straight years, but a number of them dropped their opposition after their party almost lost the House of Delegates in elections last fall and voters named health care as a top issue.

The House passed the Senate bill within hours; it will now go to Mr. Northam’s desk. The measure includes a requirement that many adult recipients who don’t have a disability either work or volunteer as a condition of receiving Medicaid — a provision that was crucial to getting enough Republicans on board.

“That is debt, and I have four kids who are going to be having to pay for that for the rest of their lives,” Senator Amanda Chase, a Republican from Chesterfield, said of the federal funds spent on Medicaid expansion, explaining her vote against it on Wednesday.

This year, Republican governors and state lawmakers, encouraged by the Trump administration, have focused on adding new requirements for Medicaid eligibility, such as requiring adults without disabilities to work or volunteer, and many beneficiaries to pay premiums.


It is an outrage that Trump administration officials contend that taking away health benefits from individuals who are unable to find qualifying employment is a policy that “may improve health outcomes.”

We can be thankful to Danielle Garrett, Ann Hwang, and Clare Pierce-Wrobel for writing this article and for Health Affairs for publishing it. It is important that the nation understands what these policies really mean. As the authors state, “It is nonsensical for a policy that is pitched by policymakers as improving health to actually do the opposite, as people will lose access to health care.”

This is not some theoretical consideration; it is really happening. Virginia legislators have fought Medicaid expansion for years and now agree to it only because the work requirement was added.

We are seeing more pleas for everyone to come together to address these social problems for the betterment of all of us. But when a policy goal of accessible and equitable health care for all conflicts with a policy goal of erecting barriers to health care (work requirements, unaffordable deductibles, narrow provider networks, spartan plans, unaffordable benefit tiers, etc.), how can we ever find common ground?

Those supporting health care for all clearly hold the moral high ground. Those who would deliberately create barriers to health care for some should explain to the rest of us the moral basis for their positions that seem to rest on very shaky ground. They should provide us with a credible explanation of how they are sharing with us a firm moral footing. The fact that health care costs money is not an adequate excuse since we are already spending enough to provide care for everyone if we would just change our policies to those that work, such as with an improved Medicare for all.

Really. It is depressing to see our nation’s political leaders support these inherently cruel policies. What is it that the voters see in them? Aren’t we entitled to a reasonable explanation of why these legislators should be the ones to dictate policy?

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Everyone agrees: Trump’s new insurance rules are terrible

Posted by on Wednesday, May 30, 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’s new insurance rules are panned by nearly every healthcare group that submitted formal comments

By Noam Levey
Los Angeles Times, May 30, 2018

More than 95% of healthcare groups that have commented on President Trump’s effort to weaken Obama-era health insurance rules criticized or outright opposed the proposals, according to a Times review of thousands of official comment letters filed with federal agencies.

The extraordinary one-sided outpouring came from more than 300 patient and consumer advocates, physician and nurse organizations and trade groups representing hospitals, clinics and health insurers across the country, the review found.

State insurance regulators from both political parties have also warned that the administration’s proposals could destabilize insurance markets, raise premiums for sick Americans and open the door to insurance fraud.

And dozens of industry leaders and other experts have called on the administration to rethink moves to scale back consumer protections enacted through the Affordable Care Act, often called Obamacare.

“Basically anybody who knows anything about healthcare is opposed to these proposals,” said Sandy Praeger, a former Republican state insurance regulator in Kansas and onetime president of the National Assn. of Insurance Commissioners. “It’s amazing.”

After the failure to repeal the healthcare law last year, the Trump administration is weighing two controversial new rules to loosen regulations governing health plans. One would expand the availability of short-term coverage plans that last less than a year. The other would make it easier for self-employed Americans and small businesses to band together to form so-called association health plans.

These plans — which administration officials say will be more affordable — would not have to offer the full set of health benefits required under the 2010 law and in some cases could turn away sick customers.

Altogether, more than 95% — or 266 of 279 — of the healthcare groups that filed comments about the proposed association health plan regulation expressed serious concern or opposed it, the Times analysis found.

And more than 98% — or 335 of 340 — of the healthcare groups that commented on the proposal to loosen restrictions on short-term health plans criticized it, in many cases warning that the rule could gravely hurt sick patients.

Among the groups were virtually every leading patient advocate in the county, including the American Lung Assn., the American Heart Assn., the Cystic Fibrosis Foundation, the March of Dimes, the National Multiple Sclerosis Society, Susan G. Komen, AARP and the advocacy arm of the American Cancer Society.

Not a single group representing patients, physicians, nurses or hospitals voiced support in the public comments for the two Trump administration proposals.

These concerns were echoed by the leading health insurance trade groups, as well as many individual health insurers that cautioned that rates would only increase as looser rules further destabilized insurance markets across the country.

The Trump administration has not indicated when it will finalize the proposed new insurance regulations.


Donald Trump, Alex Azar and Seema Verma just don’t get it. Everyone, expect for a few ideologues, agrees that the administration is mismanaging our nation’s health care policies. Obviously we need to change course.

The policies that would accomplish the goals of universality, access, equity, and affordability are not secret. They are those policies contained within a well designed, single payer, improved Medicare for all. We simply need an administration and Congress who agree and are willing to enact and implement such a system.

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The Comprehensive Primary Care Initiative at four years

Posted by on Tuesday, May 29, 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 Comprehensive Primary Care Initiative: Effects On Spending, Quality, Patients, And Physicians

By Deborah Peikes, Stacy Dale, et al (Mathematica Policy Research and Center for Medicare and Medicaid Innovation)
Health Affairs, May 23, 2018


The Comprehensive Primary Care Initiative (CPC), a health care delivery model developed by the Centers for Medicare and Medicaid Services (CMS), tested whether multipayer support of 502 primary care practices across the country would improve primary care delivery, improve care quality, or reduce spending. We evaluated the initiative’s effects on care delivery and outcomes for fee-for-service Medicare beneficiaries attributed to initiative practices, relative to those attributed to matched comparison practices. CPC practices reported improvements in primary care delivery, including care management for high-risk patients, enhanced access, and improved coordination of care transitions. The initiative slowed growth in emergency department visits by 2 percent in CPC practices, relative to comparison practices. However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures. As CMS and other payers increasingly use alternative payment models that reward quality and value, CPC provides important lessons about supporting practices in transforming care.

From the Introduction

Public and private payers are increasingly experimenting with ways to improve primary care delivery, reduce spending, and improve patient outcomes. Payers are also considering ways to strengthen primary care. New primary care models, such as the patient-centered medical home, have had mixed effects on quality and spending.

The Centers for Medicare and Medicaid Services (CMS) launched the Comprehensive Primary Care Initiative (CPC) in October 2012. CPC tested whether requiring practices to implement a new approach to delivering primary care, and providing financial and technical support to help them do so, reduced spending and improved quality over a four-year period in 502 practices across seven US regions. In addition to CMS, thirty-nine other private and public payers supported CPC practices by implementing an aligned approach to changing care delivery and payment.

This article provides an update to earlier evaluation results of the first two years of CPC.


Our estimates showed no significant differences in spending growth during CPC, with or without care management fees.


Over the course of CPC, we found no significant effects on the claims-based quality-of-care process measures for beneficiaries with diabetes or on the continuity-of-care measure, defined as the percentage of primary care visits that occurred at the practice that the beneficiary was attributed to when CPC began.


Physicians in CPC practices had largely favorable views of CPC in 2016. However, many indicated that CPC’s administrative reporting was a burden and the transformation work was difficult.

Although CPC required intensive work for practices, we found no meaningful differences on measures of burnout, control over work, alignment of work with training, and job satisfaction between physicians in CPC practices and those in comparison practices in 2013 or 2016.

From the Discussion

Practices participating in the Comprehensive Primary Care Initiative improved some aspects of care delivery, which in turn led to less growth (relative to comparison practices) in numbers of ED visits and thirty-day ED revisits among fee-for-service Medicare attributed patients. However, the four-year initiative did not reduce Medicare hospitalizations or reduce Parts A and B spending enough to cover care management fees. There were no appreciable improvements in patient experience, claims-based quality of care, or physician experience, except that patients reported more follow-up care after hospitalizations and ED visits. Beyond the reduction in ED visits, the additional two years to transform care delivery did not substantively alter the earlier results from midway through the initiative.

Results from CPC illustrate how hard it is to reduce Medicare spending. There are several potential reasons why the findings were not more favorable. First, primary care practices might need stronger value-based financial incentives, accompanied by strong and consistent incentives for other providers (such as specialists and hospitals) that care for the same patients.

Second, some participating practices reported facing barriers to improving care delivery (for example, the burden of reporting, potentially limited actionability of data feedback, insufficient health information technology support for care delivery, and poor health information exchange) that may have made implementation of the initiative less robust than it might have been without such barriers.

Third, general care delivery improvements by comparison practices and other providers—for example, in response to Medicare’s financial penalties for high readmission rates—could have made it challenging for CPC practices to improve their outcomes relative to those of comparison practices.


CPC+ aims to improve on these outcomes by building several new elements on the same foundation of multipayer support and five primary care functions. First, CPC+ introduces a second track that deepens care delivery requirements for practices with more experience in delivering advanced primary care.

Second, CPC+ further moves away from traditional fee-for-service by providing a hybrid payment for practices in the second track (combining a portion of fee-for-service and global payment for evaluation and management services).

Third, CPC+ strengthens incentives. It replaces shared savings with a prepaid bonus that practices must repay if they do not meet practice-level performance targets.

Finally, CMS partners with health information technology vendors to encourage improvement in health information technology functionalities to support practices in meeting the care delivery requirements of CPC+.


Full report from Mathematica Policy Research (over 300 pages):

CMS is fixated on pushing the health care delivery system into accountable alternative payment models. The Comprehensive Primary Care Initiative is a study that has been going on for four years, and yet the improvements are negligible.

Instead of moving forward with a financing system that really would improve health care spending, CMS is going to expand this experiment with measures such as replacing shared savings with “a prepaid bonus that practices must repay if they do not meet practice-level performance targets.” That’s bizarre since we already know that such policies reduce physician satisfaction and increase burnout. That can’t be their policy goal, or is it?

Enough experimentation with alternative payment models. We definitely need to keep improving primary care, but not with financing policies that don’t work. Let’s go right to the model that does work – a well designed, single payer, improved Medicare for all. Within that system we can refine primary care to make it work well for all of us – patients and health care professionals alike.

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Malleability of single payer support

Posted by on Friday, May 25, 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.

Californians & Their Government

By Mark Baldassare, Dean Bonner, Alyssa Dykman
Public Policy Institute of California, May 2018

Health Care Policy

A single-payer state health insurance program is now under discussion. Senate Bill 562, which would establish such a program, passed in the senate last year and is currently held in the state assembly. How do Californians feel about this idea today? A majority of adults (64%) and likely voters (53%) favor a single-payer state plan. However, if this plan requires raising taxes, support declines (41% adults still favor, 41% likely voters still favor). Similar shares of adults and likely voters held this view last May. An overwhelming majority of Democrats (78%) favor a single-payer state system—including 62 percent even if it means raising taxes—while a strong majority of Republicans (67%) are opposed. A majority of independents (55%) are in favor, while 36 percent are opposed. Majorities across demographic groups favor a single-payer system, but if raising taxes is required, support falls below 50 percent for all groups—with the exception of college graduates (51%).

Q: “Do you favor or oppose having guaranteed health insurance coverage in which all Californians would get their insurance through a single state government health plan? (If favor: Do you favor it even if it means raising taxes?)”

64% – Favor
41% – Favor, even if it means raising taxes
23% – Favor, not if it means raising taxes
29% – Oppose
7% – Don’t know


Full report:

A single payer, improved Medicare for all program would be vastly superior to our current method of financing health care (even with the Affordable Care Act), and 64 percent of California adults favor “a single state government health plan.” However, significant partisan opposition persists, and even support is malleable, dropping to 41 percent when those favoring are asked “even if it means raising taxes.”

The malleability of support is important. Since no state government has been successful in both enacting and implementing a state single payer system, it has been suggested repeatedly that it should be submitted to the voters as a ballot measure. However that has already been tried in California, Oregon, and Colorado where the measures were defeated by overwhelming margins (3 to 1 or 4 to 1) since the voters proved to be very sensitive to the anti-government, anti-tax rhetoric of the opponents.

The Vermont legislature did enact what began as a single payer proposal but which was later modified because of conflicts with existing federal programs, but even the modified version was abandoned when implementation proved to be too difficult.

Many say that we should continue to push for a state single payer system to serve as an example for the nation, just as Saskatchewan served as an example for Canada that eventually led to single payer systems in all provinces. A major hurdle to that approach is that federal programs are already in place in the United States that would require comprehensive federal legislation to modify regulations and free up federal funds for use by the states. Of course there are valiant efforts in states such as New York (Gottfried) and Minnesota (Marty) to work around these federal limitations and restrictions, so we do not need to give up entirely on state efforts as transitional programs that can provide relief until we can achieve the goal of a national program for all.

What lessons can our Medicare and Canada’s Medicare provide for us? Both were accomplished through federal congressional or parliamentary acts. The people elected representatives who were supportive of Medicare (though the political process limited ours to those with the greatest needs – Medicare for seniors and Medicaid for the poor), and then the representatives enacted the programs.

We can do that again. We do need to increase our efforts at educating the public. When people hear “more taxes for health care” they need to immediately think “but a much fairer way of paying for health care for all of us.” When they hear that the government can’t do anything right, they need to remind themselves how relieved they were when they finally qualified for the government Medicare program.

If the people lead, the politicians will follow. This poll shows 64 percent support for single payer, and other polls have shown that the support is especially great when Medicare is invoked (again, malleability). We are getting there. We just need to step up our efforts to educate and activate as we head up this path toward health care justice for all.

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