Under a multi-payer system, churning is inevitable and bad for your health

Posted by on Monday, Oct 10, 2016

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.

Insurance Churning Rates For Low-Income Adults Under Health Reform: Lower Than Expected But Still Harmful For Many

By Benjamin D. Sommers, Rebecca Gourevitch, Bethany Maylone, Robert J. Blendon and Arnold M. Epstein
Health Affairs, October 2016


Changes in insurance coverage over time, or “churning,” may have adverse consequences, but there has been little evidence on churning since implementation of the major coverage expansions in the Affordable Care Act (ACA) in 2014. We explored the frequency and implications of churning through surveying 3,011 low-income adults in Kentucky, which used a traditional expansion of Medicaid; Arkansas, which chose a “private option” expansion that enrolled beneficiaries in private Marketplace plans; and Texas, which opted not to expand. We also compared 2015 churning rates in these states to survey data from 2013, before the coverage expansions. Nearly 25 percent of respondents in 2015 changed coverage during the previous twelve months—a rate lower than some previous predictions. We did not find significantly different churning rates in the three states over time. Common causes of churning were job-related changes and loss of eligibility for Medicaid or Marketplace subsidies. Churning was associated with disruptions in physician care and medication adherence, increased emergency department use, and worsening self-reported quality of care and health status. Even churning without gaps in coverage had negative effects. Churning remains a challenge for many Americans, and policies are needed to reduce its frequency and mitigate its negative impacts.


Churning – moving in and out of health plans, whether or not there are gaps in coverage – is clearly bad for the patient’s health.

In this study, the rate of churning did not differ between states with different approaches to implementing the Affordable Care Act. In a multi-payer system, churning automatically occurs due to factors such as changes in employment, changes in income and program eligibility, changes in residency, changes in plan availability, and changes because of administrative disruptions.

Regardless of the reason, churning resulted in “disruptions in physician care and medication adherence, increased emergency department use, and worsening self-reported quality of care and health status.” Negative effects occurred even without gaps in coverage.

Need it be said? A single payer national health program would totally eliminate churning and thus would improve the health of Americans caught up in the churning trap. If this were the only reason for enacting a single payer system, it would certainly be worth doing.

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Sen. John Marty’s “Healing Health Care”

Posted by on Thursday, Oct 6, 2016

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 Case for a Commonsense Universal Health System

By John Marty
MNHealthPlan.org, October 2016

During my 30 years in the Minnesota Senate, I have seen firsthand the failure of our political system to seriously address health policy. In the United States, we squander outstanding health care resources — providers, clinics and hospitals, medical research and technology — on a broken system that makes it difficult and expensive for many people to get the care they need.

Why would any society make it difficult for its people to access health care?

I wrote this book because I am tired of waiting while our political process spends billions of dollars but merely tinkers at the edges of our health care problems.

* First we take a few steps back and look at the mess we have. By doing so, we identify the problems, develop principles for a healthy health care system, and map out a logical plan based on those principles.

* Then we work through our civic process and political system, make the case for our proposal, and then work to implement that plan.

This proposed Minnesota Health Plan and the principles that underlie it are nothing more than what any caring society would desire in order to ensure good health care for all of its people.

A Call to Action

If twenty-first century progressives had been leading the nineteenth century abolition movement, we would still have slavery, but we would have limited slavery to a 40-hour work week, and we would be congratulating each other on the progress we had made.

Epilogue: It’s Time for the Minnesota Health Plan

Our current system, even with MNsure and the Affordable Care Act, still leaves many people without health coverage. Equally troubling, many Minnesotans who have health coverage still cannot afford the care they need.

Health insurance coverage fails to guarantee that people have access to health care, because insurance frequently excludes coverage for needed care such as dental, chemical dependency treatment, mental health, or long- term care.

Health insurance also requires significant out-of-pocket expenses, and it buries people and businesses with a thicket of confusing medical insurance applications and paperwork.

Despite our excellent medical providers and medical technology, Minnesota’s system is so dysfunctional that many families cannot access it even when they have insurance.

It’s time to stand up to the strong, well-financed opposition from the insurance industry and the pharmaceutical lobby.

We must replace health insurance for some with health care for all.

When European nations, Canada, and Japan are able to deliver comprehensive health care to all of their people, with better health outcomes, for roughly half the cost per person that we are currently spending, it is not an insurmountable challenge.

The Minnesota Health Plan would be an efficient health care system based on, and governed by, principles that ensure that all people receive high quality health care.

Minnesota has some of the best medical education, training, research, and technology in the world. It’s time we adopt a health care system to match.

“Healing Health Care” by John Marty can be downloaded for free at the following link:

Numerous excerpts from “Healing Health Care”:


Senate, State of Minnesota: S.F. No. 2060 – Minnesota Health Plan:

“Healing Health Care” by Sen. John Marty is not only a description of a health care reform proposal for Minnesota, more importantly it is a discussion of policies that all of us desperately need to improve the functioning of our health care financing and health care delivery systems. It is a basic primer that all concerned about health care reform could use.

“Healing Health Care” can be downloaded for free at the link above. It is an easy read of less than 150 pages. For those who do not have the time, it would be well worth reading the excerpts at the second link above. They will provide some of the essence of the message in his book.

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Canadian Medicare on trial

Posted by on Wednesday, Oct 5, 2016

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.

Could this be the beginning of the end for the Canadian single-payer system?

By Danielle Martin
DEMOCRACY, October 3, 2016

There’s an old joke that Canadians like to tell: What’s a Canadian? A gunless American with health care.

It’s only funny because we half-believe it’s true; despite the many things we have in common with our friends south of the 49th parallel, Canada’s single-tier, publicly funded health care system has long been a point of differentiation—and pride—for most Canadians. A 2012 poll found that our health care system—known in Canada as “Medicare”—was almost universally loved, with 94% of those surveyed calling it an important source of collective pride. The notion that access to health care should be based only on need is a deeply ingrained Canadian value.

But we can’t take our Medicare system for granted.

The challenges to Canadian Medicare have always been ideological and political. But, as of this month, they are also legal.

In the western province of British Columbia, a trial underway in that province’s Supreme Court is challenging the very foundations of Medicare: providing care based solely on need, and not on ability to pay.

Cambie Surgeries Corporation and the Specialist Referral Clinic, represented by Dr. Brian Day, an orthopedic surgeon in Vancouver, are suing the government of B.C., trying to knock down the laws that protect our single-payer system. If successful, some Canadians will be able to pay out-of-pocket or through private insurance for hospital and physician services—and doctors will be able to charge them whatever the market will bear.

The essence of the claim is that, because wait times for some elective surgeries in that province are longer than we would like them to be, doctors should have a constitutionally protected right to provide them more quickly and at a higher price. This would be done by charging some patients privately, either out-of-pocket or through private insurance. They allege that existing limits on charging patients privately infringe on patients’ rights to life, liberty, and security of the person under Section 7 of the Canadian Charter of Rights and Freedoms.

It is also worth noting recent efforts at tackling the main driver of this constitutional challenge: wait times for non-urgent surgery. These have come from within the public system, and include wait time targets, centralized intake for people with a common problem, and inter-professional health-care teams so that surgeons’ time does not create a bottleneck. Such initiatives show tremendous promise for reducing waits deemed unreasonable, but governments need to implement them, and health-care organizations and doctors need to help accelerate this kind of reform.

It may be that the Cambie plaintiffs will be unsuccessful in their quest to dismantle the essence of Medicare, but clearly the stakes for ordinary Canadians are very high. Like all developed countries, Canada struggles to control growth in health-care costs, meet the needs of an aging population, and provide timely care of the highest standard. Whether we continue to work to do so for all Canadians, or only some, will, in part, be determined by the outcome of the Cambie case.

Danielle Martin is a family physician in Toronto and Vice President, Medical Affairs and Health System Solutions at Women’s College Hospital.


The single payer model in Canada is closest to the ideal model of public financing/private health care delivery supported by Physicians for a National Health Program (PNHP). That model is now under legal challenge in Canada. If the Cambie lawsuit succeeds, the very concept of providing health care based on need rather than ability to pay will have suffered such a blow in the international community that we may never achieve that goal in the United States.

The trial will last an estimated six months and then will surely be appealed to the Supreme Court of Canada. Now, more than ever, Canadians need our moral support. And, oh yes, we need theirs.

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Harvard’s shameful stance on insurance for low-income employees

Posted by on Tuesday, Oct 4, 2016

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.

Harvard’s low-income workers deserve affordable health insurance

By Micah Johnson and Sanjay Kishore
STAT, September 30, 2016

There’s an outbreak of a hidden epidemic — unaffordable employer-based health insurance, especially for low-income workers — at Harvard, a place where it should never occur.

As medical students at Harvard, we were deeply troubled to learn that our university was proposing changes to dining workers’ health plans that would make essential health care unaffordable. After months of negotiation, the dining workers’ union voted to authorize a strike, which will launch on Wednesday if a deal is not reached. The campus has rallied around the workers, circulating a petition of support signed by 2,500 students, including us, in advance of federal mediation held earlier this week.

In the dining workers’ fight with Harvard, we see a microcosm of current challenges for health insurance across America.

The affordability of health insurance plans comes down to two factors: premiums and out-of-pocket costs. How affordable are employer plans? A team of Harvard medical students compared the plan Harvard proposed for the dining workers to what would be available on the Massachusetts health exchange.

For a family of three earning $30,000, the Harvard plan requires an employee to contribute a premium of $233 a month, while the health exchange has plans that require no premium at all. Harvard Medical School faculty and the World Health Organization have defined any health spending over 10 percent of annual income as a catastrophic expenditure. The Harvard plan comes perilously close to this with premiums alone. The cherry on top? Harvard’s plan also has higher co-pays than the exchange plans.

It is shocking that these low-income workers would be better off financially if they were not offered employer-sponsored insurance.

This may seem confusing. After all, exchange plans have been lambasted for their soaring costs. But the sobering truth is that the situation is worse among employer-provided plans. A recent Urban Institute study showed that total premiums were lower in exchange plans than in employer-provided plans in more than 80 percent of major US markets. In Boston, the premiums for exchange plans were 35 percent less expensive than employer plans. The gap would likely be even larger for lower-income employees, who would be eligible for more robust subsidies in the exchange plans.

Harvard’s proposal for its dining workers threatens to widen health disparities along lines of race and class. Many of the dining workers are immigrants, over half identify as people of color, and nearly half earn less than $35,000.

Innovation in health care is more likely to happen when big employers, rather than low-income workers, feel the burden of health care costs. Institutions like Harvard hold tremendous untapped power to implement novel programs and pressure health systems to make badly needed reforms.

Not every creative intervention will work. But only by moving beyond the status quo will we learn which new ideas have real benefits. Simply making poor families pay more for essential services like insulin prescriptions and hospital admissions is an unacceptable cop-out.

As physicians in training, we cannot stand by as the world’s richest university forces its most vulnerable employees to choose between dinner and a doctor’s visit. Harvard can do better, and this “better” can have a ripple effect on other unions, other universities, and other workplaces across the nation. Employers like Harvard must pursue real innovation, not simply balance their budgets on the backs of those least able to afford it — and least likely to survive it.

Micah Johnson and Sanjay Kishore are second-year students at Harvard Medical School.



Harvard students freak out as dining hall workers prepare to strike: ‘I don’t need to worry about where my food is coming from’

By Meg Wagner
New York Daily News, October 4, 2016

Harvard’s dining hall staffers are about to go on strike, much to the dismay of starving, stressed-out students.

“I understand it’s for legitimate purposes, but I’m worrying about midterms right now,” freshman Sofia Garcia told the Washington Post. “I don’t need to worry about where my food is coming from.”

It’s unclear if students — who pay a whopping $36 a day for unlimited dining hall access — will be refunded for any lost meals.

Union negotiator Michael Kramer said the 750 workers demand “the ability to earn at least $35,000 a year and a health insurance program that does not shift costs onto those who can least afford it.”

The university countered that the workers receive “some of the most generous hourly wages and benefits” for food service workers in the region and that it is proposing “modest” health care changes already accepted by thousands of other unionized university workers.


Creeping deterioration of employer-sponsored health insurance seems to lie in the background as concerns are directed to many other more obvious deficiencies in America’s dysfunctional health care financing system. But creeping deterioration is occurring and the seriousness of it is demonstrated by Harvard – an employer that should be carrying the banner towards comprehensive reform but instead is shamefully joining the trend toward shifting unaffordable health care costs onto its employees, seriously impacting affordability and access especially for its lowest wage employees.

It is gratifying to see that two of Harvard’s medical students, Micah Johnson and Sanjay Kishore, are joining in the effort to publicize the plight of low-income Harvard employees in their stalled negotiations over maintaining essential health benefits.

But Harvard defends itself by saying that the reductions are modest and commonplace, while Johnson and Kishore suggest that we need to experiment with creative intervention. And student Sofia Garcia simply doesn’t want to worry about where her food is coming from during the strike.

We have decades of creative intervention and that has only resulted in the highest costs and the most dysfunctional health care financing system of all industrialized nations.

This problem is much greater than being simply a negotiating point in a labor dispute. Harvard, their students, and everyone else needs to demand enactment of a health care financing system that will make health care affordable and accessible for all of us – a single payer national health program. Harvard’s dining hall staffers might still need to negotiate for decent wages, but at least they would have affordable and accessible health care permanently.

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As the cost of health insurance and care continues to go up with little restraint by the Affordable Care Act (ACA), the insurance industry is getting ever more creative in finding new revenue streams to cover gaps in coverage. The latest new market is to offer insurance to cover the cost of insurance. High deductibles have become a growing burden of out-of-pocket expenses for individuals, families, and employers. As one marker, deductibles for employer-sponsored health insurance have gone up by 255 percent over the last ten years. (1)

The ACA was intended to rein in insurers’ abuses by regulating the industry. However, large and self-insured employers were exempted from its requirements. Another provision outlawed “mini-med” plans that would cap annual benefits at, say $2,000. About 2 million people were covered in 2013 by limited benefit mini-med plans, marketed mostly by Aetna and Cigna. New ACA rules were enacted in 2013 that allow a number of limited-benefit plans to be offered as supplementary insurance. A variety of such plans are now being marketed, including critical illness plans (e.g. for cancer), indemnity plans (that pay only a pre-determined amount regardless of the total charges), “hospital cash” policies,” and short-term plans that less than 12 months. (2). These kinds of plans provide relatively small, one-time lump sum payments toward the generally much higher costs incurred by patients if they experience a major illness or hospitalization. These skimpy plans can be offered at low premiums, at least for younger healthier people, with high profits for insurers. As bare-bones policies, they have been called “junk insurance” by Consumer Reports. (3)

Since these gap plans are not major health insurance, they escape  scrutiny and regulation by the ACA. Insurers can ask potential enrollees about their health status and deny coverage for pre-existing conditions. More than 90 percent of people purchasing insurance through the ACA’s exchanges in 2016 chose plans with an average annual deductible of $3,000 or more. As one example, a 26 year-old healthy person with a $6,000 deductible can expect to pay $600 a year for a gap policy for deductibles. (4)

Gap policies call into question whether or not they are worth it. They are just another way to evade the ACA’s requirements and another grab for profits in a failing health insurance industry. They also represent another failure of the ACA to rein in health insurers in the public interest. These latest gap policies for high deductibles are losers for patients and families and unearned winners for health insurers.

It is beyond time to abandon cost-sharing as a means to control health care spending. As a main premise of consumer-directed health care (CDHC), the “more skin in the game” concept has been discredited as a cost containment mechanism by more than 25 years of experience. It is now obvious that the more cost-sharing increases with patients and families, the more they delay or forgo necessary care and have worse outcomes. (5) Yet it persists and grows into even new forms, such as now “insuring” us against high deductibles, all in insurers’ interest and not in ours as patients. As Dr. Don McCanne, senior health policy fellow for Physicians for a National Health Program, observes:

We don’t need insurance to insure our insurance. We need a national health program that would ensure that everyone has affordable access to all essential health care services. This will never happen with our current system; ACA patches cannot possibly accomplish that. Single-payer Medicare for All, without gaps, is what we need. (6)

John Geyman, M.D. is the author of  The Human Face of ObamaCare: Promises vs. Reality and What Comes Next and How Obamacare is Unsustainable: Why We Need a Single-Payer Solution For All Americans

visit: http://www.johngeymanmd.org

1. Woolhandler, S, Himmelstein, DU. Healthcare inequality on the rise. The Hill, August 2, 2016.

2. Andrews, M. Short-term plans can skirt health law requirements. Kaiser Health News, October 28, 2013.

3. Appleby, J, Hancock, J. Bare bones health plans expected to survive health law. Kaiser Health News, August 25, 2013.

4. Sable-Smith, B. Would you like some insurance with your insurance? Kaiser Health News, September 21, 2016.

5. Geyman, JP. Moral hazard and consumer-directed health care: A fundamentally flawed concept. Intl. J Health Services 37 (2): 333-346, 2007.

6. McCanne, D. Doubling down by insuring against losses from insurance gaps. Quote of the Day, September 22, 2016. (don@mccanne.org)

Ask Minnesota if the individual insurance market is stable

Posted by on Monday, Oct 3, 2016

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.

Individual health plan premiums to jump at least 50 percent in Minn.

By Christopher Snowbeck
StarTribune, September 30, 2016

Health insurers are hiking premiums and limiting enrollment in Minnesota’s individual market next year, with regulators saying the emergency measures were needed to avert a market collapse.

The moves are a clear sign that the market for some 250,000 people who buy coverage for themselves is dysfunctional and needs reform, said Commerce Commissioner Mike Rothman during a Friday news conference.

While rate increases of more than 50 percent aren’t fair to consumers, Rothman said, things could have been worse. He described a period this summer when all health insurers in the state seemed prepared to abandon that segment of the market.

The premium jumps and enrollment caps are confined to the individual market, where about 5 percent of state residents buy coverage. The market includes the MNsure exchange and has undergone significant changes with the federal Affordable Care Act.

Premiums will jump by an average of 50 percent to 67 percent, depending on the insurer. Regulators also are taking the unusual step of letting most health plans limit the number of enrollees they’ll cover.

The caps will pressure consumers to shop early during the coming open enrollment period, since some plan options could disappear once insurers hit their limits. And regulators say the policies being sold for next year will feature tighter controls on the doctors and hospitals that enrollees can use.

The premium hikes and enrollment caps amount to a “finger in the dike” that’s meant to buy time while the state figures out what to do, said Jim Schowalter, chief executive of the Minnesota Council of Health Plans, a trade group for insurers.

“What I think no one really appreciated until today was the trouble that the insurance market is in,” Schowalter said. “This announcement is another sign that how people are getting their own insurance isn’t working.”

“These rising insurance rates are unsustainable and unfair,” Rothman said. “Middle-class Minnesotans, in particular, are being crushed by the heavy burden of shouldering these costs.”


We keep hearing that ACA is working as intended, that all we need to do is enroll more younger, healthier individuals in the plans and all will be well. Ask the people in Minnesota how it is going. And they certainly are not the only state with problems.

Our politicians on the one hand tell us that all we need is a couple of patches, and on the other hand tell us that we should dump the system and let the markets work. Well, the system is not amenable to patches – we need comprehensive reform of the financing infrastructure – and the market cannot possibly work when prices far exceed the discretionary income of most of those who need health care.

The current patches in Minnesota include large premium hikes, and allowing the insurers to put limits on the total number of enrollees. Those patches might help the insurers, but for patients they make insurance less affordable and less accessible. Wasn’t reform supposed to take care of patients?

Regular readers know what would work – a well designed single payer national health program. Everyone would be covered by a system that would be affordable for each one of us. Minnesota should be leading the way on this.

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How would a Medicare buy-in and a public option be designed?

Posted by on Friday, Sep 30, 2016

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.

Designing a Medicare Buy-In and a Public Plan Marketplace Option

By Linda J. Blumberg and John Holahan
Urban Institute, September 2016

Medicare is an attractive basis for developing an insurance alternative (either a direct buy-in or a public option based in some way on Medicare rates) because the program generally has lower provider payment rates and lower administrative costs than private insurers. However, Medicare’s structure and cost-sharing requirements are different from private insurers’ as well. A Medicare-related proposal could provide more plan choice for those eligible, which would have a significant effect where few or even only one insurer offers coverage in the nongroup insurance market. Depending upon how the proposal is structured, it could reduce costs for younger adults in the private insurance market as older adults leave the risk pool. However, designing such programs raises myriad issues, each with specific implications for costs and benefits to different age groups.

Medicare Buy-In for 55- to 64-Year-Olds

We assume that a Medicare buy-in option would offer enrollees the same covered benefits and cost-sharing structures offered to current Medicare beneficiaries. Even so, a buy-in directly into the existing Medicare options would lead to questions necessitating policy decisions:

*  Would potential enrollees have the choice of traditional Medicare, Medicare Advantage, or both?

*  Would eligibles be able to choose between a Medicare option and Marketplace-qualified health plans for which they are currently eligible, or would Medicare be their only option outside of employer-sponsored insurance?

*  Would enrollees be allowed to make separate purchase decisions for Medicare Parts A, B, and D, or would they have to purchase all if they purchase any? How will consumers respond to offers of coverage that, unlike private insurance options, have no out-of-pocket maximum? Would Medigap or some other supplemental plans be available to the 55- to 64-year-olds?

*  How would the unsubsidized cost of coverage be determined? For example, what premium would be charged to individuals with high incomes? Would 55- to 64-year-olds be charged the same premiums as those age 65 and older, even though the premiums would not reflect the cost of coverage for those enrolled? Or would actuaries set premiums based on the benefits provided and cost-sharing requirements for each component? Would the high income surcharges in the current Medicare program apply to the buy-in population?

*  Assuming that 55- to 64-year-old enrollees would not pay the same premiums as current-law Medicare enrollees, would premiums reflect the health care costs of only the 55- to 64-year- olds enrolling? Or would premiums be set to reflect enrollees’ health care costs being shared by others? For example, their costs could be shared with other nongroup market enrollees or perhaps with current-law Medicare enrollees, but that would require the development of a mechanism for achieving it.

*  Would the 55- to 64-year-olds buying in to Medicare be eligible for financial assistance similar to that for Medicare beneficiaries today (e.g., 75 percent of Medicare Part B costs for all but the high-income beneficiaries? Would they be eligible for ACA-like financial assistance, advanced premium tax credits and cost-sharing reductions? Or would no financial assistance be offered at all? If subsidies are provided, how would they be structured? Would actuarial differences between Medicare and Marketplace silver coverage be taken into account, affecting both advanced premium tax credits and cost-sharing reductions?

*  Would 55 to 64 year olds with access to an affordable employer insurance plan be permitted to enroll in a Medicare buy-in option?

A Public Option for All Age Groups

A public option is a qualified health plan that would be sold through the ACA’s government-created Marketplaces (either federal or state). The public option would bear health insurance risk like other insurers, complying with the ACA’s insurance reforms (e.g., modified community rating, guaranteed issue, and essential health benefits) and offering coverage in the same actuarial value tiers.

A public option avoids complexities associated with a Medicare buy-in for 55- to 64-year-olds. Because the option would be structured and operated in much the same way as any other Marketplace-qualified health plan, it would not have different actuarial values, cost-sharing structures, or premium structures than other Marketplace options. The appropriateness of applying a Marketplace subsidy structure to a Medicare product would not be an issue, and risk-sharing questions across different age groups would not arise. Yet several design decisions would remain:

*  How would provider payment rates be set? Would they be set consistent with Medicare rates, set consistent with Medicare rates plus some percentage, or based on some other fee schedule? Many states have self-insured plans for their employees; this is another potential platform for creating a public option offered in a state Marketplace.

*  If rates are set at the Medicare level (or at some other level that falls below those paid by private insurers), what leverage would the plan have to ensure sufficient provider participation? How does a state’s leverage compare with that of the federal government in this respect?

*  Should public options be set up in all geographic areas or only those with high premiums, high premium growth, or otherwise weak insurer or provider competition? If the latter, who will judge appropriate locales, and by what metric will an area’s appropriateness be assessed?

From the Summary

Regardless of the approach taken, providers are likely to resist new insurance options that may move more patients into plans paying lower rates. While this is to be expected, it highlights the perpetual quandary of health care cost containment. Health care spending and its growth cannot be reduced without either paying less, on average, per unit of service rendered or reducing the quantity of services provided. No matter the strategy for containing costs, achieving that goal will take money out of the pockets of providers. To protect providers financially means abdicating cost-containment efforts of any type.


There is considerable enthusiasm for expanding on the advances of the Affordable Care Act by adding a Medicare buy-in for those 55 to 64, and by adding a public option – an insurance program run by the government competing with private health plans. What is lacking in this discussion is a precise description of either proposal considering that there are a multitude of policy options that must be decided on in order to construct these programs.

In this Urban Institute paper, Linda Blumberg and John Holahan discuss some of the design options, and there are many more. Each option has its own advantages and disadvantages, so it is inevitable that the eventual design would forge a compromise between benefits and deficiencies. Building these two programs on top of our highly fragmented financing infrastructure inevitably perpetuates inefficiencies.

Each program would require an act of Congress. We need only to look at the insurance industry influence in the legislative process that developed the designs for the private insurance exchanges under ACA, for the Part D Medicare drug program, for the private Medicare Advantage plans, for the privatization  of the Medicaid programs, for the previous public option proposals that never got off the ground, and for the co-op model that is failing in the marketplaces, and it will be obvious that the Medicare buy-in and public option will be designed to maximize the leverage of the private insurance industry at a cost to potential enrollees and taxpayers. The insurers will introduce features that are designed to make public programs noncompetitive or even cause them to fail.

When you hear people advocate for a Medicare buy-in or for the public option – and those people are everywhere – demand that they show you their model that was distilled from the multitude of policy options. (Be sure to read the Blumberg and Holahan paper so that you understand at least some of the issues.) Without such a model, the design will default to the private insurers.

Once advocates present their definitive model then analyze it to see how well it meets our reform goals. Will it ensure that everyone is covered? (No) Will it slow the increase in health care costs? (No) Will it ensure that everyone has free choice of health care professionals and institutions? (No) Will it remove financial barriers to care? (No) Will it fill in all of the gaps in coverage of our traditional Medicare program? (No)

Efforts to enact a single payer national health program are rejected because the program supposedly is not politically feasible. Does anyone really believe that a Medicare buy-in and a public option would be politically feasible in a Congress dominated by conservatives and neoliberals? It’s not the goal of a single payer model that needs to be changed; it’s the politics. That takes work. A lot of it.

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Gerald Kominski discusses the politicians’ proposals and the future of U.S. health care

Posted by on Thursday, Sep 29, 2016

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 Presidential Candidates: Their Health Plans”

By Dr. Gerald Kominski
Director, UCLA Center for Health Policy Research
Professor, UCLA Fielding School of Public Health

The UCLA Center for Health Policy Research
Health Policy Seminar Series, September 27, 2016

Excerpt at 0:52:24 of the video:

Question: Will the U.S. move to universal health care in the next ten years or so?

Gerald Kominski: Wow! I’ve spent my entire career talking about the history of the effort to get universal health care in the United States. And, again, I’m looking at Mark Peterson whose written about this extensively as well and knows the history. Our history is that we have been trying to do this now for 120 years in the United States. We’ve made progress, but the progress is glacial. Having said that, we never stop fighting for that. First of all, that’s why we’re in Public Health. It’s why this center – The Center for Health Policy Research – does what it does, and it’s why thousands of people across the country, across the state…millions of people are working towards this goal. But the next ten years are very difficult…we are so divided politically right now, it is very, very difficult to imagine the scenarios that lead us to true universal access through, say, a single payer system in the next ten years. But I’m an optimist, and I believe that there are people in this room who will one day see a single payer system in this country. Now I may not be around, but some of you will be. And we’re getting there. It just takes a long time.

Video, with PowerPoint:

In this seminar Gerald Kominski discusses the health care proposals of presidential candidates Democrat Hillary Clinton and Republican Donald Trump plus those of Libertarian Gary Johnson and Green Party candidate Jill Stein.

Health policy wonks and others certainly understand the complexity of the proposals of the two leading candidates and even that of Libertarian Gary Johnson, as described by Professor Kominski. But he was able to describe Jill Stein’s proposal in full in one brief, elegant sentence. Here is his full description of her plan (at 0:41:12 of the video):

“Jill Stein, the Green Party candidate, is for a Medicare for All plan, basically a single payer plan with no copayments, no deductibles, basically free health care for all Americans.”

That’s it!


Physicians for a National Health Program is a nonpartisan educational organization. It neither supports nor opposes any candidate for public office.

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Wellmark Blue Cross and Blue Shield placing greater squeeze on patients

Posted by on Thursday, Sep 29, 2016

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.

Wellmark announces individual ACA market changes in Iowa and South Dakota

Wellmark, September 28, 2016

Wellmark Blue Cross and Blue Shield announced today it will make changes in the individual Affordable Care Act (ACA) market in Iowa and South Dakota.

For the past two years, Wellmark members with individual ACA plans have endured double-digit increases. In addition, Wellmark has lost approximately $99 million over the same time period in the individual market in Iowa and South Dakota.

“Wellmark’s mission is to create affordable health insurance for people to access quality health care. And, for the majority of the past 75 years, we’ve been able to achieve that,” said Wellmark Chairman and CEO John Forsyth. “However, it’s apparent that continuing to offer plans with broad networks, combined with the rich benefits of the ACA, is not consistent with managing continually rising costs. While we could seek additional premium increases to mitigate rising costs, this is not sustainable for our members’ pocketbook.”

Iowa changes

In Iowa, Wellmark will narrow its product choices to offer plans that are lower priced and encourage health care delivery by Iowa providers. Specifically, Wellmark will no longer offer gold tier plans nor will the company promote individual under 65 plans that use its Preferred Provider Organization (PPO) network in Iowa.

Wellmark will also continue its plans to introduce a new, simplified HMO plan called Blue Simplicity℠. This plan is like no other on the market today and is designed to help consumers understand the true value of care through simple copay plans – providing members with transparency and predictability of cost as they seek and use medical services.

South Dakota changes

In South Dakota, Wellmark will no longer offer individual Affordable Care Act (ACA) plans effective Jan. 1, 2017.

“Although the ACA has done many positive things, it has also had its challenges and those challenges vary by state,” said Forsyth. “Fortunately, in 2017, the ACA gives states the ability to begin addressing those challenges with the goal of stabilizing the individual under 65 health insurance market. We look forward to working with Iowa and South Dakota policymakers on those solutions in the near future.”


The largest health insurer in Iowa, Wellmark Blue Cross and Blue Shield, is discontinuing their more comprehensive gold tier plans and is discontinuing the promotion of its PPO plans with wider provider networks. They are also introducing a new HMO plan “designed to help consumers understand the true value of care through simple copay plans” (i.e., making them better shoppers by having to bear more of the costs). These changes are compounding the two problems plaguing insurance purchasers today: requiring higher out-of-pocket spending for health care, and narrowing the selection of health care providers covered by the plans.

This is a one-way path designed to keep insurance premiums as competitive as possible. As Chairman and CEO Forsyth states, “continuing to offer plans with broad networks, combined with the rich benefits of the ACA, is not consistent with managing continually rising costs.” Insurers are not going to cover more out-of-pocket costs by increasing the actuarial value of their plans (percent of costs they will pay), and they are not going to expand their networks when they can negotiate lower prices by promising provider exclusivity.

Look, as long as we leave these people in charge, we can anticipate that they will engage in strategies that will protect and improve their own market advantage. If we had our own public program, our stewards who work for us would be engaging in strategies that would ensure our access to the health care that we need. There really is a difference. If only for selfish reasons, we should prefer the latter. The fact that it helps everyone else is a bonus.

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Employee health deteriorated under award-winning wellness program

Posted by on Wednesday, Sep 28, 2016

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.

Top wellness award goes to workplace where many health measures got worse

By Sharon Begley
STAT, September 27, 2016

When Idaho’s Boise School District receives the workplace wellness industry’s highest award Wednesday at a celebration in Atlanta, it is expected to be applauded for helping its 3,000-plus employees and their families improve their health and reduce their risk of illness.

It is “an exemplary program,” said Dr. James Fries, an emeritus professor of medicine at Stanford University and member of The Health Project, an industry-sponsored group that makes the annual award. Program participants, he said in an announcement this month, “showed improvements in health behavior,” helping Boise save money on medical costs.

Data collected by the company that sold Boise the wellness program and trumpeted the “Koop Award,” however, cast doubt on that claim. More key measures of health deteriorated than improved. Self-reported quality of health got worse. And health care costs jumped around in a way that suggests any changes were due at least in part to random fluctuations and possibly employee turnover, not any benefits of the wellness program.

This would not be the first time the Koop Award, named for the late US Surgeon General Dr. C. Everett Koop, stirred controversy. Employees in the wellness program that won in 2015, for instance, collectively achieved a lower reduction in smoking than the national average. More gained weight than lost, more raised their total cholesterol level than lowered it, and more had higher blood glucose levels after participating in the wellness program than before.

Such cases reinforce a growing recognition among experts that wellness programs — which constitute an $8 billion a year industry — “don’t lead to any visible results,” Stanford’s Emma Seppala recently wrote in Harvard Business Review. “At best, these initiatives are nothing more than lip service or PR. But at worst, they actually cause more stress.”


We still hear that employers are adopting wellness programs in order to reduce the future costs of their health benefit programs by making their employees healthier. There could be no better evidence that these programs do not work than the fact that the top award for a workplace wellness program went to an employer whose employees’ health deteriorated.

If employers really want to do something about controlling health care costs, they should get on the single payer bandwagon. Not only would that eliminate the hassle and expense of administering their health benefit programs, all of their employees would have health care automatically, and future increases in health care costs would be reduced to sustainable levels.

Any employers reading this who are not yet convinced about single payer would benefit by watching a movie developed by and for the business community, “FIX IT – Healthcare at The Tipping Point.”


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