Value-based care would improve under single payer

Posted by on Tuesday, Sep 18, 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.

Payers and Providers Remain Far Apart

By Leemore Dafny, Ph.D. and Namita Seth Mohta, M.D.
NEJM Catalyst, March 2018

Health care stakeholders are not aligned in important goals and in large part are not working together to achieve value-based care, according to the NEJM Catalyst Insights Council. They are waiting on government regulators to change the payment model – including, possibly, single-payer health care.

More than half (58%) of Insights Council survey respondents indicate that their individual organizations are not aligned in working toward achieving value-based care. A higher percentage of clinicians (63%) than clinical leaders (53%) think that payers and providers at their organization are not aligned. At the health care industry level overall, the outlook is even bleaker, with 77% reporting a lack of alignment.

Unlike many industries where the private sector typically takes the lead in driving change, our survey confirms other research that in health care, government payers set the blueprint for private payers to piggyback on. Respondents rate regulatory payment model changes (such as from Centers for Medicare & Medicaid Services) as the most influential among drivers to improve payer-provider collaboration.

Single-Payer Health Care Would Have a Positive Effect on Value-Based Care

Would the ability to provide value-based care get better, worse, or stay the same under single-payer health care?

61% – Better
22% – Worse
16% – Stay the same

Single-payer health care would have a strongly positive impact on the ability to provide value-based care, say Insights Council respondents. This reaction is consistent across all three audience segments of executives, clinical leaders, and clinicians. In verbatim responses, many respondents single out single-payer as the systemic change that would most improve payer-provider collaboration. These results continue the trend that NEJM Catalyst has observed among Insights Council members holding a positive view of single-payer health care.…

In the quest to change from volume to value in health care financing, gimmicky models such as accountable care organizations are being implemented, but the lack of alignment between payers and providers has not achieved the goal of value-based care. This survey of clinicians, clinical leaders and executives reveals that they believe that a single payer approach would have “a strongly positive impact on the ability to provide value-based care.”

Rather than continuing on the path to nowhere laid down by the politicians, bureaucrats, and policy community, doesn’t it seem logical that we should look at the model that those in the trenches – the clinicians, clinical leaders and executives – believe would actually work? Rather than having the payers attempting to align the providers, we should be having the providers who understand the delivery of health care give guidance to the design of the financing system. It becomes ever more evident to those providing the care that instead of a fragmented, dysfunctional market of private payers we should have a single, efficient public payer if we want to inject greater value into our health care system.

It would be infinitely better for the providers to give guidance to the design of the financing system to make it work optimally for patients than it would be to continue to allow the payers to try to design the health care delivery system. That’s how we have ended up with MACRA, MIPS, APMs, ACOs and other screwball ideas. Let’s work on improving the clinics and hospitals instead – under a single payer system. That’s where the value is.

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I just want my blood pressure pills, dammit! (and why it should matter to others)

Posted by on Monday, Sep 17, 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.

In the big picture of health care in America, the following anecdote is quite trivial, but, as I’ll explain, the implications are of great consequence.

Through the years my wife and I have had great care coordinated by our highly competent primary care physician. He retired recently and his practice was taken over by another physician. I needed a refill on my two blood pressure medications, but rather than interacting with the physician, I was now interacting with OptumCare Medical Group, a subsidiary of UnitedHealth. (You’ve no doubt read about insurers consolidating with physician groups – it’s very real.) Although we have avoided the private Medicare Advantage plans, I found by perusing OptumCare’s website that, without my knowledge, I was assigned to their Medicare Pioneer ACO.

The trivial complaint of mine is that I had to have numerous contacts through an always-busy telephone system and a non-responsive contact point on their website which resulted in many days of effort just trying to get my two basic blood pressure medications refilled. Several errors were made and, in fact, they never were correct even after repeated attempts. The prescriptions had the names of two different nurse practitioners on them, and finally one had the name of my new primary care physician after I was finally able to see him. Part of these glitches were due to the fact that they were transitioning to a computer system.

Not only were my prescriptions under the control of OptumCare, I was also covered by a Part D Medicare drug plan through Anthem Blue Cross. All I wanted was a 90 day supply of each pill with 3 refills, just as I had had under our previous physician. Well, somewhere between OptumCare and the Anthem drug plan, our independent pharmacist of many years was authorized to fill only a 30 day supply, but for only one of them since it was too early to fill the other one. This meant that I would have to come back every 15 days indefinitely to pick up only one prescription at a time. I checked the Anthem website and found that not only was my pharmacy not on the preferred list, it was no longer listed in the Anthem network at all (with a statement that pharmacies could be changed at any time without notice).

I discovered that I could receive 90 day supplies by mail through Anthem’s pharmacy benefit manager, but it seemed unfair to me that they should take over the bread and butter trade of easy long term prescriptions while leaving the local pharmacist with the need to carry a huge stock of a great variety of prescription items that are filled usually only once, creating an overhead headache without a volume offset.

I finally gave up. Since I still have my medical license, I ordered stock jars of 1000 pills each through a medical supplier so I wouldn’t be bothered with the hassle any more (a strategy not available to most people). Of course, that’s not covered by the Part D plan, but I had had enough. (I should mention that though it is unethical for a physician to prescribe for himself, these two medications were actually prescribed by my primary care physician and by my cardiologist.)

Yes, this is very trivial compared to some of the horrendous problems that others face in our health care system. But it is what this annoyance represents that is so objectionable. The system should work so that I can get my very common, tier one generic medications every three months with an effortless system of refilling them. Instead, my physician has been hijacked by one of the largest insurers in the nation, and my pharmacist has had barriers erected by another of the largest insurers, together making it much more difficult for me to obtain my straightforward maintenance medication. What value are these giant insurers adding that we should have to tolerate their inanity?

The reason that everyone should be concerned is that this takeover of health care is expanding rapidly, with no relief in sight. If it doesn’t work well for minor routine matters, how could it work well for the big stuff? A well designed, single payer improved Medicare for all program as is advocated by Physicians for a National Health Program would solve most of the problems with our highly dysfunctional health care financing system. Although there is widespread public support for such a model of reform, look very carefully at what is actually happening in the political arena.

Congress and the administration are continuing to expand the private Medicare Advantage and private Medicaid managed care models. They are continuing to push alternative payment models including accountable care organizations and other so called value-based proposals that involve intrusions by insurers and other managers. While using the Medicare for all rhetoric, they are quietly suppressing the bona fide single payer model while giving the business intermediaries an even greater role in (mis)managing our health care system.

HR 676, the Expanded and Improved Medicare for All Act contains many of the principles of a well designed single payer system. People are enthused to see the formation of a Medicare for All caucus in the House. There has also been considerable enthusiasm over the introduction in the Senate of Bernie Sanders’ bill, S 1804, as supposedly being a single payer Medicare for All bill in the Senate. However, to gain cosponsors, many compromises were made. Exemplifying them is the inclusion of the following:

“Sec. 611 (b) Application Of Current And Planned Payment Reforms.—Any payment reform activities or demonstrations planned or implemented with respect to such title XVIII as of the date of the enactment of this Act shall apply to benefits under this Act, including any reform activities or demonstrations planned or implemented under the provisions of, or amendments made by, the Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 114–10) and the Patient Protection and Affordable Care Act (Public Law 111–148).”

This means that the payment models of ACA and MACRA with MIPS and APMs including ACOs would be perpetuated under S 1804. What is especially alarming is that members of the House Medicare for All caucus, instead of protecting and supporting the single payer features of HR 676 and encouraging the Senate to endorse the same, they want to change HR 676 to include the highly flawed features of S 1804. It appears that the intent of Congress is to perpetuate the entities that are creating many of the very problems that we are trying to solve with PNHP’s version of an improved Medicare for all. Leaving our dysfunctional system in place while merely adding a Medicare Advantage-style public option is no solution at all.

My wife and I have transferred our care to another excellent physician. We left OptumCare but are continuing with the traditional Medicare program with a Medigap supplement to protect us in the event of catastrophic events. We also are continuing with our Part D drug plan to protect us against the potential of those $100,000 drugs that are becoming so commonplace. But wouldn’t it be nice to have the Medigap benefits and the drug benefits rolled into the traditional Medicare program along with the other improvements that would be ideal in an improved Medicare for all? We’re not going to have that unless we start communicating more effectively with our members of Congress, even if it means using our boot.

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The support for Medicare for all is solid

Posted by on Friday, Sep 14, 2018

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

The Nation’s Pulse: Year Four

Texas Medical Center Health Policy Institute
Survey completed June-July 2018 (4,020 national participants)

Support for Medicare for All U.S. Adults

Q: Are you in favor of the federal government providing Medicare insurance coverage for all U.S. adults?

59% – All
71% – Democrats
46% – Republicans
55% – Independent…

Although this question asks about providing Medicare insurance coverage for all U.S. adults without mentioning children, nevertheless it still shows strong support for Medicare for all, including close to one-half of Republicans.

Efforts are being made to discredit these surveys by tacking on questions such as “even if it means the government raising your taxes,” or “even if it means losing your choice of health plans,” or “even if it means they take away your insurance through your work.” Inevitably these questions slightly reduce polling support for Medicare for all.

Polls that we don’t see are those that would tack on questions that would increase the credibility of the Medicare for all model. Instead of threatening an increase in taxes, suppose they were asked, “even if it meant that all but the very wealthiest would end up paying on average less overall for health care.” Instead of threatening loss of choice of health plans, suppose they were asked “even if it meant that you would no longer be limited to a list of physicians and hospitals dictated by the insurer but rather you had complete free choice of your health care professionals and institutions.” Instead of threatening loss of your health plan through work, suppose they were asked, “even if it meant that you would never have to worry about health insurance again because you would automatically have full comprehensive coverage for life.”

Obviously we could go further. “Even if Medicare for all meant that we would save hundreds of billions of dollars in administrative waste.” “Even if Medicare for all meant that nobody would ever have to go without care because they couldn’t afford it.” “Even if it meant that wherever you are in the country, you would never have to worry whether your insurance is good.” “Even if it meant that you would never have to busy yourself with insurance paperwork because coverage and billing is automatic.” “Even if it meant that you would not have to worry about whether you could afford the care you are about to receive since out-of-pocket costs would be eliminated for all essential health care services.”

Well, the good news is that people are gaining a better understanding of the benefits of the Medicare for all single payer model. Republican voters are realizing that the Republican promise of a better replacement for Obamacare proved to be false, and yet they understand that we need more than what the Affordable Care Act brought us. Democratic voters largely understand the benefits of single payer, but they are just beginning to realize that some Democratic politicians are using the Medicare for all rhetoric deceptively to maintain the status quo that caters to the insurers and pharmaceutical firms. It is no wonder that we are seeing an increase in independent voters who are wary of both major parties but who also seem to understand that Medicare for all seems to be a much better option than our current dysfunctional system.

We need to keep on with what we’re doing, except do a whole lot more of it. Maybe those of us who are octogenarians will no longer have to say, “but not in my lifetime.”

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The coverage of the uninsured has plateaued

Posted by on Thursday, Sep 13, 2018

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

Health Insurance Coverage in the United States: 2017

By Edward R. Berchick, Emily Hood, and Jessica C. Barnett
United States Census Bureau, Current Population Survey Annual Social and Economic Supplement (CPS ASEC), September 2018

In 2017, 8.8 percent of people, or 28.5 million, did not have health insurance at any point during the year. The uninsured rate and number of uninsured in 2017 were not statistically different from 2016 (8.8 percent or 28.1 million).…

This definitive report on the health insurance status of U.S. residents provides an extensive breakdown of the statistics on insurance coverage, but the one highlight above pretty well summarizes the status. There was no statistically significant change in the numbers of uninsured between 2016 and 2017.

Although the reported change from 28.1 million to 28.5 million uninsured may not be statistically significant, there are likely 400,000 people out there who personally believe it is significant for themselves even if the statistical analysis is dismissive of it. At any rate, there are still over 28 million people who can’t be pleased with their lack of insurance coverage.

The major lesson in this report is that the gain from the Affordable Care Act has appeared to plateau, although the numbers may not have fully stabilized yet, largely because of the policies being adopted by the Trump administration and the various state governments. But it is safe to say that complete elimination of uninsurance is not imminent and cannot possibly occur without a major policy change.

One of the least promising policy changes would be a Medicare public option, or Medicare buy-in, which some have mislabeled as Medicare for All. It would provide only one more option in the market of plans that already exists and thus would have very little impact on overall coverage or affordability since the other options are already available.

Of course, the most promising policy change under consideration that would be fully effective would be a single payer national health program – a bona fide Improved Medicare for All.

It has now been a decade since we started down the path of Obamacare. Regarding the goals of universality, equity, affordability, administrative efficiency, and guaranteed lifetime coverage, it is clear that the Affordable Care Act has been a failure. Rather than merely adding a Medicare Advantage-like public option to our expensive but mediocre system, we should finally provide the fix our system truly needs – an Improved Medicare for All. Just make sure it’s the real thing.

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Without pharmaceutical price regulation, gouging is to be expected

Posted by on Wednesday, Sep 12, 2018

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

Pharma chief defends 400% drug price rise as a ‘moral requirement’

By David Crow
Financial Times, September 11, 2018

A pharma executive has defended his decision to raise the price of an antibiotic mixture to more than $2,000 a bottle, arguing there was a “moral requirement to sell the product at the highest price.”

Last month, Nostrum Laboratories, a small Missouri-based drugmaker, more than quadrupled the price of a bottle of nitrofurantoin from $474.75 to $2,392, according to Elsevier’s Gold Standard drug database.

Nitrofurantoin is an antibiotic used to treat bladder infections that was first marketed in 1953, which appears on the World Health Organization’s list of essential medicines.

In an interview, Nirmal Mulye, Nostrum chief executive, said he had priced the product according to market dynamics, adding: “I think it is a moral requirement to make money when you can…to sell the product for the highest price.”

Mr. Mulye said Nostrum was responding to a price rise from Casper Pharma, which makes a branded version of the product known as Furadantin. Casper increased the price of its product by 182 per cent between the end of 2015 and March 2018, taking a bottle to $2,800, according to the Elsevier database.

He also defended the actions of Martin Shkreli, who became infamous in 2015 for his decision to raise the price of an Aids and cancer drug from $13.50 to $750 per tablet. Shkreli was jailed earlier this year on unrelated fraud charges.

“I agree with Martin Shkreli that when he raised the price of his drug he was within his rights because he had to reward his shareholders,” said Mr. Mulye.

Mr. Mulye pointed out that Shkreli was able to increase the price of Daraprim so dramatically because his company was the only one making it.

“If he’s the only one selling it then he can make as much money as he can,” said Mr. Mulye. “This is a capitalist economy and if you can’t make money you can’t stay in business.”

In a tweet responding to Mr. Mulye’s comments, Scott Gottlieb, FDA commissioner, said, “There’s no moral imperative to price gouge and take advantage of patients. FDA will continue to promote competition so speculators and those with no regard to public health consequences can’t take advantage of patients who need medicine.”…

Appalling drug price gouging will continue until our government fulfills its responsibility to protect the consumer, that is, the patient. FDA Commissioner Scott Gottlieb represents the view of current and previous administrations when he says that we need to promote competition, as if the market will take care of it.

But that’s not the way markets really work. The 400 percent price increase of this generic nitrofurantoin was to bring the price closer to the competition – the branded version, Furadantin. Nostrum chief executive Nirmal Mulye explains to us the way markets really work, “I think it is a moral requirement to make money when you can…to sell the product for the highest price.” A moral requirement, he says.

Maybe we should begin discussions of nationalizing the pharmaceutical industry. That might make them nervous enough that they would finally agree to regulation of prices as is done in other civilized nations. Whether they agree or not, we need to do it.

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Inequities of social spending

Posted by on Tuesday, Sep 11, 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 Government-Citizen Disconnect

By Suzanne Mettler
Russell Sage Foundation

From Chapter 1 – A Time of Contradiction

Over the past four decades, Americans’ relationship to the federal government has evolved in a deeply paradoxical manner. As a society, we appear to regard government with ever greater disdain, as evidenced by popular discourse, numerous polls, and election results. Yet people depend on the federal government more than ever to help them attain economic security, health care and educational opportunity.

Yet over these very same decades, Americans have increasingly counted on the federal government’s assistance in their personal lives. Nationwide, the share of the average citizen’s income that flows from federal social “transfers” – including Social Security, food stamps, the Earned Income Tax Credit (EITC), and more than forty other programs – increased from 7 percent in 1969 to 17 percent in 2014. On a per capita basis, the rate grew fairly steadily over time, escalated more quickly with the onset of the 2008 financial downturn, and then declined somewhat more recently. The amount received by the average person increased from $1,853 in 1969 to $7,729 in 2014, in 2014 dollars.

These figures do not include the most generous social benefits, which are either channeled through the tax code, such as home mortgage interest deduction, or provided in tandem with private organizations, such as tax-subsidized, employer-provided health and retirement benefits. These policies serve the same function as social benefits delivered as direct payments or services – such as helping families to afford health care, housing, or education – but in permitting beneficiaries simply to pay less in taxes, they differ in design. If we consider only public social spending or government transfers, the U.S. welfare state is smaller as a percentage of GDP than that of other affluent nations, ranking twenty-fourth worldwide, but if we account also for the social expenditures channeled through the tax code and tax-subsidized payments from employers, the United States has the second largest welfare state in the world after France.

From Chapter 3 – We Are All Beneficiaries

Sheila Turner, who was born in 1973, is a self-described “stay-at-home-mom” who lives in Dallas, Texas, in a middle-income household. She considers herself to be extremely conservative on politics and identifies with the Republican Party. When asked what she thinks of when she hears the term “government social programs,” she says, “Giving money to those who don’t want to work.” Her views of such programs are “mostly negative,” she reports, because they provide support for “people who don’t prioritize their budgets and pay for their (own) bills.” She believes that “government does a poor job of managing things,” and that “people should provide for themselves.”

Yet Turner readily acknowledges that her family has used several specific policies. Her daughter used financial aid to attend college, both Pell Grants and student loans. Her husband used Unemployment Insurance for several months while unemployed, about which she comments, “Every little bit helps when you have no income.” She and her family have also utilized several features of the tax code, including the EITC, the home mortgage interest deduction, and the tax-free status of employer-provided health and retirement benefits. She does not view these tax expenditures as government social benefits, but rather as incentives for making certain decisions, explaining, “They give people a reward for using their money the right way”

American rhetoric about government benefits implies that we are a deeply divided nation of “us” and “them,” the deserving and the undeserving. Yet the evidence tells a different story. When we consider individual Americans across different incomes, parties, and ages, nearly all have used social benefits, and although usage patterns vary, particularly with respect to policy types, the commonalities loom larger than the differences. Similarly, when we consider Americans with respect to the communities across the country where they live, whether rich or poor, they are far more likely to use more such benefits today than Americans did thirty-five years ago. We nearly all benefit from the federal government’s social policies, and we nearly all contribute to those policies. whether through payroll taxes, income taxes, or both.

Percentage of Americans Who Report Having Ever Used Specific Social Policies:

55.3 – Employer-provided retirement (current only)
49.9 – Employer-provided health care (current only)
45.6 – Home mortgage interest deduction
38.5 – Unemployment insurance
34.4 – Earned Income Tax Credit
27.4 – Student loans
25.7 – Child and Dependent Care Tax Credit
25.4 – Food stamps
22.2 – Medicare
17.5 – Medicaid
16.0 – Pell Grants
15.8 – Social Security – retirement and survivors’
13.9 – Welfare/public assistance
10.0 – Hope or Lifetime Learning Tax Credit
9.7 – Social Security Disability Insurance
8.7 – Government-subsidized housing
8.1 – Supplemental Security Income
8.0 – Head Start
5.9 – GI Bill
5.1 – 529 plan or Coverdell Education Savings Account
4.6 – Veterans’ benefits (other than GI Bill)

From Chapter 4 – Different Lenses

In sum, when Americans think about government, only in some instances does their memory of the social policies they have benefited from hover at the top of their minds. As a result, the strong antigovernment attitudes that prevail in the United States today can be found even among many people who themselves have benefited a great deal from social policies. These views may attract Americans to candidates and organizations that articulate such views, even if they hold positions that threaten the very policies from which individuals have benefited.

From Chapter 5 – Unequal Voice

How is it that the nation has shifted to electing more officials who want to undermine social policies at the very same time as citizens depend on them more than before? The answer is in part for reasons we saw in chapter 4, that many Americans use benefits that make government’s role less than apparent, and that when they evaluate government, other considerations and affiliations loom more heavily in their minds than their social policy experiences. But it is also a matter of who shows up to participate in political activity. Those who have benefited from more visible government programs are both more aware of the role that government has played in their lives and more supportive of social spending. Yet they tend to participate less than other Americans, for reasons related to their socioeconomic status and also because candidates, parties, and groups do less to mobilize them and involve them. As a result, their voices are less likely to be heard in the political process, which meanwhile overrepresents those who are less aware that government has made a difference for them. The American polity is skewed by a participatory tilt that exaggerates the views of those who remain incognizant of government’s role in their lives and drowns out those of others. But it does not have to be this way.

From Chapter 6 – Reconnecting Citizens and Government

Although the United States has nevertheless increased the extent to which it provides economic security and educational opportunity to citizens, many Americans who are beneficiaries of these policies do not perceive government to be responsive to them. This conundrum amounts to a government-citizen disconnect.

Policy designs do not speak for themselves in communicating the value of government. Even if appealing internet tools and other procedures help citizens make sense of how government has helped them and their families over time, the impact on assessments of government may still be minimal. In our highly polarized polity, where organizational linkages that connect citizens and government have frayed and some groups beat the antigovernment drum, more is needed. Organizations that seek to strengthen democracy must step up to play these roles, making connections for citizens and drawing them into politics when the fate of policies is at stake. They can do so effectively by developing activists, including individuals from communities that are usually excluded from civic engagement. In the process, they can help people see how government matters in their lives – through social policies like those examined here as well as through others – and spur their involvement in the political process.

As Americans face the future, far more unites us than divides us. We are not a nation of moochers and takers. Rather, we are a political community, one built on respect for the ideas that all are created equal and that “we the people’ can govern ourselves. We can advance by honoring our reciprocal obligations to each other through the bonds of citizenship. By reaffirming that quest, we can carry on together, as citizens of a democracy.

Suzanne Mettler is Clinton Rossiter Professor of American Institutions in the Government Department at Cornell University.…

Because much of our social spending is not transparent, most people do not realize just how much they benefit from these government social policies. Those who benefit the most, especially though tax expenditures (tax deductibility of retirement plans, health plans, home mortgage interest, etc.), frequently do not consider the government’s largess accruing to their benefit as a government social program, yet they are resentful when others of lesser means receive more visible support to meet basic needs such as food stamps, unemployment benefits, public assistance, or Medicaid.

Yet the opaque social benefits the wealthy receive to help pay for their large mortgages, generous retirement plans or executive health benefit programs are frequently much more than the person with the food stamps at the super market checkout stand is receiving. Further, there is a prevailing attitude that somehow the person working at a job with poverty-level wages is not deserving of a government handout, whereas the very wealthy individual has somehow earned, as a reward, much greater benefits through tax expenditures, which is still a government handout, but for the rich.

It seems that we could inject a much greater dose of fairness into our social spending programs, and this is where health care financing enters the scene. Everyone should have health care, and they could if we used progressive tax policies to fund an equitable universal system such as an improved Medicare that covered everyone. If the system already existed, the rich would not be resentful of poor people getting the health care that they need. At least the rich don’t seem to be so in other nations that have equitable, universal systems.

We really could have the same here, but we’re going to have to acknowledge that we must change our attitude that low-income workers are not deserving of support for basic needs while the rich are entitled to tax expenditures to support their more extravagant lifestyles.

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Ask Medicaid-eligible individuals what a work requirement would do

Posted by on Monday, Sep 10, 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.

Medicaid Recipients’ Early Experience With the Arkansas Medicaid Work Requirement

By Jessica Greene
Health Affairs Blog, September 5, 2018

In June, Arkansas became the first state to implement a work requirement in its Medicaid program.

Little is known to date about how those impacted by the new Medicaid work requirement feel about the policy. To explore Medicaid recipients’ attitudes about Arkansas’ work requirement and their early experiences with the policy, in mid-August I conducted in-depth interviews with 18 adult Medicaid recipients in northeast Arkansas.

While this group is far too small to provide generalizable results, the interviews do illustrate how the state’s policy is interacting with the day-to-day lives of Medicaid recipients to produce serious potential consequences that have little to do with policy’s stated objectives.

Lack Of Awareness

Two thirds of the Medicaid recipients (12/18) I interviewed had not heard anything about the new work requirement. “First time I’ve ever heard anything [about it],” a 31-year old man, who had started a vocational training program the day we spoke, said. “You’d think it’d be on the news or something. I ain’t seen it on the news, and I watch Channel 8 news every night.”

At Risk Of Losing Coverage

Of the nine people who, based on their age, should have received a DHS letter letting them know they were subject to the work requirement, four said they had received a letter. Two said the letters indicated they were exempt because they already met the SNAP work requirement.

The other two were at risk for losing Medicaid coverage. One, a 47-year old woman, said she had received her letter about three months earlier; she believed, incorrectly, that she had three months to report her hours. When I asked her if reporting her hours was an obstacle, she said she was struggling with very stressful life issues, including a mentally ill sister, and as a result the work requirement had not received much of her attention. The other person, a 40-year-old woman, described being overwhelmed by receiving the letter: “Basically… I’m like, okay, I’ve got this letter. I file it and I don’t know what to do with it…”

The other five who should have received a work requirement letter were either not sure if the letter arrived or thought it had not. When asked about receiving a DHS letter, a 42-year-old woman said, “I don’t know, I’m going to have to check and make sure [I didn’t receive the letter], because I need my Medicaid card for my sugar pill and my blood pressure pills.” A 46-year-old man, who had recently completed an inpatient drug treatment program, kicking a multi-decade drug addiction, wasn’t sure either. “I may have [received the letter]…I’m horrible about opening mail….I probably throw’d it away.” While the three others did not believe they received the letter, they were all exempt by either working and/or having children in the home, but likely needed to report their hours and exemptions in the portal to maintain Medicaid coverage.

Policy Not Sparking Work-Related Changes

Of the nine participants who were likely subject to the policy, only two were not meeting the 80 hour work-related activity requirement and did not seem to qualify for an exemption. Both told me that they were actively seeking work, and that the work requirement had not at all impacted their job seeking. In addition, those I interviewed between the ages of 19-29, who will be subject to the policy in 2019, either worked, went to school, and/or had children under 18 years old in the home. No one I spoke with reported that the policy had or would spark them to change their work-related activities.

Online Portal Challenging For Many

Participants described a very wide range of computer and online skills and access. Approximately a third said that reporting hours on the online portal would not be possible for them: “I can’t do that. I don’t have a phone. I don’t have a computer.”

Several, who were confident of their own skills, mentioned family members who would struggle. “Half my family probably doesn’t have a smart phone….A lot of people here don’t have internet still,” a 19-year old woman explained.

Mixed Attitudes About Linking Medicaid And Work-Related Activities

Almost all the participants believed that people who could work should be working. “I believe if you are able to work and you want the extra help that Medicaid gives, then you should work,” said a 28-year old woman who was currently working and has young children. But several expressed concern about those who had mental or physical conditions that would prevent them from meeting the requirement. One man raised questions about people who were “borderline” who were not officially considered disabled but still had serious health conditions. A 42-year-old woman, who works with people with disabilities said, “I think it’ll do more harm than good…. What they supposed to do, just get cut off Medicaid because they can’t meet those requirements?”

Others raised concerns about transportation needed to get to work and volunteering. “Some people don’t have vehicles, and sometimes it’s not necessarily their fault. Sometimes something happens and they lose their money… It’s not fair,” said a 21-year old recipient who is a college student. When I asked a woman who was looking for work whether she had tried to get help from the Department of Workforce Services, she said that she couldn’t get there because it was 30 miles away and there is no public transportation.

Not Going To Lift People Out Of Poverty

Participants were very skeptical about the Governor’s claim that the work requirement policy would help them out of poverty, as many were already working and still struggling financially.

One participant argued that the policy was not about getting people to work at all, but about reducing the number of Medicaid recipients: “It seems like a ploy for the state to save money. That’s all it is. It’s nothing about trying to get people back to work…”

Summing Up

Of the people I interviewed who were at risk of losing Medicaid coverage as a result of the work requirement, most were at risk because they lacked awareness of the policy or were overwhelmed by it, rather than because they were not meeting the 80 hours a month of work-related activities or the terms of an exemption. If this is true more broadly, the state will be ending people’s health coverage for the wrong reasons, adding credence to those who argue this policy is about reducing the rolls, rather than supporting people to get employment.

A 38-year-old woman who recently had to quit her job to get her niece, who she mothers, a birth certificate and other paperwork to start school argued that the policy does not take into account the complex lives of low-income people. “You are saying this should be possible, but you don’t know my circumstances. You haven’t been here,” she explained.

Dr. Jessica Greene is a Professor and the Luciano Chair of Health Care Policy at Baruch College, City University of New York.…

Sometimes you simply do not need extensive health policy research to understand what impact various policy proposals would have. As an example, to understand what a work requirement to qualify for Medicaid would mean for the low-income, target population, just ask them.

This brief series of interviews of Medicaid beneficiaries done by Professor Jessica Green provides enough anecdotes that are fully predictable. This relatively unsophisticated, low-income population is already struggling with just trying to make ends meet. Throwing in an employment reporting requirement just further complicates their personal agendas. Besides, none of them believe that the program will cause them to change their work-related activities.

The purpose of Medicaid is to provide access to medical care for individuals who cannot afford it. Does requiring work as a condition of Medicaid enrollment advance that goal? No, just the opposite. Under this requirement many will lose their Medicaid coverage and thus lose access to medical care.

Look. We’re trying to get people the health care that they need. We already understand the policy decisions that would do that. A well designed, single payer, improved Medicare for all would take care of it. We do not need the injection of screwball ideas based on sterile ideology rather than benevolent compassion.

As one interviewee said, “you don’t know my circumstances; you haven’t been here.” But we do know how to get her and everyone else the health care program that they need. That’s what we need to be working on.


Additional Comment:

By Stephen Tarzynski, M.D.

Republican opposition to government-regulated medical care is partially based on the view that government governs best which governs least. Conservatives associate liberty with markets.

They may not realize it but they have more than a little in common, ideologically, with the early 17th century British statesmen who crafted the Elizabethan Poor Laws. These laws gave local governments the power to raise taxes to maintain almshouses and provide relief for the “worthy” poor, including the elderly. But they also mandated that the “able-bodied poor” be set to work in a House of Industry and sent the “idle poor” to Houses of Correction. In their twisted logic, poor people were only desperate because they were lazy or morally inferior to the wealthy.

GOP legislators echo these obsolete ideas when they talk about indigent “able-bodied adults” needing to work to deserve health insurance.

From my decades of experience as a doctor, it seems to me that no market-driven healthcare system can simultaneously limit costs, guarantee universal coverage and deliver desired outcomes. Overwhelming evidence demonstrates that the best way to reduce costs and guarantee healthcare to everyone is to have the largest risk pool — that is, the entire nation. These facts compel the United States to move to a single-payer system guided by comparisons with other countries’ experiences and by our own American successes, such as Medicare and Medicaid.

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Stan Brock

Posted by on Friday, Sep 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.

Stan Brock, 82, Intrepid Provider of Health Care in Remote Areas, Dies

By Sam Roberts
The New York Times, September 6, 2018

Stan Brock died on Aug. 29 at RAM’s offices in Rockford, Tenn., where he had lived ascetically since he founded the nonprofit outfit in 1985. He was 82.

(The Remote Area Medical clinic service, or RAM) began operating initially in British Guiana and then expanded to the United States in 1992, starting out with a single pickup truck that hauled a single dentist’s chair. It opened its first American clinic in Sneedville, Tenn., in 1992 and still runs an airborne ambulance operation in what is now the independent nation of Guyana.

The organization estimates that it has provided medical, vision and dental care to more than 700,000 patients since its founding, in areas ranging from Appalachia to New York City, and in Puerto Rico in the aftermath of Hurricane Maria.

Last year, about 1,400 health professionals volunteered to treat 2,300 people who showed up at one of RAM’s outdoor clinics at the fairgrounds in the western Virginia town of Wise. Some had camped out for three days to make sure they would be treated.

“The health fair reminded me of scenes I’ve witnessed in refugee camps in South Sudan,” Nicholas Kristof wrote in his Op-Ed column in The New York Times. “But here in America?”

“I’m just the voice of the homeless and the underserved,” he said. “But unless they fix these basic things, we’re going to be doing this long after my lifetime.”

Asked in an interview about his legacy, Mr. Brock said, “I hope that a hundred years from now, nobody will remember me at all because this will be a thing of the past.”

“But,” he added, “there seems to be no end in sight.”…

For those who want to see that all of us receive the health care that we should have, each of us approaches the deficiencies in our own way. Stan Brock’s high-profile efforts were quite unique. Besides serving people in need, he continued to provide us with an unambiguous visual image of how great the unmet need is.

When he recognized that the need was not only in poor countries but also right here in the United States, he began holding these Remote Area Medical (RAM) clinics in this country. At the time he began, the nation was ready for comprehensive health care reform which many thought that we would have under the Clinton administration. When that effort failed, people were still ready. Eventually the Affordable Care Act was enacted, but it was not the comprehensive reform that we needed. A quarter of a century after Brock began, people are still camping out at the RAM clinics in hopes of receiving just a modicum of care, here in America!

When asked about his legacy, Mr. Brock said, “I hope that a hundred years from now, nobody will remember me at all because this will be a thing of the past. But there seems to be no end in sight.”

No end in sight… here in America? We have to change that ASAP.

And thanks, Mr. Brock, for pointing that out.

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A physician/policy wonk faces our health care financing system

Posted by on Thursday, Sep 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.

As consumers’ out-of-pocket costs grow, will the patient bill-of-rights movement rise again?

By Harris Meyer
Modern Healthcare, September 1, 2018

Emergency physician Dr. Matthew Wetschler was body surfing off Ocean Beach in San Francisco last November when a wave slammed him head-first onto the ocean floor, breaking his neck and paralyzing him. Another surfer pulled him out of the water just before he drowned.

He was taken to Zuckerberg San Francisco General Hospital, the closest hospital that was well-equipped to treat him, where neurosurgeons performed surgery to fuse five vertebrae and maintain blood flow to his spinal cord. After months of physical therapy at Santa Clara Medical Center and Valley Medical Center, he’s walking, but still has no feeling in his hands.

During his grueling recovery, Wetschler received frequent calls from bill collectors seeking payment of nearly $500,000 in medical bills from the hospitals and physicians, plus a $13,000 bill from the air ambulance company that flew him 40 miles to Santa Clara for rehab care. Those providers were not in network for his insurer, Oscar Health.

Wetschler’s experience with a large out-of-network bills and opaque healthcare bureaucracies is common. Nearly 18% of hospital stays for members of large-employer health plans resulted in patients facing out-of-network balance bills, the Kaiser Family Foundation recently found. That rose to 27% when patients passed through the emergency department.

Healthcare consumers also face other common problems with cost, coverage and access, which may increase as the federal government allows the expansion of skimpier, less-regulated health plans. These problems include:

* Coverage denials for emergency department visits that insurers later deem unnecessary.

* Lack of access to specialty providers in health plan networks.

* Difficulty in getting coverage for mental health and substance abuse treatment from health plans.

* Delays in receiving care due to plans’ preauthorization requirements on providers.

* Patients’ inability to find out from providers ahead of time how much they will owe for particular services.

* Large out-of-pocket costs for prescription drugs, particularly specialty medicines.

“There’s plenty to do in the area of consumer protection, with high deductibles and out-of-network bills,” said Dr. David Blumenthal, president of the Commonwealth Fund. “But there is an anti-regulatory fervor we’re seeing in Congress and conservative circles that will be an obstacle to moving a consumer-protection agenda.”

Wetschler, the doctor injured in the surfing accident, has finally gotten the hospitals, physicians and his health plan, Oscar Health, to waive most of out-of-network bills. But he still gets calls from collectors on about $27,000 of that total, including $13,000 for air ambulance services from ProTransport-1.

In his view, there should be consumer protections in place so patients don’t find themselves in this type of terrible situation, which can destroy their finances.

“I’m a doctor with a master’s degree in health policy, yet I feel so overwhelmed that it’s almost paralyzing,” Wetschler said. “I’m stuck in no man’s land. For a person with no medical training, what hope is there?”…



Oscar’s story begins, fittingly, in a hospital room. In 2012, Oscar CEO Mario Schlosser and his wife were going through their first pregnancy in New York. Confronted with a maze of insurance jargon and no practical way to identify the best obstetrician, their first meaningful experience with the health care system put them at a loss as to how to navigate care or hold anyone accountable.

Mario’s friend Josh Kushner had recently had his own frustrating encounter following what should’ve been a routine treatment for an injury. Mario and Josh knew that their experiences were reflective of a larger problem in health care: consumers were powerless. That spring, they founded Oscar Health.

Oscar has been focused on one mission – to be a health insurance company centered around the patient.

A young emergency physician with a master’s degree in health policy should understand better than anyone how to interact with our health care financing system. Dr. Wetschler was insured by Oscar, a relatively new health insurance company cofounded by Josh Kushner, the brother of Jared Kushner of White House fame – a company that professes to be centered around the patient. Yet if the system is not working well in this situation, it could hardly be expected to work better for the rest of us.

Imagine having an improved version of Medicare wherein you receive the medical care you need, when you need it, and wherever you need it, and payment is taken care of automatically through a public system of health care financing. Instead we have a system in which even the most innovative insurers, like Oscar, restrict your choices and burden you with further debt. How can Oscar claim to be “a health insurance company centered around the patient” when they create additional problems for the patient that would be unnecessary in a well designed, publicly-financed and publicly-administered system?

It appears that President Trump and his son-in-law and advisor Jared Kushner are not going to help resolve these problems even though there is already more than enough money in the health care system, and they both profess to know a lot about how to manage money. Maybe instead of having a political leadership of money managers dedicated to business interests, we should replace them with political leaders who are dedicated to serving the people. It would really be nice to be rid of these unnecessary barriers to health care, and it wouldn’t cost us any more than we are already spending collectively.

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Beyond The ACA: Paths To Universal Coverage In California

Posted by on Wednesday, Sep 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.

By Andrew B. Bindman, Marian R. Mulkey, and Richard Kronick
Health Affairs, September 2018


California has long sought to achieve universal health insurance coverage for its residents. The state’s uninsured population was dramatically reduced as a result of the Affordable Care Act (ACA). However, faced with federal threats to the ACA, California is exploring how it might take greater control over the financing of health care. In 2017 the state Senate passed the Healthy California Act, SB-562, calling for California to adopt a single-payer health care system. The state Assembly did not vote on the bill but held hearings on a range of options to expand coverage. These hearings highlighted the many benefits of unified public financing, whether a single- or multipayer system (which would retain health plans as intermediaries). The hearings also identified significant challenges to pooling financial resources, including the need for federal cooperation and for new state taxes to replace employer and employee payments. For now, California’s single-payer legislation is stalled, but the state will establish a task force to pursue unified public financing to achieve universal health insurance. California’s 2018 gubernatorial and legislative elections will provide a forum for further health policy debate and, depending on election outcomes, may establish momentum for more sweeping change.

Barriers to Unified Public Financing

California would need to overcome daunting technical and political challenges if it were to transition to a system of unified public financing, whether single- or multipayer. It would be doubly challenging to accomplish this transition at the state level, in part because political agreement would be needed from two levels of government—state and federal. Concerns about providers fleeing the state or sick people being drawn to the state complicate the technical challenges of establishing a unified publicly financed health care system at the state level. These concerns would be minimized if unified public financing were enacted at the federal level.

Accomplishing such a sweeping transition would require substantial and unprecedented changes in federal and state law as well as decisions regarding many design parameters. To implement such a system, Congress would need to pass legislation to redirect payments away from individual Medicare beneficiaries and providers to whatever state agency was operating California’s unified public financing program.

Current federal law might allow federal waivers to redirect federal funds for Medi-Cal and subsidies for individuals in Covered California into a unified state pool, but such waiver requests would be unprecedented. In addition to establishing an initial set of assurances about payments, determining the rate at which the federal payment to California would grow over time would require political agreement. It is hard to imagine that the current Congress or administration would approve such requests. Even with a hypothetical Democratic Congress and president, such approvals would be far from certain.

At the state level, a move to unified public financing of health care would also face significant political challenges. Very large new state taxes would be required to generate program revenue to replace employer-sponsored insurance funding, support those who are currently uninsured, and cover the administrative costs of operating the program. Given anticipated savings from reduced billing and insurance-related costs and potentially (at least eventually) some reduction in low-value care and in the rate of growth of prices, it seems likely that total spending would be less over time than under the status quo. But even if total health spending declined (or at least did not increase), transforming employer-sponsored funding into public funding would be a massive undertaking.

Other challenges include developing processes to match the rate of spending growth to the rate of revenue growth and to determine the “right” revenue growth rate. Physicians, other providers, and some patients would be concerned that a system of unified public financing would overly constrain spending growth, denying Californians the benefits of outcome-improving technology. On the other side, some would be concerned that as a result of regulatory capture, health spending would increase more quickly than justified by the rate of improvement in outcomes, leading to tax increases that did not produce commensurate increases in value or to squeezing out other government spending.

The Select Committee hearings convened to explore these and other issues did not delve into the details of how new taxes might be constructed to support unified public financing; however, the California Legislative Analyst’s Office provided broad tax alternatives with ballpark estimates. Assuming that the current amounts being spent by Medicare and Medicaid could be contributed to a unified public financing approach, new taxes would be needed mainly to substitute for the current employer and employee contributions. Because employer and most employee contributions are made with pretax dollars, purchasers of employer-sponsored coverage benefit today from a discount in the form of a federal tax subsidy. Other methods of financing might increase Californians’ federal income tax burden. Based on the Legislative Analyst’s Office estimates, a 3 percent gross receipts tax levied on all sales and services at all stages of production would generate approximately $120 billion—an amount similar to that spent in California for employer-sponsored insurance. Alternatively, a similar amount could be generated with a 9 percent payroll tax.

A payroll tax could be applied uniformly to all employers, or the state could consider a firm-specific payroll tax in which the tax rate for each firm approximated the percentage of the payroll that the firm pays for health benefits under the status quo—with a plan to narrow the gap between high- and low-rate firms over time. A firm-specific payroll tax would have the political advantage of creating fewer winners and losers, compared to most other financing approaches, and would also minimize any effect on federal income tax liabilities.

Amendments to the California constitution would be required to implement unified public financing in the state. Proposition 98 requires that a portion of any new taxes, regardless of the stated rationale for them, must be directed to K–14 education. The Gann limit, passed by voters via a 1979 statewide ballot initiative, sets appropriation limits on state budget categories supported by taxes. A new tax to support unified public financing would almost certainly exceed the limit. Therefore, adequate funding for unified public financing would require a majority vote of the state’s population to modify the limit.

Even if an amendment to the California constitution were not required by Proposition 98 and the Gann limit, support from California voters for a system of unified public financing would be important for at least two reasons. First, as we have seen with the Affordable Care Act, opponents of change will likely not concede after a legislative loss and will continue to litigate, both in court and in the court of public opinion. A statewide vote in support of change would not prevent that activity but would reduce its effectiveness. Second, and more important, obtaining the federal legislative changes and administrative approvals needed to implement unified public financing would be challenging, and a statewide expression of support could increase the chances of success.…

The September, 2018 issue of Health Affairs is on “California: Leading The Way?” Of importance to not only California, but the entire nation, is California’s effort to enact a single payer program of health care financing. The article by Bindman, Mulkey, and Kronick describes the process that has been taking place. In the excerpt above they describe the barriers to unified public financing, whether single payer or multipayer. The policy community in other states and in the nation at large may find this information useful in their own work.

If California were an independent nation it would be the world’s fifth-largest economy. Yet, as described in another report by Zelman and Wulsin, California has had a very long history of attempting to achieve universal health insurance, but the goal has remained elusive. Even though the state has been very successful in implementing the Affordable Care Act, it still falls far short on most important goals of reform. There is even an article by Enthoven and Baker, still touting managed competition in spite of its obvious shortfalls. The state seems to be mired in health policy innovations that somehow seem to be adding to the muck that we’re trying to wade through.

The full article by Bindman, et al certainly acknowledges the benefits and virtues of a single payer system, but it is discouraging since it seems to default to the misguided direction in which we are headed in health care reform. The barriers, though clearly surmountable with the cooperation of state and federal legislators and their administrations, seem to be distracting the policy community as they redirect to approaches that perpetuate the fragmented, multipayer infrastructure we have, while adding yet more costly administrative complexity that leaves patients exposed to financial hardship and loss of choices in health care.

Bindman and his colleagues conclude, “Implementation of unified public financing in California is technically feasible, but leadership, vision, and persistent public and private commitment—both in California and in Washington, D.C.—are needed to make it happen. Recent deliberations within the California legislature demonstrated both the compelling logic of and the growing emotion associated with movement away from today’s unequal, complex, and fragmented health insurance arrangements. It remains to be seen whether the proponents of change can overcome status-quo interests, renegotiate state and federal responsibilities, and set a new course toward universal coverage.”

That will not happen unless the people lead.

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