Using Medicaid Section 1115 waivers to take away health care

Posted by on Thursday, Jan 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.

State 1115 Proposals to Reduce Medicaid Eligibility: Assessing Their Scope and Projected Impact

By Sara Rosenbaum, Vikki Wachino, Rachel Gunsalus, Maria Velasquez and Shyloe Jones
The Commonwealth Fund, January 11, 2018

In a marked contrast to the Clinton, Bush, and Obama administrations, which encouraged states to use Section 1115 demonstrations to expand Medicaid coverage for low-income adults, the Trump administration has signaled its desire to move in the opposite direction by using 1115 — which allows the U.S. Department of Health and Human Services (HHS) and states to test innovations in Medicaid and other public welfare programs without formal legislative action — to shrink eligibility and enrollment, in expansion and nonexpansion states alike. Guidance released today by the Centers for Medicare and Medicaid Services could speed up the approval of such demonstrations.

The administration likely will integrate 1115 Medicaid eligibility reduction demonstrations as part of its anticipated initiative to reduce the scope of means-tested public assistance.

Ten States with Pending Medicaid Section 1115 Waiver Applications

Arizona: Work requirement; additional eligibility redeterminations; five-year lifetime limit on coverage

Arkansas: Work requirement; elimination of retroactive eligibility

Indiana: Six-month lockout for failure to provide necessary information at reenrollment; work requirement; increased premiums

Kansas: Work requirement; three-year lifetime time limit on coverage

Kentucky: Enforceable premiums accompanied by lockout; elimination of retroactive eligibility; and a work requirement

Maine: Work requirement; reintroduction of an asset test; elimination of retroactive eligibility; and elimination of hospital presumptive eligibility (that is, temporary eligibility while a full application is being considered)

Mississippi: Work requirement

New Hampshire:  Work requirement

Utah: Work requirement; enrollment caps; five-year lifetime limit on coverage; removing presumptive eligibility

Wisconsin:  Denying eligibility for premium nonpayment; a 48-month time limit (with the ability to gain additional coverage time by working); and behavioral modification requirements

These proposals raise significant questions, such as whether a proposal that lacks impact estimates or that claims to have no impact satisfies 1115 requirements. Federal regulations governing 1115 demonstrations would seem to say no. Another, perhaps deeper, question is whether proposals that purport to impose criteria that will result either in the loss of health insurance or the future denial of benefits even fall within the scope of authority 1115 confers on the HHS Secretary. The purpose of 1115 is to enable the Secretary to undertake demonstrations that promote the objectives of programs that are the subject of the demonstration. In the case of Medicaid, its objective, as stated in law, is to furnish medical assistance to people who need it. In any demonstration, it is likely that potential gains are weighed against risks. In these pending demonstrations, however, the scale appears lopsided, with only downsides for the poor. How, exactly, do proposals to deny or end health insurance advance Medicaid’s basic program objective? While achieving greater efficiencies are laudable and necessary aims of any program, especially one as large as Medicaid, simply culling the rolls of needy residents should not be confused with efficiency; indeed, such a result runs counter to the program’s most basic purpose of providing care to those who need it.

http://www.commonwealthfund.org…

***

You’re Sick. Whose Fault Is That?

By Dhruv Khullar
The New York Times, January 10, 2018

The idea that Americans should take personal responsibility for their health has recently received renewed attention. Vice President Mike Pence has argued for “bringing freedom and individual responsibility back to American health care.”

Mick Mulvaney, director of the Office of Management and Budget, expressed a more punitive view, saying, “That doesn’t mean we should take care of the person who sits at home, eats poorly, and gets diabetes.”

What does it actually mean to take personal responsibility for health?

The basic idea is that if we adopt healthful lifestyles, are compliant patients and save money for our own medical care, we’ll feel better, spend less and reduce our burden on others.

Medicaid reform is the policy context in which personal responsibility is most frequently discussed.

Seema Verma, administrator of the Centers for Medicare and Medicaid Services, previously helped shape Indiana’s Medicaid expansion. To get full benefits in Indiana, patients must contribute monthly to a “personal wellness and responsibility account.” If they fail to pay, they may have benefits cut or lose coverage entirely for six months.

Personal responsibility is not always demanded equally of people at every income level. Many lawmakers want more “skin in the game” for Medicaid recipients, but not as many clamor for higher deductibles for wealthy Americans — even though they’re more likely to have enough “skin” to meaningfully play “the game.”

Personal responsibility is an attractive goal with deep roots in American culture. But if it’s too aggressively pursued, it may conflict with another worthy ideal: In a nation as wealthy as the United States, sick humans deserve health care — even if they can’t pay, and even if they’ve made some bad choices.

https://www.nytimes.com…

Medicaid is a program designed to help low-income individuals obtain the health care that they need. Section 1115 waivers are a process established to allow states to facilitate the goal of furnishing medical assistance to people who need it (the purpose as stated in law). Yet the current administration is encouraging the use of the waivers to shrink eligibility and enrollment – taking health care away from those in need – the exact opposite of the intent and letter of the law.

Representatives of the administration cloak this in terms of encouraging personal responsibility for one’s own health. Taking away an individual’s health benefits is not a policy that improves health; it impairs it.

Nobody is going to argue that an individual should not be expected to take care of his own health. But the role of society should be to encourage good health through educational efforts and appropriate social programs. One of the most important programs is the provision of health care which should be rendered regardless of ability to pay, even for those individuals who may have made some bad choices (as have we all).

If a person does not complete his lessons in a school class does that mean that he should be deprived of any further education? If a person receives a speeding ticket, does that mean that she should be denied access to our nation’s highways? If person has a grease fire flare up on her stove does that mean that fire protection services should be denied in the future? If a person was unable to contribute to an IRA, does that mean that future Social Security benefits should be denied? If a person ran over their municipal water allotment does that mean that their water services should be cut off permanently? If a person under 65 is unable to find a job does that mean that she should she be denied health care? Of course not to all of these.

Where personal responsibility does lie is with our public stewards and their obligation to make our public programs work for the people. Now there we can be justly critical of their failure to fulfill their own personal responsibility while serving in their stewardship. Should we take way their health care? (No, just fire them.)

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Mandating employment for Medicaid eligibility

Posted by on Wednesday, Jan 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.

Understanding the Intersection of Medicaid and Work

By Rachel Garfield, Robin Rudowitz, and Anthony Damico   
Kaiser Family Foundation, January 5, 2018

As of December 2017, 32 states have implemented the ACA Medicaid expansion.1 By design, the expansion extended coverage to the working poor (both parents and childless adults), most of whom do not otherwise have access to affordable coverage. While many have gained coverage under the expansion, the majority of Medicaid enrollees are still the “traditional” populations of children, people with disabilities, and the elderly.

Some states and the Trump administration have stated that the ACA Medicaid expansion targets “able-bodied” adults and seek to make Medicaid eligibility contingent on work. Under current law, states cannot impose a work requirement as a condition of Medicaid eligibility, but some states are seeking waiver authority to do so.

This issue brief provides data on the work status of the nearly 25 million non-elderly adults without SSI enrolled in Medicaid (referred to as “Medicaid adults” throughout this brief) to understand the potential implications of work requirement proposals in Medicaid.

Data Findings

* Among nonelderly adults with Medicaid coverage—the group of enrollees most likely to be in the workforce—nearly 8 in 10 live in working families, and a majority are working themselves.

* Most Medicaid enrollees who work are working full-time for the full year, but their annual incomes are still low enough to qualify for Medicaid.

* Many Medicaid enrollees working part-time face impediments to finding full-time work.

* Nearly half of working adult Medicaid enrollees are employed by small firms, and many work in industries with low employer-sponsored coverage offer rates.

* Among the adult Medicaid enrollees who were not working, most report major impediments to their ability to work.

Policy Implications

* Under current law, states cannot impose a work requirement as a condition of Medicaid eligibility.

* Some states have proposed tying Medicaid eligibility to work requirements using waiver authority that may be approved by the Trump Administration.

* Research shows that Medicaid expansion has not negatively affected labor market participation, and some research indicates that Medicaid coverage supports work.

* Implementing work requirements can create administrative complexity and put coverage at risk for eligible enrollees who are working or who may be exempt.

https://www.kff.org…

***

Verma Outlines Vision for Medicaid, Announces Historic Steps Taken to Improve the Program

CMS.gov, November 7, 2017

In a significant shift from prior policies, in speaking about the new approach to Section 1115 demonstrations, Seema Verma emphasized the agency’s commitment to considering proposals that would give states more flexibility to engage with their working-age, able-bodied citizens on Medicaid through demonstrations that will help them rise out of poverty. engagement and work activities.

“We will not just accept the hollow victory of numbers covered [in the program], but will dig deeper and demand more of ourselves and of you,” said Verma. “For those unable to care for themselves, we will create sustainable programs that will always be there to provide the care you need, to provide choices and allow you to live as independently as possible. For those that just need a hand up, we will provide you the opportunity to take charge of your health care and assist and empower you to rise out of poverty and government dependence to create a better life for yourselves and your family.”

https://www.cms.gov…

***

Daugaard: S.D. seeking to impose Medicaid work requirement

By James Nord
Sioux City Journal, January 9, 2018

South Dakota is asking the Trump administration to allow the state to require some Medicaid recipients to work to qualify for the government-funded health coverage for the poor, Gov. Dennis Daugaard said Tuesday in his State of the State address.

“Work is an important part of personal fulfillment,” Daugaard said. “By making this adjustment to our Medicaid program, we can continue to help those who need it the most and start to connect those who can work with jobs that give them that sense of self-worth and accomplishment.”

The governor has made workforce development a key policy focus. He said South Dakota doesn’t have enough workers in many skilled fields, which is a barrier to economic growth. In metro Sioux City, which includes Union County, unemployment below 3 percent has made it more difficult for new and expanding workers to find qualified applicants.

http://siouxcityjournal.com…

With encouragement oƒ CMS Administrator Seema Verma, many states are now applying for Medicaid Section 1115 waivers that would allow them to establish work requirements as a condition for enrollment in the Medicaid program. There are two policy issues here – health care and jobs.

Public policies should be established to ensure that everyone has access to affordable health care and that jobs are available for those who need employment. Since Medicaid was designed to help low-income individuals and families, then  everyone who is qualified on an income basis should automatically be covered. Also the government should support jobs programs to minimize the scourge of unemployment.

Instead, our current government administration is driven by ideology that would achieve the opposite results. They would place the burden of obtaining employment on the individuals, even when there are essentially no jobs available. Then to penalize them for their failure, they would deprive them of their Medicaid coverage. Seema Verma refers to this as empowering them “to rise out of poverty and government dependence to create a better life for yourselves and your family.” No job, no health insurance does not make for a better life. South Dakota Gov. Dennis Daugaard is about to show us the perversities of these policies. Besides, the Kaiser Foundation paper shows us that they are attempting to address a problem that hardly even exists.

What policies do we have that would deprive Medicare beneficiaries of their coverage? Of course, we do not have any such policies. Medicare is a social insurance program that is a right for those qualified. We don’t use the threat of cancellation as a stick to shape people up. We simply give them medical care when they need it.

Medicare does need some major revisions to make it a better program. Then it can be used to provide automatic health care coverage for absolutely everyone. Then we can go to work to be sure that every individual has a right to employment within the limits of their capabilities. When the private sector doesn’t come through, there are plenty of potential public projects that can make this a better nation for all of us.

But first we have to select government stewards who have their policy priorities aligned with the people. Democracy anyone?

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Update on California single payer bill

Posted by on Tuesday, Jan 9, 2018

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

Assembly Speaker Says Single-Payer Remains Shelved

By Ben Bradford
Capital Public Radio, January 8, 2018

“Absolutely nothing has happened with the bill,” Assembly Speaker Anthony Rendon, a Los Angeles-area Democrat, says of the high-profile Senate measure to establish single-payer health care.

Rendon shelved the bill last year, after it passed the Senate, calling it “woefully incomplete,” because it does not specify how the state would would seek federal approval, bypass constitutional spending limits and cover as much as a $400 billion cost.

Six months later, the speaker says the status of Senate Bill 562 remains the same.

“The sponsors of the bill have sat on their hands and done nothing for the past six months,” Rendon says. “None of the authors have made any significant amendments.”

Those pointed words about the sponsor refer to the California Nurses Association, the liberal union known for flashy and no-holds-barred advocacy of its causes.

The speaker says he’s more interested in developing a universal health care proposal, which could mix government and private coverage options, rather than focusing solely on a single-payer system.

An Assembly Committee is meeting again next week to discuss universal coverage legislation.

http://www.capradio.org…

***

Nurses Catch Assembly Speaker in Lie About Healthy California Bill

RNs to Rendon: “No Excuses. We’ve Done Our Job; You Do Yours.”

California Nurses Association/National Nurses United, January 4, 2018

The nearly 100,000 registered nurses of the California Nurses Association (CNA)—co-sponsors of SB 562, the Healthy California Act, which would guarantee healthcare to all Californians—strongly condemn California Assembly Speaker Anthony Rendon’s statement this week that SB 562 sponsors have “sat on their hands and done nothing the past six months.”

“Perhaps Speaker Rendon is confusing his own inaction, after undemocratically parking SB 562, with the clear, loud stand thousands of Californians have taken for months, demanding Rendon unfreeze this lifesaving bill so it can move forward,” said CNA Associate Executive Director, Bonnie Castillo, RN. “Nurses have watched our patients suffer and die for far too long, and that’s why we are unrelenting in our demand for guaranteed healthcare. We expect our elected officials to work on the bill, not breach the public’s trust by halting the normal legislative process or waste time.”

The Healthy California Act, SB 562 passed the full Senate in June and was set for consideration in the Assembly when Speaker Rendon abruptly refused to let it out of the Rules Committee. In response, RNs and other backers of the bill have rallied, canvassed and organized in support of SB 562, in a grassroots movement across the state.

SB 562 sponsor and advocate actions in the past six months include:

* Published study by expert economists at UMass Amherst, setting forth a mechanism on how to pay for SB 562
* 17 amendments proposed
* 200 canvassing events held statewide, covering all 80 Assembly districts
* 15,000 supporters gathered at in-person events across California
* 6,000 doors knocked
* 1,500 new volunteers added to canvassing efforts
* 35 district office visits conducted
* Thousands of phone calls made
* 21 more canvasses are scheduled for January, 2018 alone

“SB 562 supporters don’t have time to sit on our hands, because our hands have been too busy knocking on doors, picking up phones, opening legislative office doors, and holding up ‘Medicare for All’ signs all over California,” said CNA co-president Deborah Burger, RN. “It’s beyond insulting that Speaker Rendon would tell working people, including the nurses who have spent countless hours standing up for our patients’ right to life saving care, that WE haven’t done enough. Allowing this bill to move forward is Rendon’s job, and he needs to stop shifting blame and get to work.”

“Every day that the Assembly members keep talking about it, people get sick and die. They’re inside [the state capitol] with their suits and ties and good health care, and every day people are dying,” said RN Cathy Kennedy. “We’ve done the research, and we know that in California there is money to provide health care for all. It’s time they stop talking about it and do something about it!”

A recent survey showed that a full 70 percent of Californians favor establishing a public, Medicare for all type system providing universal single-payer health coverage. CNA also sponsored the aforementioned study by expert economists at University of Massachusetts Amherst on how to pay for SB 562—revealing that enacting the bill would save Californians $37 billion off our current cost for healthcare.

With widespread public support and a funding mechanism, nurses say Rendon’s recent comments only reveal that elected officials need to stop standing in the way of what their constituents want: guaranteed healthcare.

http://www.nationalnursesunited.org…

***

California State Assembly

Select Committee on Health Care Delivery Systems and Universal Coverage: Arambula, Wood, Chairs

Informational Hearing: Achieving Better Access and Greater Value in California’s Health Care System
Wednesday, January 17, 2018
1 p.m. to 5 p.m.
State Capitol, Room 4202

http://healthcare.assembly.ca.gov…

***

SB-562: The Healthy California Act:
https://leginfo.legislature.ca.gov…

The nature of the dispute between California Assembly Speaker Anthony Rendon and the California Nurses Association on the status of SB-562, The Healthy California Act, a single payer bill for California, can be gleaned from the reports above.

Probably the most significant statement is the following: “The speaker says he’s more interested in developing a universal health care proposal, which could mix government and private coverage options, rather than focusing solely on a single-payer system.”

A series of informational hearings on health care reform in general is taking place now, but the Select Committee will not be able to take any legislative action. It is difficult to see how these hearings could result in any meaningful legislation for this session of the state legislature. The hearings seem to be merely a diversionary tactic on the part of Rendon.

Why this update? If any state could enact a semblance of single payer legislation, it would be California. This demonstrates the barriers we have even with supposedly optimal political alignment.

The lesson? We need a large-scale social movement in support of greater Democracy. Read Page and Gilens, “Democracy in America?” and then act on it:

http://www.pnhp.org…


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Political support for single payer still falls short of the threshold needed

Posted by on Monday, Jan 8, 2018

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

On health care, Democrats are shifting to offense

By Ricardo Alonso-Zaldivar
Associated Press, January 8, 2018

Democrats are shifting to offense on health care, emboldened by successes in defending the Affordable Care Act. They say their ultimate goal is a government guarantee of affordable coverage for all.

With Republicans unable to agree on a vision for health care, Democrats are debating ideas that range from single-payer, government-run care for all, to new insurance options anchored in popular programs like Medicare or Medicaid.

Democrats are hoping to winnow down the options during the 2018 campaign season, providing clarity for their 2020 presidential candidate.

Obama’s former health secretary, Kathleen Sebelius, says she sees Democrats reclaiming a core belief that health care should be a right guaranteed under law.

Here’s a sample of ideas under debate by Democrats and others on the political left:

Medicare for All: Vermont Sen. Bernie Sanders made single-payer, government-run health care the cornerstone of his campaign for the 2016 Democratic presidential nomination. It remains the most talked-about health care idea on the left.

Medicare-X: The legislation from Sen. Tim Kaine, D-Va., and Sen. Michael Bennet, D-Col., would allow individuals in communities lacking insurer competition to buy into a new public plan built on Medicare’s provider network and reimbursement rates.

Medicare Part E: Yale University political scientist Jacob Hacker has proposed a new public health insurance plan based on Medicare, for people who don’t have access to job-based coverage meeting certain standards. He’s working with Democrats in Congress to turn the concept into legislation.

Medicaid Buy-In: Sen. Brian Schatz, D-Hawaii, and Rep. Ben Ray Lujan, D-N.M., have introduced legislation that would allow states to open their Medicaid programs up to people willing to pay premiums.

Expect more ideas as the year unfolds, said Neera Tanden, president of the Center for American Progress and a former top aide to Obama as well as Hillary Clinton. “Democrats are much more comfortable with an expansionist view,” said Tanden. “Almost every Democrat is talking about truly universal health care.”

But in Sanders’ home state of Vermont, primary care physician Dr. Deborah Richter says she believes it’s only a matter of time before the Unites States adopts single-payer. Activists who failed in an earlier attempt in the state are now focused on passing a plan that would cover just primary care.

“I think the next election will be a move to the left,” said Richter. “Whether Democrats will be willing to go for the whole system is pretty doubtful. I feel it might be possible for us to do it in phases.”

https://www.apnews.com…

Single payer advocates can be encouraged by the improved understanding and greater support of the single payer Medicare for All concept engendered by the campaign of Sen. Bernie Sanders. The Republican politicians continue to reject the concept, but just how much support is there amongst the Democrats in office?

About one-third of the Democrats in the Senate have signed on as cosponsors of S. 1804, Sen. Sanders’ Medicare for All Act, but they did so knowing that it was a safe move – it could not possibly pass and be signed in the 115th Congress. Many of them actually support incremental measures that build on the current system as being more feasible politically (and less offensive to the campaign supporters of some of them – the insurers and pharmaceutical firms).

In spite of the national support for single payer, many of the Democrats in office are supporting, as their preference, incremental measures such as Medicare-X, Medicare Part E, and Medicaid Buy-In. Neera Tanden, who helped lead the forces that prevented single payer from being included in the last Democratic Party platform, is giving lip service to “an expansionist view,” but you can be sure that her view of expansion falls far short of single payer. Even some of the most respected single payer activists within our own camp have grown frustrated after a couple of decades of effort with no results and thus support phasing in single payer incrementally.

Why shouldn’t we go ahead and support the incremental proposals? Isn’t expanding coverage to include more individuals better than holding firm to a fight that we haven’t been able to win so far? The problem is that support for the golden standard of single payer reform is inversely proportional to the perceived need. If we continue to tweak the system so that it is at least barely tolerable for the majority, then we cannot meet the political threshold required to enact a bona fide single payer system.

You might say, “So what, if we’re most the way there, isn’t that good enough?” But limiting ourselves to the goal of providing nominal health care coverage for a large majority of U.S. residents not only leaves out those who do not qualify or can’t afford it, but it leaves in place all of the other deficiencies that would be corrected by a well-designed single payer system. Under single payer, people would have their choice of health care professionals and institutions. Financial barriers to care, such as high deductibles, would be eliminated. Separate planning and budgeting of capital improvements would improve access. A massive reduction in administrative waste along with adoption of the other efficiencies of a single payer system would redirect wasted funds to programs that we all support (such as health care for the currently underserved, education, infrastructure, etc.).

Medicare-X, Medicare Part E, Medicaid Buy-In, and a program limited to primary care might be nice improvements, but they alone do not scratch the surface of what we need to do.  We have just gone through another decade without real reform because we went along with the Affordable Care Act, and costs have continued to increase, financial barriers have increased, choices of providers have decreased, and waste has not been reduced.

We can do it, but we need greater democracy in America. Big business and the very wealthy now control our government. Benjamin Page and Martin Gilens in their book, “Democracy in America?,” explain what has gone wrong and what we can do about it. It will not be easy, but action is an imperative. The book is described in a recent Quote of the Day available at the following link:

http://www.pnhp.org…


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The days of having your own doctor and a stable way to access care are rapidly disappearing as the drive to increase corporate mergers of health care giants gains further momentum. Under the guise of bringing patients more convenience in accessing care, we are seeing instead increasing fragmentation of health care as merging giants get even bigger and more profitable.

Here are some recent examples of this fast-moving trend:

UnitedHealth Group
As the largest health insurer in the U. S. by market share and the largest health care company in the world by revenue, UnitedHealth Group has been moving aggressively into the direct delivery of health care by buying up doctors’ groups and clinics across the country. UnitedHealth already had a roster of some 30,000 physicians across more than 230 urgent care centers and 200 surgery centers as well as its pharmacy benefit manager serving 65 million people. Within its broader goal of building a larger ambulatory care business, it recently bought the DaVita Medical Group for about $4.9 billion. That purchase added about 280 clinics offering primary and specialist care, together with 35 urgent care centers and 6 outpatient surgery centers. Its longer-term goal is to provide primary care and ambulatory services in 75 markets, representing about two-thirds of the U. S. population. (Mathews, AW. UnitedHealth to Buy Large Doctor Group for $4.9 Billion. Wall Street Journal, December 7, 2017: B3).

CVS-Aetna merger
CVS Health, the second-largest U. S. drugstore chain with some 9,700 drugstores, recently bought Aetna, the nation’s third largest health insurer, in a $69 billion deal. This merger will combine Aetna’s insurance products with CVS drugstores, walk-in clinics, and drug-distribution operation. Consumers are being told that this will make health care more convenient and accessible at CVS locations, and that costs can be cut with improved quality of care. (Tracer, Z. Forget Amazon. Health companies really want to be UnitedHealth. Bloomberg News, December 4, 2017).

Dignity Health/Catholic Health Initiatives
As patients increasingly go to walk-in clinics or urgent care centers, or use an app on their cellphones to check out a skin rash or monitor their diabetes, they are bypassing more expensive sites of care such as physicians’ offices and hospital emergency rooms. In another response to this general trend, Dignity Health and Catholic Health Initiatives have recently announced their plan to become a national chain of Catholic hospitals and clinics that span 28 states. This merger is expected to include 139 hospitals, more than 700 sites of care, employing more than 25,000 physicians and other clinicians. (Abelson, R. Hospital giants vie for patients in effort to fend off new rivals. New York Times, December 18, 2017).

These mega-deals are likely accelerating as the specter of Amazon looms over the health care industry. Although that Internet behemoth hasn’t yet made moves into health care, many observers speculate that it may enter some part of the prescription drug business, such as distribution or retail, and use technology to deliver virtual medical care through cell phones and computers. This prospect may well have played a role in the CVS-Aetna merger.

These mergers will have a number of adverse impacts for patients. They will find that their choice of providers, clinics, pharmacies, and hospitals will be sharply limited within merged systems. Limited health services, mainly first contact care, will be provided, but way short of primary care, with little or no continuity of care. Patients will see nurses instead of physicians in many of these walk-in clinics, without primary care responsibility that by definition includes comprehensive care, coordination and monitoring of all of the patient’s clinical conditions, with continuity of care over years. Instead, what is already a frayed primary care system will become even more fragmented and inadequate. We cannot expect that increased convenience of “care” will result in improved quality or outcomes of care.

While the CEOs of corporate giants pocket big profits with these mergers, shareholders whistle to the bank. As one example, CEO Mark Bertolini of Aetna is expected to receive a payout of about $500 million, including increased valuation of his stock shares, when operational control of the combined company is transferred to the new CEO. (Mattioli, D, Mathews, AW, Becker, N. Aetna CEO in line for $500 million payout. Wall Street Journal, December 6, 2017: B1).).

We know from long experience that larger market share in our mostly for-profit system does not contain costs for patients. It just gives larger hospital or other systems more latitude to charge what the traffic will bear. Despite the Affordable Care Act, enacted in 2010, health care costs keep going up at uncontrolled rates for Americans in our system with no significant price controls. Individuals and families face increasing costs of insurance, higher deductibles, copayments, coinsurance, and out-of-pocket expenses. The average family of four now pays about $26,000 a year for insurance and care. A new poll has found that 48 percent of Americans name health care as their top problem for the government to focus on, up by 17 percent in the last two years and higher than any other expense. (The Associated Press-NORC Center for Public Affairs Research. New year, same priorities: The public’s agenda for 2018.) Steven Brill, attorney, journalist, and author, has this to say about the failure of our system to control health care costs:

It’s about money: Healthcare is America’s largest industry by far, employing a sixth of the country’s workforce. And it is the average American family’s largest single expense, whether paid out of their pockets or through taxes and insurance premiums. (Brill, S. America’s Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Health Care System. New York. Random House. 2015, pp. 7-8.)

Bottom line on this merger frenzy—it’s all about giving health care organizations and facilities even more ability to grow their patient base and increase their profits. We have no reason to believe that health care costs will be reined in or that quality of care will improve.

One promising development that could counter the adverse consequences of mega-mergers is a bill being brought forward by the new Congressional Antitrust Caucus. If enacted, it would force such regulators as the Federal Trade Commission and Department of Justice to examine evidence that monopolies and massive companies bring higher prices, lower wages, job losses and environmental damage, not the jobs and higher wages that they promise. (Townsend, T. Keith Ellison and the new ‘Antitrust Caucus’ want to know exactly how bad mergers have been for the American public. New York Magazine, December 4, 2017). We can hope that this effort will be productive in reining in the concentrated economic and political power of massive corporations.

John Geyman, M.D. is the author of Common Sense about Health Care Reform in America (2017), and Crisis in U.S. Health Care: Corporate Power vs. The Common Good, and The Human Face of ObamaCare: Promises vs. Reality and What Comes Next

Visit John at: http://www.johngeymanmd.org/

David Blumenthal on life expectancy and the American health care system

Posted by on Friday, Jan 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.

Drop in U.S. life expectancy is an ‘indictment of the American health care system’

By David Blumenthal
STAT, January 4, 2018

The economy may be growing and the stock market booming, but Americans are dying younger — living shorter lives than previous generations and dying earlier than their counterparts around the world.

It is easy to place the blame squarely on our nation’s opioid epidemic, but if we do that we miss seeing the abysmal new life expectancy data from the Centers for Disease Control and Prevention for what they are — an indictment of the American health care system.

At first glance, substance abuse would seem more a social and economic problem than one of health care, and there is no question that socioeconomics are a major player in causing the so-called deaths of despair associated with substance abuse.

But, we cannot let our health care system off too easily.

The epidemic of drug abuse and overdose deaths has not affected other developed countries the way it has ours. With 4 percent of the world’s population, the U.S. accounts for 27 percent of the world’s overdose deaths. The European Union, with a population of 507 million, reported 6,800 overdose deaths in 2014, compared to 47,055 in the U.S.

Why has it been it so much worse here? One reason is that the U.S. doesn’t have strong social safety nets that buffer the effects of recessions and job loss as other nations do. Another reason is the way the U.S. health care system functions.

The profitability of drugs in the United States, a result of sky-high and skyrocketing drug prices, has made the aggressive marketing and sale of new prescription opioids an almost irresistible temptation for American pharmaceutical companies.

The opioid epidemic is not the only area in which the U.S. health system lags. In 2015, life expectancy at age 65 in the U.S. ranked 26th among the 37 members of the Organization for Economic Cooperation and Development, which includes most developed nations. It is widely accepted that the accessibility and quality of medical services strongly affect life expectancy among the elderly and elderly Americans fall behind their counterparts overseas when it comes to being able to get and afford the health care they need.

This may seem surprising given that Americans over 65 enjoy universal health insurance coverage under Medicare. But as valuable as Medicare is, it provides far less protection against the cost of illness, and far less access to services, than do most other Western countries. In a recent cross-national survey, U.S. seniors were more likely to report having three or more chronic illnesses than their counterparts in 10 other high-income countries. At the same time, they were four times more likely than seniors in countries such as Norway and England to skip care because of costs. Medicare, it turns out, is not very good insurance compared to what’s available in most of the western world.

We are the wealthiest nation on earth, but far from the healthiest, and things are getting worse, not better. The CDC report is yet another call to action for fundamental health system change that should include, among other things, reforming our pharmaceutical markets and making good health insurance available to all Americans. These need to be urgent priorities in 2018 for a government that should care as much about the health of Americans as their wealth.

David Blumenthal, M.D., is president of the Commonwealth Fund.

https://www.statnews.com…

The excerpts from David Blumenthal’s article speak for themselves. Life expectancy in the United States is declining, partly due to the opioid epidemic, but deficiencies in our health care system and how we pay for it certainly contribute to the poor performance.

That includes our Medicare program. As Blumenthal states, “Medicare, it turns out, is not very good insurance compared to what’s available in most of the western world.”

So don’t be too urbane when speaking of Medicare for all, and don’t ever omit “improved,” as in Improved Medicare for All.

Now that “single payer” has become widely accepted terminology, don’t hesitate to use that term in advancing the PNHP golden standard of single payer:

http://www.pnhp.org/nhi

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NHS strains under flu epidemic

Posted by on Thursday, Jan 4, 2018

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

PM sorry for NHS chaos as thousands queue in ambulances

By Chris Smyth
The Times, January 4, 2018

Theresa May has apologised to patients hit by winter chaos in the NHS as figures showed that thousands of patients who arrived at hospital by ambulance struggled to get into A&E because hospitals were so full.

Long waits for ambulances to hand over patients doubled in a week as flu increased over Christmas.

NHS leaders say that so many patients arriving in A&E need admitting that they are running out of beds. Hospitals were well above the 85 per cent bed occupancy level considered safe, with a national average of 91.7 per cent last week.

Professor Derek Alderson, president of the Royal College of Surgeons, said: “That many hospitals have full wards, even after cancelling operations, shows that we simply don’t have sufficient numbers of beds in English hospitals.”

Sir Vince Cable, the Liberal Democrat leader, said: “Every day seems to bring yet more bad news about the state of the health service. The blame lies firmly at the government’s door. Ministers refused to provide the funding top NHS officials said was necessary and now patients are paying the price.”

Professor John Appleby of the Nuffield Trust think tank agreed that the NHS simply did not have enough money or staff to cope. “The sobering reality is that winter for the NHS has hardly started,” he said. “The service is likely to face another three months of exceptional need for care, and it is starting from a precarious position. There is an underlying mismatch between the capacity to deliver care and the level of care patients require.”

The NHS 111 urgent care helpline had its busiest week on record as almost half a million patients called for advice over the Christmas period, resulting in 58,000 ambulances being sent out.

https://www.thetimes.co.uk…

***

Socialized medicine update: Britain cancels 50,000 surgeries as NHS hospitals face winter crisis

By Philip Klein
Washington Examiner, January 4, 2018

American liberals such as Sen. Bernie Sanders like to tout socialized healthcare systems such as Britain’s for spending less and covering everybody, but here’s a reality check you shouldn’t expect to hear in any of his fiery speeches: the British government-run National Health Service has abruptly canceled 50,000 nonemergency surgeries due to overcrowding at hospitals this winter.

Do we think Americans are going to stand for a system in which government officials cancel surgeries en masse based on bureaucratic judgments about what is urgent and go on TV to offer inadequate apologies?

http://www.washingtonexaminer.com…

It is expected to be a bad year for influenza, and the United Kingdom is already experiencing an overload of its health care delivery system. Because of the overload, 50,000 nonemergency surgeries are being postponed. What lessons are there for the United States?

The capacity of the system is crucial, and that requires balance. If there is excess capacity then personnel and facilities are underused and that wastes money. Furthermore, excess capacity results in overutilization of services that may be of little value. When capacity is at the right balance, services of little or no value tend to be crowded out, while essential services are readily accommodated.

When capacity is inadequate, excessive queues for elective services tend to form, and acutely ill patients may be subjected to crowded conditions such as being admitted to hospital corridors, or, worse, being held in ambulances for hours. Though hospitals should not deliberately create excess capacity, they do need to have plans for surge capacity such as with epidemics or major catastrophes. Triage becomes even more important during times that the system is stressed.

At such times, postponing elective procedures in order to handle the surge in urgent problems may reflect appropriate planning. But if the system is running near capacity at times of less urgent demand, then the capacity may be deficient. The same can be said if excessive queues persist throughout the year, including times when no reasons for surges exist.

It appears that the conservative and neoliberal governments of recent decades may have underfunded the NHS resulting in deficient capacity. Certainly the opponents of single payer reform in the United States are going to attack the NHS for cancelling surgeries (see Philip Klein’s comment, above). Underfunding is a vulnerability of publicly financed systems during inevitable intervals of conservative control. But the counter to this is the popularity of public programs that drives political support for them.

Lessons? Support public planning of a balanced capacity in the system. Support public stewards who will fund the system adequately. Counter the naysayers by spreading the truth about a well designed single payer system that would work well for all of us in the United States.

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Another gimmick to overpay private Medicare Advantage plans

Posted by on Wednesday, Jan 3, 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.

2019 Medicare Advantage Part I Advance Notice – Risk Adjustment

CMS.gov, December 27, 2017

Today, the Centers for Medicare & Medicaid Services (CMS) released Part I of the 2019 Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates and Part D Payment Policies (the Advance Notice), which contains key information about proposed updates to the Part C Risk Adjustment Model and the use of encounter data.

2019 Part C Risk Adjustment Model proposal

The 21st Century Cures Act amended the Social Security Act by, in part, requiring CMS to make improvements to risk adjustment for 2019 and subsequent years. In response to these requirements, we are proposing changes to the CMS-HCC Risk Adjustment model that is used to pay for aged and disabled beneficiaries enrolled in Medicare Advantage plans. These proposals reflect changes to risk adjustment required by the 21st Century Cures Act, including an evaluation of adding mental health, substance use disorder, and chronic kidney disease conditions to the risk adjustment model and making adjustments to take into account the number of conditions an individual beneficiary may have, as well as a variety of additional technical updates.

For 2019, CMS is proposing a model that includes additional mental health, substance use disorder, and chronic kidney disease conditions in the risk adjustment model.

With respect to taking into account the number of conditions an individual beneficiary has, in Part 1 of the Advance Notice we describe a proposed new risk adjustment model and discuss an alternative model. The model we are proposing – the “Payment Condition Count model” – takes into account the number of conditions that a beneficiary has, only among the conditions that are included in the payment model. The model discussed as an alternative – the “All Condition Count model” – takes into account all conditions that a beneficiary has, including both those in the payment model and those not in the model.

Overall, while the experience of individual plans would vary, the Payment Condition Count model is projected to increase MA risk scores by 1.1%, while the All Condition Count model would decrease MA risk scores by -0.28%. Under the Payment Condition Count model, the change in MA contracts’ risk scores is generally positive and less varied than the All Condition Count model. The change in MA contracts’ risk scores under the All Condition Count model is more varied, with both negative and positive changes.

https://www.cms.gov…

***

CMS.gov

NOTE TO: Medicare Advantage Organizations, Prescription Drug Plan Sponsors, and Other Interested Parties

SUBJECT: Advance Notice of Methodological Changes for Calendar Year (CY) 2019 for the Medicare Advantage (MA) CMS-HCC Risk Adjustment Model

https://www.cms.gov…

***

CMS floats Medicare Advantage payment tweaks that would boost insurers’ risk scores

By Leslie Small
Fierce Healthcare, January 2, 2018

Over the holidays, Medicare Advantage insurers got a gift from the federal government.

That gift arrived on Dec. 27, when the Centers for Medicare & Medicaid Services released part one (PDF) of its 2019 advance notice of changes to MA capitation rates and Part D payment policies.

To comply with the Cures Act, CMS is proposing an MA risk adjustment model that includes additional mental health, substance use disorder and chronic kidney disease conditions. The agency uses risk adjustment models to adjust payments based on the characteristics and health conditions of each plan’s enrollees, with the goal of preventing insurers from enrolling only the healthiest patients.

The agency is also proposing a “Payment Condition Count model” for risk adjustment, which takes into account the number of conditions that a beneficiary has—but only among the conditions that are included in the payment model. This model is projected to increase MA risk scores by 1.1%, meaning more government reimbursement would be flowing toward health plans.

By comparison, the alternative “All Condition Count model”—which takes into account all conditions that a beneficiary has—would have decreased MA risk scores by 0.28%, CMS said.

The proposed methodological change to risk adjustment is “more industry friendly than the status quo,” Leerink Partners analysis Ana Gupte wrote in a research note (PDF). It’s the most positive for Humana, UnitedHealth and WellCare, she said, but also a good sign for the sector as a whole.

Such changes are consistent with the MA-friendly stance of the Trump administration.

https://www.fiercehealthcare.com…

The private Medicare Advantage plans have continued to be overpaid deliberately. Each year the administration, whether Democratic or Republican, uses quirky arcane rules to ensure an adequate revenue buffer so that private insurers can compete favorably with the traditional Medicare program by offering lower premiums and cost sharing and expanded benefits. This year’s gimmick is to use a “Payment Condition Count model” instead of an “All Condition Count model” which then increases Medicare Advantage risk scores by 1.1% and thus pads the margins for the private plans.

For those who need a reminder, this is intended to privatize Medicare, converting it to a premium support (voucher) model. Once a critical mass has enrolled in private plans, Congress will gradually reduce the relative value of the voucher-equivalent, reducing the government component of the funding of Medicare by shifting more costs to the Medicare beneficiaries.

It’s working. Medicare Advantage enrollment has increased each year and was at 33% as of 2017 (19 million enrollees). With continued coddling by Congress and the administration, we can anticipate further increases. The current House leadership now wishes to accelerate this change by reducing government expenditures in the traditional Medicare program (“we can’t afford it,” especially after the tax cuts).

Although we describe their sequential innovative chicanery each year, nobody seems to get excited about it. As disgusting as the analogy is, we seem to be the proverbial frog in the water being heated over the stove. Get out your health care justice thermometers or traditional Medicare will be cooked before we see the pot come to a boil.

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It’s the prices, but why are they high?

Posted by on Wednesday, Jan 3, 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.

Why the U.S. Spends So Much More Than Other Nations on Health Care

By Austin Frakt and Aaron E. Carroll
The New York Times, January 2, 2018

The United States spends almost twice as much on health care, as a percentage of its economy, as other advanced industrialized countries — totaling $3.3 trillion, or 17.9 percent of gross domestic product in 2016.

But a few decades ago American health care spending was much closer to that of peer nations.

What happened?

A large part of the answer can be found in the title of a 2003 paper in Health Affairs by the  Princeton University health economist Uwe Reinhardt: “It’s the prices, stupid.”

The study, also written by Gerard Anderson, Peter Hussey and Varduhi Petrosyan, found that  people in the United States typically use about the same amount of health care as people  in other wealthy countries do, but pay a lot more for it.

Ashish Jha, a physician with the Harvard T.H. Chan School of Public Health and the director of the Harvard Global Health Institute, studies how health systems from various countries compare in terms of prices and health care use. “What was true in 2003 remains so today,” he said. “The U.S. just isn’t that different from other developed countries in how much health care we use. It is very different in how much we pay for it.”

Did we do more for patients in each health visit or inpatient stay? Did we charge more? The JAMA study found that, together, these accounted for 63 percent of the increase in spending from 1996 to 2013. In other words, most of the explanation for American health spending growth — and why it has pulled away from health spending in other countries — is that more is done for patients during hospital stays and doctor visits, they’re charged more per service, or both.

Though the JAMA study could not separate care intensity and price, other research blames prices more.

There are ways to combat high health care prices. One is an all-payer system, like that seen in Maryland. This regulates prices so that all insurers and public programs pay the same amount. A single-payer system could also regulate prices. If attempted nationally, or even in a state, either of these would be met with resistance from all those who directly benefit from high prices, including physicians, hospitals, pharmaceutical companies — and pretty much every other provider of health care in the United States.

https://www.nytimes.com…

Our very high per capita health care spending certainly has been associated with high prices. So why hasn’t market competition (competing private health plans) or government price controls (Medicare and Medicaid) controlled prices? Simply it is what is built into those prices that is unique in the United States – our profoundly wasteful administrative excesses. Ratcheting down prices either through the market or through regulation would not change our fragmented, dysfunctional financing infrastructure with all of its waste and would result in intolerable underfunding of the actual health care delivery system.

Frakt and Carroll suggest that an all-payer system might work, but that would fall short since most of the dysfunctions of the current system would remain in place. On the other hand, a well-designed single payer system (an improved Medicare for all) would recover close to half a trillion dollars that is wasted on administration and other excesses.

It is likely that prices would be reduced for health care professionals and facilities, but only by the savings in administrative excesses that would no longer be required. The net income for the health care delivery system would remain about the same.

It has been about fifteen years since Anderson, Reinhardt and their colleagues told us, “It’s the prices, stupid.” We really are pretty stupid to have wasted trillions of dollars in administrative excesses since that time.

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The most important qotd message this year

Posted by on Friday, Dec 29, 2017

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.

Whither 2018…and beyond?

By Don McCanne, M.D.

When Ronald Reagan became president the Dow Jones Industrial average was about 800. Now the Reagan era has brought it to almost 25,000. So the nation’s optimism is resting on a bubble; you can bet your bitcoins on that.

We have problems, beginning with the most expensive and dysfunctional health care financing system of all wealthy nations (what this blog is all about). Although that is a multi-trillion dollar problem, it is only but a small portion of all of our nation’s and the world’s ills.

Recite in your mind some of the many problems we have. You realize that most of them have reasonable solutions – solutions that most of us support. So why are we not moving forward to address them?  In yesterday’s message, Benjamin Page and Martin Gilens described what has gone wrong and what we can do about it. Basically we need better public policies along with government officials dedicated to carrying them out.

What is holding us back? We are a Democracy aren’t we? Well, that seems to be a problem. Although we have the right to vote, most of us are unable to influence what actually happens in government. In their classic 2014 paper in Perspectives on Politics, Gilens and Page showed us that “economic elites and organized groups representing business interests have substantial independent impacts on U.S. government policy, while average citizens and mass-based interest groups have little or no independent influence.”

What we lack is policy responsiveness to ordinary citizens – Page and Gilens’ definition of democracy. What we need is for all of us who care to join together in a social movement for Democracy. Only then can we hope to make progress in combating the other ills of our society (including correcting the deficiencies in our expensive but dysfunctional health care system).

As you see, for the last message of the year, I decided to repeat yesterday’s theme – the most important message I’ve sent out all year. Read “Democracy in America?” and then let’s all join together and act on it.

Benjamin I. Page and Martin Gilens, “Democracy in America? What Has Gone Wrong and What We Can Do About It”

The University of Chicago Press, November 2017
http://press.uchicago.edu…

Quote of the Day on “Democracy in America?”
December 28, 2017
http://www.pnhp.org…

Martin Gilens and Benjamin I. Page, “Testing Theories of American Politics: Elites, Interest Groups, and Average Citizens”
Perspectives on Politics, September 2014
https://www.cambridge.org… (page has link to full article)

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

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