Elisabeth Rosenthal: ‘An American Sickness’

Posted by on Monday, Apr 17, 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.

How Healthcare Became Big Business and How You Can Take It Back

By Elisabeth Rosenthal
Penguin Random House, April 2017

From the Introduction

Everyone knows the healthcare system is in disarray. We’ve grown numb to huge bills. We regard high prices as an inescapable American burden.

The current market for healthcare just doesn’t deliver. It is deeply, perhaps fatally, flawed. Even market economists themselves don’t believe in it anymore.

All the harrowing tales in this book occurred despite the 2010 passage and the 2014 enactment of the Patient Protection and Affordable Care Act (the ACA, also known as “Obamacare”). The ACA is not a failure, as some still assert, but the “affordable” in its name was an overreach to win over votes and public opinion.

Each market has certain rules that are determined by the conditions, incentives, and regulations under which it operates. Currently, we buy and sell medical encounters and accoutrements like commodities, but how do participants in the marketplace make purchasing choices? Prices are often unknowing and unpredictable; there’s little robust competition for our business; we have scant information on quality to guide our decisions; and very often we lack the power ourselves to even choose.

The rules governing the delivery of health care in the United States have grown out of the market’s design. The type of healthcare we get these days is exactly what the market’s financial incentives demand. Some have to get wise to them, and be smarter, far more active participants in this ugly, rough-and-tumble world. More important, we have to change the rules of the game, with different incentives and new types of regulation.

The economist Adam Smith spoke of an “invisible hand” with respect to income distribution. But in American healthcare, there’s a different type of invisible hand at work: it’s on the till.



Why an Open Market Won’t Repair American Health Care; A Review of Elisabeth Rosenthal’s “An American Sickness”

By Jacob S. Hacker
The New York Times, April 4, 2017

It was March 2012, and the Affordable Care Act (a.k.a. Obamacare) was before the Supreme Court. Justice Antonin Scalia zeroed in on its controversial requirement that all Americans purchase health insurance. Yes, everybody needs health care, Scalia conceded, but everybody needs food too. If the government could make people buy insurance, why couldn’t it “make people buy broccoli”?

The Affordable Care Act survived, of course — though not before a fractured court made the expansion of Medicaid optional, leaving millions of poorer Americans without its promised benefits. But the question Justice Scalia asked remains at the heart of a debate that has only intensified since: Why is health care different? Why does it create so much more anxiety and expense, heartache and hardship, than does buying broccoli — or cars or computers or the countless other things Americans routinely purchase each day?

For those leading the charge to roll back the 2010 law, the question has a one-word answer: government.

Where Rosenthal’s account falls short is in explaining why this deeply broken system persists. Early on, Rosenthal seems to side with Speaker Ryan and Senator Paul, describing “the very idea of health insurance” as “in some ways the original sin that catalyzed the evolution of today’s medical-industrial complex.” But, as Rosenthal (too briefly) discusses, countries where people are much better insured don’t have anything like our self-dealing, upside-down incentives and outrageous costs. Somehow, despite largely keeping citizens’ skin out of the game, other rich democracies manage to have much lower costs per person — as well as greater utilization of physician and hospital services and better basic health measures.

The difference between the United States and other countries isn’t the role of insurance; it’s the role of government. More specifically, it’s the way in which those who benefit from America’s dysfunctional market have mobilized to use government to protect their earnings and profits. In every country where people have access to sophisticated medical care, they must rely heavily on the clinical expertise of providers and the financial protections of insurance, which, in turn, creates the opportunity for runaway costs. But in every other rich country, the government not only provides coverage to all citizens; it also provides strong counterpressure to those who seek to use their inherent market power to raise prices or deliver lucrative but unnecessary services — typically in the form of hard limits on how much health care providers can charge.

In the United States, such counterpressure has been headed off again and again. The industry and its elected allies have happily supported giveaways to the medical sector. But anything more, they insist, will kill the market. Although this claim is in conflict with the evidence, it is consistent with the goal of maximum rewards to (and donations from) the industry.

Without a clear view of the political economy of health care, it’s easy to see the problem as Justice Scalia did. If we could just start treating health care like broccoli, the market would solve the problem. But as Rosenthal’s important book makes clear, the health care market really is different. Speaking of her Times series in 2014, Rosenthal told an interviewer her goal was to “start a very loud conversation” that will be “difficult politically to ignore.” We need such a conversation — not just about how the market fails, but about how we can change the political realities that stand in the way of fixing it.


In her book, “An American Sickness,” Elisabeth Rosenthal has provided an excellent description of the dysfunction of the business model of health care delivery in the marketplace. On this basis alone it is an invaluable resource for every health policy library – home or institutional.

Rosenthal makes a valiant effort to describe what we can do about it, but she does so apparently under the assumption that we are going to have to live with this system for the indefinite future. Her recommendations largely require a very aggressive stance in dealing with the health care delivery system, especially with the business transactions. A limitation of this approach is that it requires not only access to the system by virtue of good insurance coverage or personal wealth, but it also requires a personality capable of rough-and-tumble negotiations. Most people would not really qualify and thus would not be effective in taking on the medical-industrial complex. She also quite appropriately recommends more aggressive regulation, though, except for the quite modest reforms of ACA, that has not been forthcoming in the environment of political polarization that has dominated the scene in the past few decades.

However this “sickness” is unique in the United States, so hope springs from observing how other nations have made their systems work. I am going to yield to Yale political science professor Jacob Hacker, who also reviewed her book, to provide us with a description of what accounts for other nations’ success, but in one word, it is government.

Rosenthal mentions single payer, but is far too timid here, suggesting, at most, allowing individuals over 55 to purchase Medicare. It is true that single payer reform alone would not correct all of the sins of capitalizing on unfettered market opportunities for excess revenues, but changing the milieu from the market business model to the public patient service model would go a long way toward realigning incentives of the providers. It would be a refreshing environmental change to concentrate on how the health care needs of the patients can best be served instead of wasting time trying to figure out how to pull in more big bucks.

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CMS final rule benefits insurers, not patients

Posted by on Friday, Apr 14, 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.

CMS issues final rule to increase choices and encourage stability in health insurance market for 2018

Centers for Medicare &  Medicaid Services, April 13, 2017

The Centers for Medicare & Medicaid Services (CMS) today issued the final Market Stabilization rule, to help lower premiums and stabilize individual and small group markets and increase choices for Americans.

The final rule makes several policy changes to improve the market and promote stability, including:

* 2018 Annual Open Enrollment Period: The final rule adjusts the annual open enrollment period for 2018 to more closely align with Medicare and the private market. The next open enrollment period will start on November 1, 2017, and run through December 15, 2017, encouraging individuals to enroll in coverage prior to the beginning of the year.

* Reduce Fraud, Waste, and Abuse:  The final rule promotes program integrity by requiring individuals to submit supporting documentation for special enrollment periods and ensures that only those who are eligible are able to enroll. It will encourage individuals to stay enrolled in coverage all year, reducing gaps in coverage and resulting in fewer individual mandate penalties and help to lower premiums.

* Promote Continuous Coverage: The final rule promotes personal responsibility by allowing issuers to require individuals to pay back past due premiums before enrolling into a plan with the same issuer the following year. This is intended to address gaming and encourage individuals to maintain continuous coverage throughout the year, which will have a positive impact on the risk pool.

* Ensure More Choices for Consumers:  For the 2018 plan year and beyond, the final rule allows issuers additional actuarial value flexibility to develop more choices with lower premium options for consumers, and to continue offering existing plans.

* Empower States & Reduce Duplication:  The final rule reduces waste of taxpayer dollars by eliminating duplicative review of network adequacy by the federal government. The rule returns oversight of network adequacy to states that are best positioned to evaluate network adequacy.

“CMS is committed to ensuring access to high quality affordable healthcare for all Americans and these actions are necessary to increase patient choices and to lower premiums,” said CMS Administrator Seema Verma. “While these steps will help stabilize the individual and small group markets, they are not a long-term cure for the problems that the Affordable Care Act has created in our healthcare system.”


The final rule (139 pages):

Would people prefer that their health care coverage be adequate and affordable or would they prefer that their insurers thrive in the market even if to the detriment of the beneficiaries? That’s a ridiculous question though the Trump administration has given a ridiculous answer: cater to the private insurers and forget the patients.

The open enrollment period is essentially the only time individuals can enroll in the plans, and they are cutting the eligibility time in half. Further, they are closing the enrollment period two weeks before the end of the year which ensures that procrastinators who wait until the last two weeks before coverage begins are out of luck since they are prohibited from enrolling at all. This will have an obvious detrimental impact to those who tend to put things off or are simply unaware of the early cutoff date. The insurers can target their marketing to healthy populations and get them in quickly and then close the door before the sick people get wind of the short open enrollment period.

Documentation requirements are being increased for special enrollment periods. Since many of those seeking to enroll outside of the open enrollment period do have medical problems that they need to have covered by insurance, the more stringent requirements will allow insurers to refuse coverage for this more expensive population simply because of inevitable difficulties that patients would have in complying with these requirements. Insurers benefit, and people who need care will go without.

People who are unable to pay their premiums because of often unavoidable circumstances, such as loss of employment, will be denied coverage until the delinquent premiums are paid. The insurers get to clear their rolls of poor credit risks while those who do have such problems may have them compounded by being denied insurance coverage.

The rule allows insurers to tinker with the actuarial values of the plans to allow “more choices” (of stripped down plans that offer less protection) and “lower premium options” (for those deficient plans). The insurers get more sales of plans that pay fewer benefits whereas the patients face greater financial hardship should they need health care.

The adequacy of provider networks is a serious problem now, and yet the new rule abandons the federal role in providing oversight of the adequacy off these networks, leaving it to the states, many of which show little regard for such oversight. The insurers profit by ratcheting down the numbers and fees of providers while the patients are left with less certainty that they can access the care they need.

Though we know what increasing choices and lowering premiums really means, our new CMS Administrator, Seema Verma, describes this as “ensuring access to high quality affordable healthcare for all Americans.” It is insurance, not health care, that they are trying to make more affordable, and they certainly are not making actual access to care affordable with the increases in out-of-pocket cost sharing.

We should be particularly concerned with Verma’s statement that these steps “are not a long-term cure for the problems that the Affordable Care Act has created in our healthcare system.” Listening to her answers to questions at her confirmation hearing, she was heavy on the “choice,” “higher quality at lower cost,” and “access” rhetoric while refusing to reveal any real policies that she had in mind. We only know that she, in her own words previously, wants patients to “have more skin in the game.” How can they when so many of them already have been skinned alive?

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MedPAC questions effectiveness of MACRA’s MIPS

Posted by on Thursday, Apr 13, 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.

Evidence-Based Diagnosis and Faith-Based Solutions

By Kip Sullivan JD
The Health Care Blog, April 11, 2017

It’s official: the Medicare Payment Advisory Commission (MedPAC) has at long last decided that MACRA’s MIPS (Merit-based Incentive Payment System) can’t work. MedPAC reached this decision at its January 12 and March 2, 2017 meetings.

Its principle rationale was that measuring “merit” (quality and cost) at the individual physician level, which is what MIPS requires CMS to do, is not possible. As one MedPAC staff person put it at the January meeting, “A redesign of the MIPS program should build off a clear-eyed assessment of the limit of the national Medicare program’s ability to assess clinician performance.”

But the transcripts of the January and March meetings indicate that although MedPAC is now willing to say MIPS is a mess, the commission had not reached a decision about what to do about the mess by the close of the March meeting. The commission’s challenge is obvious. As its chairman Dr. Francis Crosson put it, the issue squarely before the commission now is “whether we just … sit there and watch a dysfunctional thing unravel, or whether we try to make some recommendations which are constructive….”

In previous posts  I have argued that both parts of MACRA – the MIPS program and the Alternative Payment Model (APM) program – can’t work and that MedPAC should recommend that Congress repeal or drastically amend MACRA (the Medicare Access and CHIP Reauthorization Act).

Here is how MedPAC staffer Kate Bloniarz summarized the commission’s indictment of MIPS at the March meeting:

“To reiterate some of the issues with MIPS, first, MIPS uses hundreds of clinician-reported quality measures. Second, two of the other components of MIPS, meaningful use and clinical practice improvement activities, only require attestation by a clinician and haven’t been proven to correspond to high-value care. Third, for any given clinician, there are a relatively small number of Medicare cases, which can contribute to noisy performance. Fourth, under MIPS each clinician is judged based on their own set of measures that they reported, and so the results aren’t comparable across clinicians. In total, we don’t expect that MIPS will be able to identify high- and low-value clinicians and will not be useful for beneficiaries, clinicians, or the program.”

I applaud the commission for being so forthright. I do wonder why it took them so long to reach this conclusion. This conclusion was obvious even before MACRA was enacted, which was two years ago.


The Medicare Payment Advisory Commission (MedPAC) is an independent federal commission that advises Congress on the administration of Medicare. It currently is evaluating the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) established by the Medicare Access and CHIP Reauthorization Act (MACRA) – the replacement for the flawed Sustainable Growth Rate (SGR) method of determining Medicare payments.

There was much celebration when SGR was eliminated by MACRA since it would have caused a drastic reduction in Medicare payment rates, but too little attention was given to the substitution in spite of warnings from knowledgeable individuals such as Kip Sullivan. Why is it a problem? As yesterday’s Quote of the Day message indicated, “desktop medicine” has displaced half of face-to-face clinical contact with patients and MIPS is destined to expand the desktop component – a major factor in exacerbating the epidemic of physician burnout. Burned-out physicians glued to desktops cannot be good for patient care.

It took forever to get rid of SGR. It is likely that MedPAC’s recommendations for MIPS and APMs will be all too feeble – recommending bland modifications that will do little to address the fundamental structural problems with the program. As the MedPAC staff member Kate Bloniarz stated, “we don’t expect that MIPS will be able to identify high- and low-value clinicians and will not be useful for beneficiaries, clinicians, or the program.”

The wheel-spinning taking place right now is mostly about replacing volume with value when actual efforts have been quite unproductive. It would be far better to concentrate on reforming our financing system with a well designed single payer national health program – an improved Medicare for all. Once we get the financing right, we can concentrate on much more rational methods of fine tuning that financing.

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The surge of desktop medicine

Posted by on Wednesday, Apr 12, 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.

Electronic Health Record Logs Indicate That Physicians Split Time Evenly Between Seeing Patients And Desktop Medicine

By Ming Tai-Seale, Cliff W. Olson, Jinnan Li, Albert S. Chan, Criss Morikawa, Meg Durbin, Wei Wang and Harold S. Luft
Health Affairs, April 2017


Time spent by physicians is a key resource in health care delivery. This study used data captured by the access time stamp functionality of an electronic health record (EHR) to examine physician work effort. This is a potentially powerful, yet unobtrusive, way to study physicians’ use of time. We used data on physicians’ time allocation patterns captured by over thirty-one million EHR transactions in the period 2011–14 recorded by 471 primary care physicians, who collectively worked on 765,129 patients’ EHRs. Our results suggest that the physicians logged an average of 3.08 hours on office visits and 3.17 hours on desktop medicine each day. Desktop medicine consists of activities such as communicating with patients through a secure patient portal, responding to patients’ online requests for prescription refills or medical advice, ordering tests, sending staff messages, and reviewing test results. Over time, log records from physicians showed a decline in the time allocated to face-to-face visits, accompanied by an increase in time allocated to desktop medicine. Staffing and scheduling in the physician’s office, as well as provider payment models for primary care practice, should account for these desktop medicine efforts.

From the Discussion

Physician burnout with EHR use has been well documented. Some organizations are using medical scribes to reduce documentation burden. Intriguing findings from the recent AMA study on five specialists who had scribes (with their own user identification) suggested that those specialists spent 43.9 percent of their time on face-to-face visits, compared to 23.1 percent among specialists without scribes. Clearly, more studies (preferably with more physicians teamed up with scribes) on the impact of scribes are needed. Our data suggested that 34 percent of logged time (2.10/6.25) was spent on progress notes. Having scribes support this effort could potentially remove one-third of physicians’ work efforts and might reduce burnout.

Twenty-four years after the implementation of the RBRVS-based Medicare Fee Schedule, the Medicare Access and CHIP Reauthorization Act of 2015 established a new framework for Medicare physician payment: the Quality Payment Program. In this program, physicians have two tracks to choose from: the Merit-Based Incentive Payment System and the Advanced Alternative Payment Models. Furthermore, CMS has also launched the Comprehensive Primary Care Plus model. The model has a separate track for practices with relatively more experience in delivering advanced primary care. These practices will receive a hybrid payment of a per beneficiary per month care management fee and fee-for-service payment for claims for evaluation and management services.

CMS has indicated its intention to monitor practices to ensure the delivery of high-quality health care under the Comprehensive Primary Care Plus model. Access logs provide a simple and unobtrusive way for health care delivery systems to examine how their clinicians spend a significant portion of their time.


Health care is, or at least should be, about the patient. This study shows that physicians are splitting their time fairly evenly between direct face-to-face patient care and desktop medicine, especially through the electronic health record. Although desktop medicine does provide some patient benefits we certainly need to ask whether much of that time is wasted for purposes other than patient care.

There is no question but that desktop medicine is contributing to the growing epidemic of physician burnout. Yet desktop medicine is expected to grow further with implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) and the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). Far too much effort is being expended on these primarily administrative models rather than being used for what health care is all about: protecting and improving the health of patients.

Let’s get our priorities right.

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Watch out! Here comes Stephen Parente

Posted by on Tuesday, Apr 11, 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.

ACA critic Stephen Parente nominated as HHS deputy secretary

By Dave Barkholz
Modern Healthcare, April 10, 2017

Stephen Parente, a healthcare economist, has been nominated to be HHS’ assistant secretary of planning and evaluation.

The University of Minnesota professor would fill a post vacated in June by Harvard economist Richard Frank. In that role, Parente would be a principal advisor to HHS Secretary Dr. Tom Price, consulting on policy, legislative efforts, strategic planning and research.

Parente is familiar with the work of Price. In 2013-2014, he analyzed Price’s ACA replacement proposal in conjunction with the conservative think-tank American Action Forum.


The White House announcement:



Stephen Parente discusses a key option for the Affordable Care Act

By Christopher Snowbeck
StarTribune, December 3, 2016

With Republicans in Washington, D.C., promising to repeal the federal Affordable Care Act, or ACA, the focus is shifting to how the GOP might try to replace it. Stephen Parente of the University of Minnesota is well-positioned to describe what could be coming. In 2013-14, Parente worked with the American Action Forum, a conservative think tank, to evaluate the budget and coverage impact from the Empowering Patients First Act, an ACA replacement plan from U.S. Rep. Tom Price, R-Ga. Last week, President-elect Trump selected Price as his health secretary. More recently, Parente worked with staffers to model the economic impact of “Better Way,” the replacement plan put forward by House Speaker Paul Ryan.

Q: I gather that the dollar value of tax credits under Better Way would be smaller than with the Affordable Care Act, but this reduction fits with lower premiums for coverage, too. Is that right?

A: Correct. One of the biggest changes is the risk-rating piece. The ACA has a 3-to-1 ratio for modified community rating, which means insurers can’t sell coverage to an adult age 64 or older for more than three times what they’d charge a 21-year-old for the same health plan. Better Way proposes a 5-to-1 ratio.

There are fewer caps on deductibles and out-of-pocket spending with Better Way, so that’s another way deregulation brings lower premiums. Finally, fewer health benefits are required to be covered by health plans under Better Way, compared with the ACA.

Q: Minnesota is one of those blue states that has offered generous benefits via Medicaid, plus the MinnesotaCare health insurance program. Will federal funding for the state’s programs decrease?

A: I think many states are probably going to see less Medicaid funding, because it’s going to have to be spread around and there will be some budget constraints. There will definitely be, in that sense, some winners and losers.


Stephen Parente is the policy genius behind Tom Price’s “Empowering Patients First Act” and Paul Ryan’s “Better Way” – two of the cruelest policy proposals of the past decade that shift health care costs from the government to patients in need – all under the guise of “it’s about access” (but not about being able to afford health care).

Parente says that there definitely will be winners and losers, but he didn’t specify that the winners will be wealthy taxpayers and the losers will be patients.

Now Stephen Parente is going to guide policy, legislative efforts, strategic planning and research for the Department of Health and Human Services, under the leadership of HHS Sec. Tom Price. When we desperately need new public policies to help make essential health care more affordable for all of us, the man in charge of policy will begin to tear down and destroy what we do have. He may become the most dangerous individual in government as far as our health care is concerned.

Remember that name – Stephen Parente – and be prepared to use all civil means available to ward off his pending nefarious ventures. Then go out into the streets and march for an improved Medicare for all.

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Conservative roadmap for improving AHCA

Posted by on Monday, Apr 10, 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.

CBO Provides A Roadmap For Improving AHCA

By Joseph Antos and James Capretta, American Enterprise Institute (AEI)
Health Affairs Blog, April 4, 2017

The future of the American Health Care Act (AHCA), the GOP-drafted plan to repeal and replace the Affordable Care Act (ACA), is unclear after the bill was pulled before the House of Representatives could vote on it. But the debate over the ACA and proposals to replace several of its key provisions is unlikely to remain off the national agenda permanently.

The best place to start is with the cost estimate of (AHCA) produced by the Congressional Budget Office (CBO).

Trump administration officials, some members of Congress, and assorted commentators have criticized CBO for this estimate, arguing that it is a fundamentally inaccurate assessment of what would occur if AHCA passed. This criticism is misplaced. While some of CBO’s assumptions are indeed questionable, there is little doubt that the agency’s bottom line assessment is basically correct: The bill, as currently structured, would trigger a rise in premiums in the short-run, a sharp increase in the number of people without insurance over the next two years, and then also a steady increase in the number of uninsured Americans over the following eight years.

Instead of trying to discredit this finding, the authors of the legislation would be better off fixing the bill. CBO’s estimate provides a roadmap for what needs to be done to improve the chances the bill will produce the results its authors intend.

Changing the ACA’s insurance rules in a coherent and systematic manner in AHCA was difficult because the proposal’s sponsors were trying to pass the measure using the budget reconciliation process.

AHCA is thus an awkward proposal. It effectively eliminates the individual mandate while leaving in place the ACA’s rules prohibiting the use of health status in setting premiums or determining what is covered by insurance. The authors of the measure propose “continuous coverage protection” as a substitute for the individual mandate. Under that provision, insurers would charge a one-year, 30 percent surcharge on premiums to anyone who has experienced more than a two-month break in their insurance coverage.

This penalty is far too weak to work. A young, healthy consumer experiencing a break in coverage has a strong incentive to stay uninsured as long as possible. Once he decides to purchase health insurance, the consumer will be required to pay a 30 percent surcharge on his premium for one year. After that, the consumer will once again pay without penalty the same community rate as everyone else of the same age and gender.

AHCA also substitutes less generous age-based credits for the income-adjusted subsidies of the ACA for lower-income households, and repeals enhanced funding to the states for the Medicaid expansion population. As a result, younger and healthier consumers would have less of an incentive to buy coverage.

That is a recipe for even more adverse selection, driving up premiums for those who remain insured through the individual market.

Needed Adjustments

* Higher Financial Penalties For Failure To Maintain Coverage

The AHCA approach is an attempt to replace governmental force with personal responsibility. Under AHCA, no one is required to have insurance, but there are financial consequences for choosing to remain uninsured. However, rather than an arbitrary fixed surcharge, the penalty should be commensurate with the added costs imposed on the health system when such people decide not to buy insurance. For example, the penalty could include a premium surcharge that increases with time out of the market, and a waiting period could be imposed before benefits are paid. Such an approach would eliminate the perverse incentive of a fixed penalty that encourages individuals to remain uninsured, avoiding premium payments, for as long as possible.

* The ‘No-Premium’ Health Insurance Option And Automatic Enrollment

Another factor reducing CBO’s estimate of the AHCA’s take-up of insurance is some people’s unwillingness to pay a premium that is larger than the value of their credit. A comprehensive revision of AHCA could broaden the types of plans offered by insurers to include at least one plan available with a premium exactly equal to the credit. Such a plan would provide protection against catastrophic losses without requiring first-dollar coverage for routine expenses. To further improve insurance take-up, AHCA should allow states to automatically enroll uninsured individuals into “no-premium” plans, with an option to change plans or opt out entirely.

* A Compromise On Medicaid Eligibility Within A Reformed Program

A new uniform national income standard could be set at a level that would free up resources to provide stronger federal support for all state Medicaid programs. Non-expansion states would not be required to expand their Medicaid eligibility to the new standard, but they would receive additional funding through a block grant. Expansion states would likely phase down their programs to the new income standard. In addition, states would be given more control over the program, allowing them to operate Medicaid in ways that promote individual responsibility and ease the transition to private health coverage.

* Additional Support For Low-Income Households Above Medicaid Eligibility

Subsidies ranging from $2,000 to $4,000 per person are not sufficient to make non-group insurance affordable for many with low incomes. AHCA should be revised to provide additional support for these families.

Looking Forward

Instead of condemning or ignoring CBO, congressional leaders would be well-advised to take full advantage of the agency’s analytic expertise to make the needed adjustments to the AHCA plan. That will ensure all sides are better prepared for serious debate when health policy again moves back onto center stage.


Published Comment:

By Don McCanne, M.D.

Trying to tweak the lousy AHCA model to make it work better is not a rational approach when more fundamental policy defects are ignored.

Worrying about keeping down spending through the federal budget doesn’t make much sense when it is total spending on health care, public and private, that is important. Federal health care spending is more efficient than spending through private insurers. In fact, eliminating private insurers reduces the profound administrative waste of both the private insurers and the burden they place on health care providers. Thus increasing the federal health care budget in this manner would produce an even greater offset in private spending. That savings could then be used to pay for the uninsured and for the excess cost sharing of the underinsured.

Inducing “personal responsibility” in health care spending is code language of conservatives for erecting financial barriers to health care – a terrible policy choice. The financing system should encourage, not discourage, access to beneficial health care services. The administrators can make better decisions than an uninformed public on what care is detrimental and should not be covered.

We already know what happens when Medicaid decisions are turned over to the states, and often it is not good for patients in need. Besides, Medicaid has a welfare stigma and would continue to be underfunded. It would be far better to cover everyone under the same comprehensive program that ensures access for everyone to all essential health care services.

Even continuing with ACA is a mistake because no matter how many tweaks are applied, we will continue to perpetuate the uninsured, underinsured, narrow networks, and excessive cost sharing (to slow premium increases to protect the private insurers instead of patients). These policies are detrimental to patients.

The policies we need are an efficient, publicly-administered universal risk pool, equitable funding based on ability to pay, removal of financial barriers to care, and free selection of health care providers. These policies benefit patients, and the models that have been constructed and are in use in some other nations would provide much better value for our health care spending.

Besides, a majority of the population now understands the superiority of single payer, including many Trump supporters. The nation is now ready for a single payer, improved Medicare for all.


Although the ACA was an improvement, it still has fundamental structural defects that prevent us from achieving the goals of true universality, affordability, equity, efficiency and access, no matter how much it is tweaked. The Republican AHCA proposal was merely another set of tweaks that went in the wrong direction, and we would have fallen further behind in the goals of reform.

Joseph Antos and James Capretta understand policy well, but they have saddled themselves with the conservative ideology professing that much of the responsibility for containing health care costs should be placed in the hands of the patient-consumer. Models to do that do reduce government spending on health care, but at today’s very high costs they impair access to beneficial health care services because of the lack of affordability of the patient’s out-of-pocket component of the spending.

Some conservatives recognize that low-income individuals need greater government support, as do Antos and Capretta, but their consumer-directed models also place too much of a financial burden on America’s workforce and their families. Also their insistence on using private insurance plans in the marketplace perpetuates the profound administrative waste that uniquely characterizes the American health care financing system, and perpetuates the deleterious tools of the private insurance industry such as sky-high deductibles and ultra-narrow provider networks.

Look specifically at the policies that Antos and Capretta consider to be beneficial. They would assess a large, progressive premium penalty after an interval of being uninsured once that individual decides to purchase insurance – a clear disincentive to bringing the uninsured into the market when policies should be designed instead to be certain everyone is always covered, not to mention that the additional penalty would make the premium unaffordable for most individuals. They would create optional plans with premiums equivalent to the government credit – an approach only made possible by further increasing deductibles and other cost sharing to truly unaffordable levels, not only perpetuating but expanding the flawed policy of offering almost worthless coverage in order to make premiums affordable. They would reduce the federal support of and privatize the Medicaid program while increasing “individual responsibility” through out-of-pocket payments that Medicaid beneficiaries simply do not have (except for the insulting token payments promoted by Pence and Verma simply to satisfy their own conservative ideological preferences).

Antos and Capretta do not reject the principle of government spending since they recommend it for low- and middle-income individuals and families. But they are quite willing to sacrifice the efficiencies and equity of a single payer system simply to include conservative ideology that places individual responsibility over social solidarity. Other nations have shown that publicly administered single payer tools are capable of slowing the increase in health care spending in a patient-friendly manner. Requiring excess cost sharing and taking away provider choice certainly are not patient-friendly.

Forget trying to tweak AHCA by placing conservative principles above patient service. Also forget trying to tweak ACA by placing the concepts of incrementalism and supposed political feasibility above patient service. Let’s go for the model that places patient service first – a well designed, single payer national health program – an improved Medicare for all.

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The Lancet Series on ‘America: Equity and Equality in Health’

Posted by on Friday, Apr 7, 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.

Editorial: America, all things not being equal

The Lancet, April 8, 2017

In an effort to better understand the conditions and mechanisms driving health disparities in the USA, this week, The Lancet breaks ground once again by publishing, America: Equity and Equality in Health — a stark and dire update to the first Series — focused on appraising where the greatest discrepancies lie. Comprising five papers, the Series looks in depth at the current inequalities in the health-care system and chronicles the beneficial influence of the ACA on health-care equity as well as the continued barriers and shortcomings in providing coverage.



Inequality and the health-care system in the USA

By Samuel L Dickman, David U Himmelstein, Steffie Woolhandler

Widening economic inequality in the USA has been accompanied by increasing disparities in health outcomes. The life expectancy of the wealthiest Americans now exceeds that of the poorest by 10–15 years. This report, part of a Series on health and inequality in the USA, focuses on how the health-care system, which could reduce income-based disparities in health, instead often exacerbates them. Other articles in this Series address population health inequalities, and the health effects of racism, mass incarceration, and the Affordable Care Act (ACA). Poor Americans have worse access to care than do wealthy Americans, partly because many remain uninsured despite coverage expansions since 2010 due to the ACA. For individuals with private insurance, rising premiums and cost sharing have undermined wage gains and driven many households into debt and even bankruptcy. Meanwhile, the share of health-care resources devoted to care of the wealthy has risen. Additional reforms that move forward, rather than backward, from the ACA are sorely needed to mitigate health and health-care inequalities and reduce the financial burdens of medical care borne by non-wealthy Americans.



The Affordable Care Act: implications for health-care equity

By Adam Gaffney, Danny McCormick

Although the ACA improved coverage and access—particularly for poorer Americans, women, and minorities — its overall impact was modest in comparison with the gaps present before the law’s implementation. We discuss proposals for change from opposite sides of the political spectrum, together with their potential impact on health equity.



Structural racism and health inequities in the USA: evidence and interventions

By Zinzi D Bailey, Nancy Krieger, Madina Agénor, Jasmine Graves, Natalia Linos, Mary T Bassett

In this conceptual report, the third in a Series on equity and equality in health in the USA, we use a contemporary and historical perspective to discuss research and interventions that grapple with the implications of what is known as structural racism on population health and health inequities. Structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. We argue that a focus on structural racism offers a concrete, feasible, and promising approach towards advancing health equity and improving population health.



Mass incarceration, public health, and widening inequality in the USA

By Christopher Wildeman, Emily A Wang

The USA is the world leader in incarceration, which disproportionately affects black populations. Nearly one in three black men will ever be imprisoned, and nearly half of black women currently have a family member or extended family member who is in prison. The emerging literature on the family and community effects of mass incarceration points to negative health impacts on the female partners and children of incarcerated men, and raises concerns that excessive incarceration could harm entire communities and thus might partly underlie health disparities both in the USA and between the USA and other developed countries.



Population health in an era of rising income inequality: USA, 1980–2015

By Jacob Bor, Gregory H Cohen, Sandro Galea

Although the increase in income inequality since 1980 has been driven largely by soaring top incomes, the widening of survival inequalities has occurred lower in the distribution — ie, between the poor and upper-middle class. Growing survival gaps across income percentiles since 2001 reflect falling real incomes among poor Americans as well as an increasingly strong association between low income and poor health. Changes in individual risk factors such as smoking, obesity, and substance abuse play a part but do not fully explain the steeper gradient. Distal factors correlated with rising inequality including unequal access to technological innovations, increased geographical segregation by income, reduced economic mobility, mass incarceration, and increased exposure to the costs of medical care might have reduced access to salutary determinants of health among low-income Americans.



Comment: An agenda to fight inequality

By Bernie Sanders

The USA is one of the richest countries in the world, but that reality means very little for most people because so much of that wealth is controlled by a tiny sliver of Americans. During the past 35 years, there has been a massive transfer of wealth away from the middle class and the poor to the top 0·1% of the US population.

Such inequality continues to be one of the greatest moral and economic issues of our time. It is also a huge health issue.

The USA’s dysfunctional health-care system is a major contributor to the nation’s health inequalities. Today, the US health-care system too often serves to enrich wealthy investors and executives, while impoverishing, and even bankrupting, many working families.

Health care is not a commodity. It is a human right. The goal of a health-care system should be to keep people well, not to make stockholders rich. The USA has the most expensive, bureaucratic, wasteful, and ineffective health-care system in the world.16 Medicare- for-all would change that by eliminating private health insurers’ profits and overhead costs, and much of the paperwork they inflict on hospitals and doctors, saving hundreds of billions of dollars in medical costs.

Making sure that every citizen has the right to child care, health care, a college education, and a secure retirement is not a radical idea. It is as American as apple pie. It will allow us to realise the ideals of the USA: that all of us are created equal — that we all have the right to life, liberty, and the pursuit of happiness.



Profile: David Himmelstein and Steffe Woolhandler: advocates for an equitable US health system

By Richard Lane

With President Donald Trump’s failure to get the American Health Care Act (AHCA) as far as a vote in Congress, are they optimistic for the future? “The AHCA’s defeat has certainly buoyed our spirits. Obamacare expanded coverage, but its adherence to a market-based approach hobbled the reform, leaving it open to Trump’s attacks”, says Woolhandler. “The surging opposition that triggered the collapse of the Republican plan signals the broad support for a non-market alternative that can create a new opening for single payer, so yes, we have some grounds for optimism,” Himmelstein says.


For those looking for something to read this weekend, you couldn’t do better than this Lancet series on the lack of equity and equality in America and its impact on health care. If you don’t have time, at least you can get the gist of the theme by reading these relatively short excerpts. Also, the articles are well worth saving as a reference source to use in our advocacy for expanding health care justice throughout America.

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It’s not just Democrats and liberals who support Medicare for all

Posted by on Thursday, Apr 6, 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.

The Economist/YouGov Poll, April 2-4, 2017

81. Opinion on health reforms – Expanding Medicare to provide health insurance to every American

Percent who favor strongly or favor somewhat:

60% Total

75% Democrat
58% Independent
46% Republican

82% Liberal
60% Moderate
43% Conservative

63% Family income under $50K
58% Family income $50-100K
63% Family income over $100K

80% Clinton voters
40% Trump voters


This poll shows once again that about 60 percent of Americans favor expanding Medicare to cover everyone. To no surprise, about 80 percent of liberals, Democrats and Clinton voters are in support. But what we should be especially aware of is that over 40 percent of conservatives, Republicans and Trump voters also support Medicare for all.

It is wrong to narrowly target the single payer message to liberals and Democrats. The message resonates with a significant percentage of conservatives and Republicans as well. They should certainly be included in the grassroots coalition efforts to support Medicare for all. The majority of the nation working together will get us there.

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Conyers: Medicare for All’s time has come

Posted by on Wednesday, Apr 5, 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.

By John Conyers Jr.
Detroit Free Press, April 3, 2017

I’m as happy as anyone with the way the Republicans’ plan to wreck our healthcare system crashed and burned last week. And President Donald Trump is right: Republicans lost because Democrats beat them. We beat them because we were organized, we were unified and we were backed by unprecedented grassroots energy. Members of the U.S. Congress hosted dozens of rallies, advocacy organizations hosted hundreds more and constituents showed up in overwhelming numbers at town halls across this country to make their voices heard.

And what exactly was their message? One of the most poignant moments came at a town hall hosted by U.S. Rep. Diane Black, Republican of Tennessee, where a constituent explained her opposition to the GOP bill using faith. As a Christian, she said, her faith was rooted in helping the unfortunate, not cutting taxes on the rich, so why not expand Medicaid and allow everyone to have insurance? And she’s not alone. Last week, a Quinnipiac survey found that voters overwhelmingly oppose cuts to Medicaid — 74% of them — including 54% among Republicans.

Given the record high support for publicly funded healthcare, economists, policy experts and commentators everywhere have called on the Democratic party to build on our momentum by supporting a single payer system. But perhaps the most convincing case I heard came from Jessi Bohan, the teacher from Cookeville, Tennessee who spoke at Rep. Black’s town hall.

The week after her question went viral she wrote to the Washington Post that she was troubled to see her comments used as a “defense of Obamacare” instead of what they were: an indictment of any healthcare policy that leaves anyone out. As Bohan so eloquently put it, “it is immoral for health care to be a for-profit enterprise” that allows insurance companies to make “enormous sums of money off the sick while people are struggling to pay their medical bills.” If she had it to do over again, she wrote, she would have explained to Black “the Christian case for universal, single-payer health insurance, which would protect all Americans.”

While her message was targeted at Republicans, it is one that many of my colleagues in the Democratic Party need to hear as well. For two weeks, I’ve watched Democrats point to the Congressional Budget Office’s analysis of the Paul Ryan bill and express righteous outrage that it would lead to 24 million Americans losing their insurance. But that same CBO score says that 28 million Americans will still be without insurance even under the Affordable Care Act. I’m impressed that the ACA has expanded Medicaid eligibility in states that have adopted it and more than 20 million previously uninsured now have insurance, but universal healthcare it is not.

Time and time again I’ve heard Democrats dodge questions about their support for universal healthcare by saying they’re focused right now on defending the ACA. Now that we have repelled Paul Ryan’s attack and Donald Trump has signaled that Republicans will move on, the time for those excuses has passed.

For years, I’ve also watched as Democrats, including our presidential nominee last year, have avoided putting their name behind single payer by saying they’re focused on politically achievable short-term goals.

Single payer is politically achievable.

Gallup, the Kaiser Family Foundation, and other polling organizations have found that there is majority support for Medicare for All in America today. But more important, elected officials are not supposed to move to the political center, we are supposed to stake out the moral center and convince others to join us there.

November’s election results showed that we can’t just say “the other side is awful,” however true that may be, and expect Americans to flock to us. To win again, we must be a party of principles and present bold ideas and a vision for the future.

It is true that single-payer healthcare has been implemented in virtually every other advanced democracy on Earth. It is also true that in those countries, people live longer and healthcare is dramatically less expensive than it is here. And finally, it is true that Medicare for All is the direction Americans overwhelmingly want us to go. Nevertheless, I want my colleagues to join me in supporting single-payer not to save money or to win elections, but because it is the moral and just thing to do. If, like me, you believe healthcare is a right to everyone and not a privilege to those who can afford it, let’s be organized and let’s be unified in our support for Medicare for All.

John Conyers represents Michigan’s 13th District in the U.S. Congress. He has introduced H.R. 676 Medicare for All bill in every Congress since 2003.


Congressman John Conyers is right on target. The time has come for an improved Medicare for all. HR 676 now has 84 cosponsors. Single payer, here we come.

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National Catholic Reporter endorses health care as a right

Posted by on Tuesday, Apr 4, 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.

Editorial: Take the lead on health care as a right

National Catholic Reporter, April 1, 2017

The survival of the Affordable Care Act means that millions of people who have never had health coverage before can continue to buy plans from HealthCare.gov or find relief from an expanded Medicaid.

So, yes, let’s breathe a short sigh of relief. But then let’s roll up our sleeves and prepare for the next battle in the war that has been declared on the American middle class and people living in poverty.

Independent Sen. Bernie Sanders of Vermont promises to introduce a bill that would move health care coverage to a single-payer, Medicare-like system. Now is the time for Democrats to come back into the spotlight and use this opportunity to work with Sanders to create a system that works — that works for those who can afford health care insurance and, more vital, for those who cannot.

Other industrialized nations, such as Canada, France and Japan, treat basic health care as a human right for all people. They built their health care systems on that tenet. It’s time for the U.S. to recognize that right in this nation. The right to receive care can no longer be predicated on one’s financial situation. Everyone in this country deserves the same treatment in the emergency rooms, hospitals, and medical and dental offices in all 50 states.

Once we’ve taken our deep breath, that should be the next fight.


Another welcome editorial making it clear that preventing the repeal of the Affordable Care Act was important but not enough. We must begin treating health care as a human right for all people by moving health care coverage to a single-payer, Medicare-like system.

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