Michigan Medicine selling queue jumping to the wealthy

Posted by on Tuesday, Mar 13, 2018

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

Exclusive U-M medical plan buys you ‘better’ care, special access

By David Jesse
Detroit Free Press, March 9, 2018

Michigan Medicine — the health system owned by the University of Michigan — is drawing fire from its own staff over a plan to offer personalized service, reduced waiting times and preferential access to physicians for a hefty yearly fee.

The plan, part of the growing nationwide movement known as concierge care, is drawing protests from U-M doctors who are concerned it strays from the institution’s public mission. The program is currently enrolling patients.

“Victors Care purports to offer ‘better’ health care to those with enough money to pay a large access fee,” says a letter sent to the health system’s administration by 200 doctors and staff. “The University of Michigan is a public institution and our commitment is to serve the public, not a private few. We do not feel this is the role of a state university and are unable to justify this to the patients and families we serve.”

The program works like this, according to the Victors Care website: People interested in the program pay a yearly fee — $2,700 now, going up to $3,600 after July 1. In exchange, the program promises shorter waits in waiting rooms, more face time with doctors, 24-hour access to a doctor via e-mail and the doctor’s cell phone number, and “assistance” with scheduling tests and other specialty appointments.

“We urge Michigan Medicine leadership to focus on increasing access for all of our patients,” the letter from the Michigan Medicine staff says. “We need greater efforts to improve infrastructure, space, and clinic support for all. We are eager to promote and strengthen primary care services at the University of Michigan, but we feel strongly this should be done for all patients, not based on their ability to pay.”

Susan Goold, professor of internal medicine and health management and policy, said she believes there are ethical questions that must be addressed.

“Does this make it harder for people who don’t pay for Victors Care to see their doctor or get in to get a test they need done?” she told the Free Press. “That’s an issue of fairness for a public university. It’s not just because it’s supported by public dollars, but our mission — we serve the public.”


Should wealthy patients have a right to buy their way to the front of a queue?

Or instead should we ask if we’ve optimized our health care resources to ensure appropriate capacity and queue management to prevent excessive queues for everyone? Rather than devoting resources to cater to the wealthy by allowing them to bypass problems in the system, wouldn’t it be better to use our resources to resolve those problems and improve the system for everyone?

The wealthy have a much greater political voice than the rest of us. If the health care system treats the wealthy the same as the rest of us, then if the system is not performing well they would be motivated to advocate for reform. If the system performs well for them but worse for everyone else, they may not be sensitive to the issues and thus not as motivated to advocate for improvement.

Then there is the matter of fairness. At the DMV, or at the post office, or at the checkout line of the supermarket, usually there is some effort to manage the queues (DMV appointments, quick check line, etc.), but we would still be offended if the wealthy were moved into the front of the line. In health care, which should be a fundamental right for all, we should be even more sensitive about queue jumping.

There is debate as to whether Americans are less egalitarian than citizens of other nations, but, regardless, we still do have some sense of fairness. Except for medical problems of great urgency, queue jumping is never fair, and we should not institutionalize it.

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Can we do something about the forthcoming high premium increases?

Posted by on Monday, Mar 12, 2018

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

Individual Markets Nationally Face High Premium Increases in Coming Years Absent Federal or State Action, With Wide Variation Among States

Covered California, March 8, 2018

Every state is at risk of significant cumulative premium increases in 2019-2021 due to continued federal uncertainty in the individual market. The uneasy conditions in many states have been exacerbated by recent decisions made at the national level, such as the removal of the federal penalty for being uninsured; the introduction of association health plans and short-term, limited-duration plans that could promote higher costs and the siphoning of healthy consumers; and the potential of continued underinvestment in marketing and outreach to consumers eligible for coverage in those states that rely on federal marketplace.


• All states’ individual markets risk higher than normal premium increases — ranging from 35 to 90 percent over three years — due to continued uncertainty at the federal level, but state variation informs understanding of local risks.

• Premium increases in the individual markets will likely range from 12 to 32 percent in 2019, and cumulative increases from 2019-2021 will range from 35 percent to more than 90 percent.

• Increases are on average more than double the rate of medical inflation as a result of healthier consumers leaving the individual market.

• The report identifies 17 states that are more likely — because of their historic risk mix and enrollment — to have cumulative premium increases of 90 percent or more and 19 additional states are at a higher risk of experiencing hikes of 50 percent.

• Policy actions could both lower premiums and promote more plan competition by reducing uncertainty — with independent actuarial analysis finding that reinsurance or similar programs could cut premium increases in half, bringing them to single digits in many states.

Federal and State Policies That Could Affect Premiums and Promote Stability:

• Institute a Reinsurance Program

• Directly Fund Cost-Sharing Reduction (CSR) Subsidies

• Provide Additional Subsidies to Consumers to Purchase Insurance

• Increase Marketing and Outreach

• State-Based Penalties for Non-Coverage

• State Regulations on Association Health Plans or Short-Term, Limited-Duration Plans

• Auto-Enrollment


This Covered California analysis of the individual insurance market in each state reveals that, in the absence of any federal policy action, premiums could increase between 35 and 90 percent over the next three years, on average more than twice the rate of medical inflation. The report also discusses various potential federal and state policies that could reduce this impact.

It is understandable that Covered California, one of the more successful programs under the Affordable Care Act, would support this study and try to suggest policies that would improve the functioning of the individual insurance market. But it is important to understand why this instability even exists, and that is because of the fragmented, dysfunctional financing infrastructure that we continue to tolerate. When you read through the report you can see a multitude of interactions that take place over which various individuals, institutions and states may have little control. As an obvious example, a private insurance risk pool heavily burdened with sick people is not able to attract the healthy in order to dilute individual risk.

This fragmentation intuitively leads to the various federal and state policies that they suggest might slow the rate of premium increases. But look at the list. These measures are not so much for the direct provision of health care, but rather they add more administrative excesses that result in still higher total health care costs. The patient they are treating is the private health insurer who wants lower insurance premiums that are more competitive in the marketplace. Not only do most of the actual patients in our global health care system fail to benefit, they face higher costs collectively because of these administrative excesses.

Now think of what it would be like if we had a well designed single payer national health program – an improved Medicare for all. Look again at the list of recommended policies. None of them would be even remotely considered to be necessary in a single payer system, that is except one – auto-enrollment – at birth, for life. Everybody in, nobody out.

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More about the crisis of lack of interoperability

Posted by on Friday, Mar 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.

A private health care information technology system

By Don McCanne, M.D.
Physicians for a National Health Program, Quote of the Day, July 21, 2004


The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care

By David J. Brailer, MD, PhD, National Coordinator for Health Information Technology
Health and Human Services, July 21, 2004

Health information technology provides a mechanism for refocusing care delivery around consumers without substantial regulation and industry upheaval. Information technology can result in better care (care that is higher in quality, safer, and more consumer responsive) and at the same time, more efficient (care that is appropriate, available, and less wasteful).

The private sector role

While the federal government plays an important role in HIT adoption, the effective use of, and value creation from, this technology lies predominantly with the private sector. The federal government will provide a vision and a strategic direction for a national interoperable health care system, but will rely on a competitive technology industry, privately operated support services, and shared investments in HIT adoption. The private sector must develop the market institutions to deliver the products and services that can transform the paper-based health care system into an electronic, consumer-centered, and quality-based system. The private sector can best ensure that HIT products are successfully implemented in ways that meet the varying needs of American health care across settings, cultures, and geographies. The private sector can also continue constant innovation in HIT and ensure that products are delivered on an affordable basis.

Federal and state governments have delegated most components of quality assurance to voluntary private organizations, including but not limited, to the JCAHO, NCQA, the National Quality Forum, residency review committees, and others. This will be true of quality and performance accountability in the future world of HIT. New market institutions need to be developed that can support clinician adoption of HIT, provide interoperability, and enhance the value realized by these investments. Close collaboration between public and private sectors can develop new methods for improving care without creating unnecessary regulation and minimizing reporting burdens on private industry.

Comment by Don McCanne, M.D. (7/21/04):

The private, competitive market has produced for us computers that are powerful yet inexpensive. Software that is used widely is quite inexpensive, and that in the public domain is essentially free after the initial development costs. With inexpensive computers and software developed in the public domain, the cost of an integrated health care IT (information technology) system should be quite modest. And the return in error reduction and administrative efficiency would far more than offset any real costs.

The Veterans Administration is far ahead of the rest of the nation in developing and utilizing an integrated IT system. And this has been developed in the public (government!) sector. Many other nations with universal health care systems have also introduced integrated IT systems primarily through the public sector.

What has the magic of the competitive marketplace produced in the way of an integrated IT system to this date? High costs, very poor penetration, and system failures! Competitive market theory dictates that we should be leading the world with a high quality health care IT system at a low cost. What went wrong?

First of all, a fragmented system of multiple private plans, public programs and uninsurance does not provide an infrastructure that is very conducive to an integrated IT system. A single payer system, or, at minimum, a highly regulated system of universal coverage through multiple plans, would provide a framework that would ensure adaptability of an integrated IT system. Of course, a single, publicly administered system would be much preferred for an integrated IT system.

But the greatest difficulty with private IT solutions lies in the very nature of these marketplace models. Their goals are, above all, to maximize profits and to maximize the market price of their shares. To achieve those goals, corporate behavior varies from that of a public entity that has a simpler goal of establishing an effective and efficient high quality system that serves the heath care system and its patients well. The public system does not have to be concerned about being a successful business enterprise, but the private model does.

What might the private sector do that doesn’t serve our interests well? They will produce products that command the highest prices that the market will bear. They will design the products to provide a continuing revenue stream. Once gaining a significant share of the market, they will design incompatibility with other systems in an attempt to garner the entire market. They will design obsolescence into their systems to ensure future markets for their new innovative products. They will partner with and perhaps acquire other related entities that can expand profit potentials through greater control of components of the health care system which their products can influence. Although these are good business practices, they are terrible policies for our health care system.

But without market incentives, wouldn’t innovation be suppressed? We have market innovations now, and they have not resulted in the IT developments that we desperately need. Public innovations have been effective in developing systems in other nations and in the VA that are already working. If private entrepreneurs can develop innovations that could benefit a public system, there is no reason that they couldn’t be sold to the government to place in the public domain. But they should be priced to reflect costs plus a fair one-time profit. We really don’t need more superfluous profit centers in our health care system.

The health information technology report released today should alarm us all. Although we all agree on the importance of an integrated IT system, the Bush administration is limiting the role of the government to being an enabler that encourages the private sector to develop a successful business model. Rather than higher quality at a lower cost, we’ll end up with mediocrity at a much higher cost, wasting even more of our health care dollars.

We desperately need strong leadership from our government in developing a health care IT system that will serve us all well. But based on the current leadership that has failed to address even the fundamental issue of adequate health care coverage for all, it is unlikely that we’ll see any enlightened leadership on this in the near future.



Meeting Meaningful Use Criteria and Managing Patient Populations

By Philip A. Verhoef, M.D., Ph.D.
Annals of Internal Medicine, November 19, 2013

To the Editor:

I read with interest DesRoches and colleagues’ article on assessing physician use of EHRs and whether such use was meaningful, as outlined by the Centers for Medicare & Medicaid Services. The fundamental flaw in the authors’ research question (and in the Centers for Medicare & Medicaid Services’ misguided use of this metric) is that the meaningful use criteria pertain to patient care, but the commercially available EHRs are invariably designed to optimize billing and insurance reimbursement. Thus, the finding that fewer than 1 in 10 physicians reported being able to use their systems to meet meaningful use criteria is hardly surprising.

The commercial EHR has resulted in more money in the pockets of physicians who use it, although it has failed to facilitate meaningful use or show overall cost-savings. Further, one need only look at the U.S. Department of Veterans Affairs Veterans Health Information Systems and Technology Architecture (VistA) Computerized Patient Record System as an example of an EHR that was designed to optimize patient care and has successfully achieved meaningful use. The West Virginia Department of Health implemented a statewide modified VistA system for one tenth the cost of the introduction of the Epic system (Epic Systems, Verona, Wisconsin) at West Virginia University.

The VistA system within the U.S. Department of Veterans Affairs allows easy exchange of information with physicians around the country because all of the hospital inpatient and outpatient sites are linked. Both Veterans Affairs and non–Veterans Affairs hospitals using the VistA system are among the few in the nation that achieve measurable meaningful use according to the Healthcare Information and Management Systems Society. Finally, the VistA system has won repeated accolades over the past 2 decades for its ease of use and for improving efficiency and optimizing prescription accuracy.

Why, then, would a physician or health system implement anything other than the VistA EHR if they seek to use an EHR in a meaningful way, as the Centers for Medicare & Medicaid Services mandates? Stated differently, and in parallel with our current health financing crisis, why do we pay so much more for a privately delivered product that is so much less effective than one developed with taxpayer dollars?



National Coordinator Rucker Urges CMIOs to Participate in Helping to Improve Interoperability, Usability

By Mark Hagland
Healthcare Informatics, March 5, 2018

Moving forward towards greater interoperability and usability will take time and effort, (National Coordinator Donald) Rucker said, but he said he remained convinced that much will change in the coming years, some of it stimulated by the federal government, but a great bulk of it stimulated by consumer empowerment and the mechanisms of the free market.


Yesterday’s message discussed the failure of our conservative government stewards, past and present, to move forward with an effective plan that would establish much needed interoperability of the health care IT system throughout the nation. More needs to be said now because the current path will have serious negative consequences for decades to come for our health care delivery system and its patients. And ultimately health care should be all about the patients.

It was mentioned that David Brailer, the first National Coordinator for Health Information Technology, had decided that the system, including interoperability, should be developed in the private sector. In a Quote of the Day message published in 2004 (above), he said that the federal government “will rely on a competitive technology industry, privately operated support services” in the creation of “a national interoperable health care system.”

Rather than repeating here, please read my comment from 7/21/04 (above). The state of the art at that time was the VA’s VistA system. It was owned by us, the people of the United States, and was a far better system at a small fraction of the cost of the systems being privately developed. Most important, the VistA system was designed to benefit patients, whereas the private systems were designed to fulfill entrepreneurial dreams of control and wealth.

A decade later, Philip Verhoef, in the Annals of Internal Medicine, describes the consequences of the decision to place control of electronic health records in the hands of the private sector. As he says, “why do we pay so much more for a privately delivered product that is so much less effective than one developed with taxpayer dollars?” And now, over four years later, the politicians still have learned nothing. (Philip Verhoef is a board member of Physicians for a National Health Program – an organization with a mission dedicated to patients.)

The current National Coordinator for Health Information Technology, Donald Rucker, at a meeting this week said that moving forward towards greater interoperability and usability will be stimulated by consumer empowerment and the mechanisms of the free market. VistA certainly is not a free market creation. Even the Internet was a government creation.

Perhaps the most arrogant comment this week was by the White House’s Jared Kushner who gleefully took credit for the “huge win” in bringing in the private IT vendor Cerner to displace the VistA system at the time that the VistA system was successfully undergoing an upgrade. The “win” is that the VA will copy the Cerner system currently being implemented for the active duty military – a process that has been described as “We took a broken system and just broke it completely.” That’s okay as long as it’s the private sector that gets to break it.

There are some things that the government does better than the private sector, like health IT. The issue is not public versus private, both have a role. The issue is that you do not elect/appoint as your government stewards people who do not believe in government, especially those individuals who support policies that take very good care of the wealthy while leaving the rest of us flat.

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Our incompetent stewards for health IT interoperability

Posted by on Thursday, Mar 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.

‘We took a broken system and just broke it completely’

By Arthur Allen
POLITICO, March 8, 2018

President Donald Trump last year hailed a multibillion-dollar initiative to create a seamless digital health system for active duty military and the VA that he said would deliver “faster, better, and far better quality care.”

But the military’s $4.3 billion Cerner medical record system has utterly failed to achieve those goals at the first hospitals that went online. Instead, technical glitches and poor training have caused dangerous errors and reduced the number of patients who can be treated, according to interviews with more than 25 military and Veterans Affairs health IT specialists and doctors, including six who work at the four Pacific Northwest military medical facilities that rolled out the software over the past year.

Prescription requests came out wrong at the pharmacy. Physician referrals failed to go through to specialists. Physicians were unsure how to do basic things such as request lab reports. Doctors complained it could take 10 minutes to get into the system, which then frequently kicked them out.

“We took a broken system and just broke it completely,” said one doctor, who like most of those interviewed requested anonymity because they lacked military authorization to speak about the project.

These and other problems, particularly concerns about the VA’s ability to share records with civilian health systems, contributed to VA Secretary David Shulkin’s decision in December to delay signing a $10 billion contract to install Cerner at the VA.

Despite the startup issues, which have been glossed over in public discussion of the project, the White House continues to make the overhaul of the military and VA medical records a centerpiece of its government reform efforts.

“This was a huge win for our service,” Jared Kushner told a health IT conference in Las Vegas on Tuesday, referring to Shulkin’s decision last spring to use Cerner following consultations with Kushner’s office. “The president wants to make interoperable health records available for all Americans.”

But Kushner’s comments gave the impression the military had already created an electronic record system, and was just waiting for the VA to connect to it. In fact, the military’s MHS Genesis project, which started rolling out in February 2017, is still in the early stages, with completion scheduled for 2022.

And the tough experiences described by doctors and others suggest a thorny path ahead.

Efficiency promises notwithstanding, the new system has resulted in significant slowdowns so far, said physicians at the two hospitals that went live with MHS Genesis in September and October, respectively. At Bremerton, the system is so cumbersome and confusing that doctors who saw 18 to 20 patients a day now see 12 or 14, they said.

Shulkin’s decision to delay the contract won widespread praise, but critics bemoan his decision last year to shutter an internal program to modernize the VA’s existing digital record system, known as VistA. Many health IT experts left the agency after cancellation of the program, which involved hundreds of staff and contractors.

“We’re doing a once-in-a-lifetime replacement of an … [existing electronic health record system] that’s pretty functional — some of our physicians like it better than Epic or Cerner,” said a recently retired VA official. “Why replace it with something that’s basically the same?”



ONC chief Donald Rucker lays out his agency’s very full plate

By Mike Miliard
Healthcare IT News, March 7, 2018

In an evening session at HIMSS18 on Tuesday, National Coordinator for Health IT Donald Rucker, MD, sat down for a candid talk about an array of issues related to federal healthcare policy.

On what makes interoperability so hard for healthcare:

What makes it hard is that you have to solve for multiple things at once. We have to solve simultaneously for just the physical wiring, the interoperability stack. We have to solve for the simple syntactic standards of data transmission. We have to come to some consensus for semantic interoperability: what was the meaning of what was transmitted. And then finally, we have to deal with the business case. And the business cases are hard to deal with because some of these cases are virtual things in the future, involving competitors, and business models that don’t exist at the present. And if that weren’t enough, we have to do it with privacy and security. That’s what makes it hard.


If we were to fulfill the dream of having immediate Internet access to any prior medical records throughout the nation, it was important that IT systems be interoperable. However, when David Brailer was appointed George W. Bush’s first IT guru, he insisted that the systems be developed in the private sector, rejecting a proven system that we, the taxpayers, already owned – the VA’s VistA system.

It was clear at the time that the private vendors did not want interoperability with any other systems than their own. Each wanted to become the dominant system, Microsoft-style, so that new purchasers of health IT systems would have to go with the dominant vendor to ensure interoperability. As it turns out, there are too many systems, and they are not interoperable. But the Trump administration is now claiming that they will bring interoperability to us, but through the private sector.

So what does the current IT guru, Donald Rucker, have to say about interoperability? He says, “we have to deal with the business case, and the business cases are hard to deal with because some of these cases are virtual things in the future, involving competitors, and business models that don’t exist at the present.” The business case.

In a speech at the same IT conference in Las Vegas this week, Jared Kushner is taking credit for the “huge win” for bringing in the private vendor Cerner to replace the VistA system, saying, “The president wants to make interoperable health records available for all Americans.” Well the interoperability is intended to be between the military’s health IT system and the VA system. He seems to assume that the military system being designed by Cerner is a given, but this report indicates that it has been a disaster and it has hardly even gotten off the ground. And that is going to be duplicated for the VA?

It’s too bad because the VistA system was undergoing modernization when the new administration shut the process down (and lost hundreds of highly competent staff and contractors).

Insisting on private sector solutions for interoperability has been a disaster, just as the private sector has been a disaster in financing of our health care system when a public single payer system would be vastly superior. Is Trump going to put Jared in charge of further privatizing our health care financing? Can hardly wait.

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White House memo on ‘Obamacare Relief Provisions’

Posted by on Wednesday, Mar 7, 2018

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

White House pitch to bolster Obamacare includes tough trade-offs for Democrats

By Paul Demko
POLITICO, March 6, 2018

The White House is seeking a package of conservative policy concessions — some of which are certain to antagonize Democrats — in return for backing a legislative package bolstering Obamacare markets, according to a document obtained by POLITICO.

The source of the document provided to POLITICO isn’t identified and it isn’t dated. The White House declined to comment on the document but didn’t question its authenticity. A spokesperson for HHS said the department does not comment on leaked documents.

Two health policy experts who have been in contact with White House officials indicated that the document is consistent with ideas the administration has discussed for creating more stability and flexibility in the insurance markets.

“It’s legit,” said one former White House policy official.



Unmarked memo purportedly from the White House

Obamacare Relief Provisions Congress Should Pursue

Obamacare has led to skyrocketing premiums and declining choices for American families. Middle-class families, in particular, have seen their premiums and deductibles soar year after year as a result of the law. Although congressional efforts to provide taxpayer money to prop up the exchanges is understandable, any such efforts must also provide relief to middle-class families harmed by the law and protect life. In order to support such efforts, the administration believes these three policies to provide greater choice and control for middle-class families must be included:

* Increase consumer options of more affordable, flexible insurance coverage by clarifying that issuers selling short-term, limited-duration insurance may offer renewals of that coverage to individuals without those individuals going through health underwriting.

* Increase control for middle-class families over their healthcare dollars by expanding Americans’ access to health savings accounts (HSAs). This will enable middle-class families to save pre-tax dollars for their healthcare expenses and help put them back in control of their healthcare. This can be accomplished by raising HSA contribution limits and allowing HSAs to be integrated with a broader number of plans.

* Modify age-rating requirements to permit premium variation of up to 5:1 in the individual and small group markets.

In addition to these three policies, any efforts to provide taxpayer money to stabilize the exchanges must be properly designed so that public dollars do the most good and that ensures all federal dollars are life-protected. The president also supports congressional efforts to fund and life-protect Obamacare’s cost-sharing reduction (CSR) payments after 2018. This would lower premiums for those who purchase their coverage on the exchanges as well as decrease federal spending due to a reduction in the premium tax credit amounts.


This brief memo from the White House seems to be authentic. It lists three policies that the administration says must be included as part of “Obamacare relief provisions” that Congress should pursue.

Perhaps the most alarming must-include policy is making short-term, limited-duration junk insurance renewable without further health underwriting. Since these policies will be almost worthless as far as the benefits they will provide, they will have low premiums and thus be affordable for those who otherwise could not pay for ACA-compliant plans. They may become popular with the perception that these plans would be better than nothing at all, though that is questionable. And making them renewable means that they are no longer limited-duration plans, and thus may become the standard for those who are not eligible for subsidized plans. An increase in personal bankruptcies for those with greater health care needs would be inevitable.

Another must-include policy is expanding “access” to health savings accounts (HSAs), enabling families to “save” pre-tax dollars for their health care expenses. The main difference between an HSA and any other savings account is the tax benefit which is highly regressive since it provides a tax expenditure that is proportional to income. Those who pay no taxes receive no benefit whereas the wealthy receive the most. Also most families with only modest incomes are not able to fund their HSAs. Having access to an empty HSA is of no value. So HSAs really do work for the healthy and wealthy, but not for many of the rest of us who don’t have the funds in the first place.

The third must-include policy is to jack up premiums for older individuals in the individual and small group markets. This may provide some premium relief for the young invincibles, but many older individuals not yet eligible for Medicare will find it very difficult if not impossible to pay premiums that are five times what younger individuals would be paying. This defeats the fundamental insurance function of arranging a transfer from the younger and healthier to the older and more infirm.

One other item in this memo is the recommendation to fund ACA cost-sharing reduction (CSR) payments after 2018. This is not as altruistic as it seems. The CSR payments would reduce the costs to the insurers, allowing them to reduce the premiums thus reducing premium subsidies that the government would be paying. That would help to reduce the federal budget deficit – an important PR move in an election year and the primary reason for this recommendation. But wouldn’t the CSR payments offset that reduction? Simple. Though it is not stated in this particular memo, they have decided to move the CSR payments off-budget, just like they pay for wars.

And about the code language of “life-protected” federal dollars…

Again, the most important item in this memo is that they want to make cheap junk insurance the new standard in the private insurance market – by making it renewable. That would destroy the private insurance markets without providing any other option. The pain inflicted might increase support for a single payer Medicare for all program, but tolerating that much physical and financial suffering is a terrible way to drive the political agenda that we need. Let’s just go to single payer now before more harm is done.

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CMS may be moving forward with Medicare vouchers

Posted by on Tuesday, Mar 6, 2018

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

GOP’s proposed Medicare voucher program would lead to demise of the system

By Max Richtman
The Hill, March 5, 2018

A request for public comment from the Centers for Medicare and Medicaid Services (CMS) has caught the eye of a group of Democratic Senators, alarmed about its implications for the future of Medicare.

In February, 15 Senators sent a letter to CMS Administrator Seema Verma expressing concern over a Fall, 2017 Request for Information (RFI) regarding a “new direction” for Medicare’s Innovation Center — and the agency’s subsequent failure to make public the more than 1,000 comments it received.

At the heart of the Senator’s concerns is ambiguous language in the RFI that suggests a shift toward converting Medicare into a voucher program, which would, “fundamentally restructure the guaranteed benefit traditional Medicare provides to older adults and people with disabilities.”

The Senator’s concerns are well-founded, since Republicans in Congress (most prominently, Speaker Paul Ryan) have long-dreamed of privatizing Medicare by turning it into a voucher system — something that we and other senior organizations adamantly oppose.

Under the GOP’s voucher system, private plans could tailor their benefits to attract the youngest and healthiest seniors, leaving traditional Medicare with older and sicker beneficiaries.

Their higher health care costs would lead to higher premiums that seniors would be unable or unwilling to pay, resulting in a death spiral for traditional Medicare.

This latest action is part of an ideological tilt to the right by CMS under Verma’s leadership — with subversion of traditional Medicare as one of the apparent aims.

The agency has demonstrated a bias toward private Medicare Advantage plans over traditional Medicare.

In the case of the implicit shift toward privatizing Medicare, the 15 Senators suggest that CMS may be breaking the law.

“We believe you are violating statutory requirements to safeguard older adults and people with disabilities from paying onerous out-of-pocket costs and going without needed health care,” says their letter to Verma.

Max Richtman is president and CEO of the National Committee to Preserve Social Security and Medicare.



Centers for Medicare & Medicaid Services: Innovation Center New Direction

Through this informal Request for Information (RFI) the CMS Innovation Center (Innovation Center) is seeking your feedback on a new direction to promote patient-centered care and test market-driven reforms that empower beneficiaries as consumers, provide price transparency, increase choices and competition to drive quality, reduce costs, and improve outcomes.

II. Provisions of this RFI

B. Potential Models

2. Consumer-Directed Care & Market-Based Innovation Models

CMS believes beneficiaries should be empowered as consumers to drive change in the health system through their choices. Consumer-directed care models could empower Medicare, Medicaid, and CHIP beneficiaries to make choices from among competitors in a market-driven healthcare system. To better inform consumers about the cost and quality implications of different choices, CMS may develop models to facilitate and encourage price and quality transparency, including the compilation, analysis, and release of cost data and quality metrics that inform beneficiaries about their choices. CMS will consider new options for beneficiaries to promote consumerism and transparency. For example, beneficiaries could choose to participate in arrangements that would allow them to keep some of the savings when they choose a lower-cost option, or that incentivize them to achieve better health. Models that we are considering testing include allowing Medicare beneficiaries to contract directly with healthcare providers, having providers propose prices to inform beneficiary choices and transparency, offering bundled payments for full episodes of care with groups of providers bidding on the payment amount, and launching preferred provider networks.

5. Medicare Advantage (MA) Innovation Models

CMS wants to work with Medicare Advantage (MA) plans to drive innovation, better quality and outcomes, and lower costs. CMS seeks to provide MA plans the flexibility to innovate and achieve better outcomes. CMS is currently implementing an MA plan model, the Medicare Advantage Value-Based Insurance Design (VBID) model, that provides benefit design flexibility to incentivize beneficiaries to choose high-value services; but this model could be modified to provide more flexibility to MA plans and potentially add additional states. More generally, CMS is interested in more models in the MA plan space and regulatory flexibility as necessary for purposes of testing such models. CMS is potentially interested in a demonstration in Medicare Advantage that incentivizes MA plans to compete for beneficiaries, including those beneficiaries currently in Medicare fee-for-service (FFS), based on quality and cost in a transparent manner. CMS is also interested in what additional flexibilities are needed regarding supplemental benefits that could be included to increase choice, improve care quality, and reduce cost. Additionally, CMS seeks comments on what options might exist beyond FFS and MA for paying for care delivery that incorporate price sensitivity and a consumer driven or directed focus and might be tested as alternatives to FFS and MA.



Letter to Ms. Seema Verma, Administrator, CMS

United States Senate, February 22, 2018


We are writing to express our continued opposition to the concepts unveiled and the process used in a Request for Information (RFI) regarding “a new direction” for Center for Medicare and Medicaid Innovation (Innovation Center). …we continue to urge you to provide clarity on the specific model types under consideration.

In the RFI, CMS appeared to seek input on a possible model to restructure Medicare through a premium support or voucher program. We interpreted the RFI to mean that CMS is considering models that would fundamentally restructure the guaranteed benefit traditional Medicare provides to older adults and people with disabilities. Other Members of Congress, select journalists as well as patient and consumer advocates have expressed a similar interpretation and voiced concerns about the Innovation Center’s intentions.

While we understand that the RFI does not explicitly mention the terms ‘premium support’ or ‘voucher,’ the ambiguity of the proposal allows for a variety of interpretations… Absent further clarification, we do not believe Members of Congress, diverse stakeholders in the health community, and the public were provided a sufficient opportunity to comment on the model concepts outlined in the RFI.

Our concern is compounded by the fact that the proposals under consideration may not allow for Medicare beneficiaries to maintain choice and that beneficiaries may not have the ability to opt out of Innovation Center models.

Additionally, we remain troubled by the Innovation Center’s plans to develop and implement the payment model described as “…allowing Medicare beneficiaries to contract directly with healthcare providers.” We believe you are violating statutory requirements to safeguard older adults and people with disabilities from paying onerous out-of-pocket costs and going without needed care.

Again, we urge you to publicly post RFI comments instead of obfuscating regular process in order to withhold unfavorable comments from public view or decide against responding to certain comments.

Signed, Senators Casey, Nelson, Brown, Whitehouse, Gillibrand, Market, Donnelly, Shaheen, Reed, Warren, Blumenthal, King, Cardin, Menendez, and Smith


Without waiting for Congress to act, the Trump administration is moving forward with policies to shift government health programs to the private sector. The conservatives have long desired to privatize Medicare through premium support (vouchers), and it appears that they have devised a deceptive means of sneaking it in through this Request for Information. We need to watch this process closely, even though it is taking place behind closed doors, lest we find that it is published in the Federal Register and becomes the regulatory law of the land by administrative fiat.

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CMS fails to verify benefits of waivered Medicaid demonstration projects

Posted by on Monday, Mar 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.

As Trump Pushes Medicaid Testing, the Grading Falls Short

By Robert Pear
The New York Times, March 4, 2018

The Trump administration is hoping to transform Medicaid by allowing states to test work requirements, premiums and other conservative policies, but a new government report says federal and state officials do not properly evaluate whether such experiments improve patient care or reduce costs.

Evaluations “generally lacked rigor,” and the findings were often kept secret for years, so they were of little use to policymakers, the Government Accountability Office, a nonpartisan investigative arm of Congress, said in the report issued last month.

Under federal law, the secretary of health and human services can waive certain Medicaid requirements so states can use federal money for the program in ways that would not ordinarily be allowed — for example, to cover people and services that would not otherwise be covered.

These waivers have been used for demonstration projects testing innovative ideas and involving millions of people and tens of billions of federal dollars. The Government Accountability Office said the number and scope of Medicaid waivers had grown in recent years, with demonstration projects now accounting for one-third of all federal Medicaid spending — and more than 75 percent in 10 states, including Texas.

The main purpose of the waivers, according to the report, is to test and evaluate new ways of providing coverage and care to people with modest incomes. But, it said, waivers have become a vehicle for wholesale changes in Medicaid, and neither federal nor state officials adequately assess the results. The evaluations have been plagued by “significant methodological weaknesses” and often leave critical questions unanswered, the report said.

The Trump administration has been flooded with requests from states seeking Medicaid waivers. They want to impose work requirements, charge premiums, suspend coverage for people who fail to pay premiums, and restrict eligibility or benefits in other ways. A few states would like to impose time limits on Medicaid coverage for some beneficiaries.

The Government Accountability Office found particular problems in the evaluation of a Medicaid waiver granted to Indiana. The state expanded Medicaid, as permitted under the Affordable Care Act, but obtained a federal waiver for policies emphasizing “personal responsibility,” including monthly premiums and incentives for healthy behavior.

The federal government wanted to know how Medicaid beneficiaries were affected by those changes, but it could not get the data it needed from the state, so its evaluation was severely limited, the Government Accountability Office said.

Conservatives see Indiana’s Medicaid program as a model, and other states are following suit. The architects of the Indiana plan include Vice President Mike Pence, who was the governor of Indiana from 2013 to January 2017, and Seema Verma, a consultant to the state who is now the administrator of the federal Centers for Medicare and Medicaid Services.


Government Accountability Office; Medicaid Demonstrations:


Success of Pence’s Medicaid expansion far from settled

By Virgil Dickson
Modern Healthcare, July 25, 2016

The success of the conservative approach to Medicaid devised by Indiana Gov. Mike Pence—Donald Trump’s pick for vice president—is a mixed bag so far, according to a report that offers fodder for both sides of the political spectrum.

A new analysis funded by the state shows both positive and concerning elements to Indiana’s alternative Medicaid expansion.

The report also comes as Indiana state officials continue to raise objections to the CMS performing its own analysis to see if Pence’s Medicaid expansion has been harmful to beneficiaries. Pence has argued there is no need for the agency to perform its own evaluation because the state already commissioned a report by the Lewin Group, an independent consultancy.



Trump approves Arkansas Medicaid work requirements

By Nathaniel Weixel
The Hill, March 5, 2018

Arkansas on Monday became the third state to get the Trump administration’s permission to impose work requirements on Medicaid beneficiaries.

The Centers for Medicare and Medicaid Services approved a Medicaid waiver that included a requirement for recipients to work, or participate in job training or job search activities for 80 hours a month.

State officials said they will begin implementing the work requirements June 1, making them the first state to do so. If a person fails to meet the requirements for three months, he or she will lose coverage for the rest of that calendar year.


Section 1115 Medicaid waivers allow states, with the approval of CMS, to establish demonstration projects that waive certain requirements of the Medicaid program as long as the objectives of the program are met. At the end of the waiver period, the results are to be formally evaluated. The GAO report shows us that these evaluations “lack rigor” and have not been released to provide important research results to the policy community.

Particularly important was the evaluation of the Indiana Medicaid waiver since it put into effect the conservative ideological preferences of Gov. Mike Pence (now vice-president) and Medicaid consultant Seema Verma (now CMS administrator). They contracted for a private study by the Lewin Group while fighting off a CMS evaluation. That is important because they both have touted the great advantages of their patient-empowerment Medicaid program when there is virtually no objective public data to show benefit – only the biased (and not all that impressive) report purchased from the Lewin Group.

Today, Arkansas followed Kentucky and Indiana to become the third state to be granted work requirements for Medicaid beneficiaries – a policy move based on conservative ideology rather than on patient benefit. We can anticipate a further expansion of anti-welfare warfare by the current administration.

When health care coverage is eventually expanded to cover everyone, it will be important to avoid segregating low-income individuals and families into an isolated welfare program. Such a program would always be vulnerable to attacks from anti-government political ideologues. Instead we need a universal egalitarian program that treats everyone fairly – a national single payer improved Medicare for all.

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Americans already believe that everyone should have the right to affordable health care

Posted by on Friday, Mar 2, 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.

Americans’ Views on Health Insurance at the End of a Turbulent Year

By Sara R. Collins, Munira Z. Gunja, Michelle M. Doty, Herman K. Bhupal
The Commonwealth Fund, March 1, 2018

The Commonwealth Fund Affordable Care Act Tracking Survey interviewed a random, nationally representative sample of 2,410 adults ages 19 to 64 between November 2 and December 27, 2017.

Do you think all Americans should have the right to affordable health care?

92% – Yes
7% – No
1% – Don’t know/Refused

Asked of the 8% who said no or don’t know/refused:

What if everyone had to contribute financially over their lifetime in order to have the right to affordable health care? Under those circumstances would you consider affordable health care to be a right?

29% – Yes
58% – No
13% – Don’t know/Refused

From the Policy Implications:

This survey’s finding that strong majorities of U.S. adults, regardless of party affiliation, believe that all Americans should have a right to affordable health care suggests there may be popular support for a discussion over our preferred path.


It has often been said that we cannot enact single payer Medicare for all until Americans agree that health care is a right. This survey shows that 94 percent of adults under 65 already agree that “all Americans should have the right to affordable health care.” Most of those over 65 already have it.

Let’s move on. We have work to do.

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The Kerner Commission 50 years later

Posted by on Thursday, Mar 1, 2018

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

The Unmet Promise of Equality

By Fred Harris and Alan Curtis
The New York Times, February 28, 2018

“Our nation is moving toward two societies, one black, one white – separate and unequal.”

Fifty years ago, on March 1, 1968, these were the grim words of the National Advisory Commission on Civil Disorders, called the Kerner Commission after its chairman, Gov. Otto Kerner of Illinois.

President Lyndon Johnson had established the commission to examine the disorders and violent protests in Detroit, Newark and well over 100 other American cities during the summer of 1967, and earlier. What it found was searing. “What white Americans have never fully understood – but what the Negro can never forget – is that white society is deeply implicated in the ghetto,” the commission concluded. “White institutions created it, white institutions maintain it, and white society condones it.”

The Kerner Commission recommended “massive and sustained” investments in jobs and education to reduce poverty, inequality and racial injustice. Have we made progress in the last 50 years?

A Return to Segregation

In many ways, things have gotten no better — or have gotten worse — since 1968. Public schools have been re-segregating for decades.

Inequality That Would Shock the Commission’s Members

The disheartening percentage of Americans living in extreme poverty — that is, living on less than half the poverty threshold — has increased since the 1970s.

The Tragedy of Mass Incarceration

At the time of the Kerner Commission, there were about 200,000 people behind bars. Today, there are about 1.4 million. Mass incarceration has become a kind of housing policy for the poor.

Fifty Years Later, We’ve Figured Out What Works

Policies based on ideology instead of evidence. Privatization and funding cuts instead of expanding effective programs.

We’re living with the human costs of these failed approaches. The Kerner ethos — “Everyone does better when everyone does better” — has been, for many decades, supplanted by its opposite: “You’re on your own.”

Today more people oppose the immorality of poverty and rising inequality, including middle-class Americans who realize their interests are much closer to Kerner priorities than to those of the very rich.

We have the experience and knowledge to scale up what works. Now we need the “new will” that the Kerner Commission concluded was equally important.

What Doesn’t Work and What Does

The Economic Playing Field

Doesn’t – Reduced health care for workers and low-income Americans
Does – Insured health care through a single-payer system

Doesn’t – Small, grudging increases to minimum wage
Does – Substantial increases to minimum wage

Doesn’t – No new tax credits or child allowances
Does – Expansion of the Earned Income Tax Credit to reduce gaps in wealth and income

Doesn’t – Supply-side, trickle-down economics for the rich and corporations; enterprise zones with corporate tax breaks
Does – Demand-side, full-employment Keynesian economics for all Americans

(Use the link to view what doesn’t and does work in the other categories of Jobs, Education, Housing, and the Justice System.)

Fred Harris, a former senator from Oklahoma, is a professor emeritus of political science at the University of New Mexico and the lone surviving member of the Kerner Commission. Alan Curtis is the president and chief executive of the Eisenhower Foundation, the private-sector continuation of the 1968 Kerner Commission and the 1969 National Violence Commission. The two are the co-editors of “Healing Our Divided Society: Investing in America Fifty Years After the Kerner Report.”


There was some good news following the release of the Kerner Commission report half a century ago and that was that the nation made gains in addressing some of the social injustices described in the report. The bad news is that we have since regressed and in some ways are worse off, especially considering the negative consequences of the massive shift to greater inequality in income and wealth.

When you access the article through the link above, the tragic backsliding becomes obvious when glancing at the graphs presented.

However, there is a potential for good news in the future if we listen to the authors of this article – Fred Harris, the lone surviving member of the Kerner Commission, and Alan Curtis, the chief executive of the Eisenhower Foundation. In a table they show us what we have learned about what doesn’t work and what does. Social justice advocates will recognize that they have organized the basics.

One category – the economic playing field – is reproduced above. Single payer advocates do not need an explanation as to why the very first item listed that does work is “insured health care through a single-payer system.” But the other items in the original article are very important as well. That is why it is not enough to limit our advocacy to the one issue of single payer reform, even though that remains the mission of PNHP. We all have to work together in coalition efforts to move forward with the other policies that do work in order to achieve a more just and equitable society – one in which we all do well.

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Expect more fragmentation of our dysfunctional health care system

Posted by on Wednesday, Feb 28, 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.

A Big Divergence Is Coming in Health Care Among States

By Margot Sanger-Katz
The New York Times, February 28, 2018

Little by little, the Trump administration is dismantling elements of the Affordable Care Act and creating a health care system that looks more like the one that preceded it. But some states don’t want to go back and are working to build it back up.

Taken together, experts say, the administration’s actions will tend to increase the price of health insurance that follows all the Affordable Care Act’s rules and increase the popularity of health plans that cover fewer services. The result could be divided markets, where healthier people buy lightly regulated plans that don’t cover much health care, lower earners get highly subsidized Obamacare — and sicker middle-class people  face escalating costs for insurance with comprehensive benefits.

But not everywhere. Several states are considering whether to adopt their own versions of the individual mandate, Obamacare’s rule that people who can afford insurance should pay a fine if they don’t obtain it. A few are looking to tighten rules for short-term health plans. Some states are investing heavily on Obamacare outreach and marketing, even as the federal government cuts back.

The result is likely to be big differences in health insurance options and coverage, depending on where you live. States that lean into the changes might have more health insurance offerings with small price tags, but ones that are inaccessible to people with health problems and don’t cover major health services, like prescription drugs. States pushing back may see more robust Obamacare markets of highly regulated plans, but the price of those plans is likely to remain higher.

The Affordable Care Act was drafted with room for state customization, but one of its primary goals was to make health insurance around the country more uniform. Thanks to state resistance to the health law, varying local conditions and a Supreme Court decision that made the Medicaid expansion optional, results have been much more uneven. Some states have seen much bigger reductions in the share of the uninsured than others. Only some states have seen insurance premiums stabilize.

“Without question I think we’re going to see a natural experiment in the states and a growing divergence in outcomes,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute.



Finally, a universal healthcare proposal that would work for everyone

By Michael Hiltzik
Los Angeles Times, February 27, 2018

But now take a look at “Medicare Extra for All.”

It’s not single-payer, exactly, but only single-payer dead-enders could object to its payer provisions. It’s the best solution to the realities, politics and drawbacks of the U.S. health insurance system yet to appear, and the time to start pushing it is now.


We should have learned something from the history of health care reform in this nation since we now have by far the most expensive system but the least efficient considering our deficiencies in coverage, access, equity and affordability. So where are we headed?

With the states assuming greater leadership in reform, we can anticipate more of the same with variations – more fragmentation, more administrative excesses, more financial barriers to care, more restrictions in choice of health care professionals, more destabilization of health care coverage – this and more with a failure to control health care spending.

The article by Margot Sanger-Katz describes well the divergence in approaches by the various states, with the best states falling miserably short on application of optimal health policy, whereas other states will perpetuate and possibly expand disastrous policies which can negatively impact the personal finances and health of their residents.

Although there has been an increase in public support for single payer reform, attention is being diverted to proposals such as CAP’s Medicare Extra for All – a proposal that has stolen the single payer rhetoric in order to sell a “politically feasible” public option that protects the private insurance industry. The media have totally bought into the rhetoric. Even highly-respected, progressive Los Angeles Times columnist Michael Hiltzik says that “the time to start pushing it is now,” as he dismisses us as “single-payer dead-enders.” Ouch!

Again, we have to change the politics, but we can’t sell out on policy on our way to health care nirvana.

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