By Lexi Churchill
ProPublica, October 31, 2019

In early August, Elizabeth Petersen was home-schooling her children in the kitchen of their northern Idaho home when she got a call from Providence Sacred Heart Medical Center, where her 4-year-old son, Paul, was set to have surgery a few weeks later.

Since having a stroke around his first birthday, Paul had been under treatment to restore use of the right side of his body. He had recently graduated from a feeding tube and needed surgery to close a hole in his stomach.

The hospital’s surgery department reached out to alert the family that Paul was no longer covered by Medicaid. Petersen broke down in tears, knowing she could not afford the surgery without the government health insurance.

“I was shocked to hear it,” Petersen said.

Petersen’s anxiety grew after she called the state Medicaid agency to find out why Paul was abruptly cut from coverage before her son was due for his reevaluation. The agency employee insisted Petersen had failed to meet an annual deadline for reporting detailed financial information — which Petersen contends she knew nothing about.

Families like the Petersens are wrestling with administrative burdens that are one reason more than 1 million children across the country are no longer covered by Medicaid and the Children’s Health Insurance Program, two government-run programs for low-income children. It is the first enrollment decline in a decade.

States across the country have implemented updated paperwork requirements, but Idaho is the first to attribute its new administrative burdens to direct instructions from the Centers for Medicare and Medicaid Services under the Trump administration.

CMS has promoted safeguards to help catch improper payments to ineligible recipients. In Idaho, this meant a major change to procedures that it established in the Obama years. Idaho led the nation in allowing Medicaid recipients to renew coverage automatically, without requiring additional documentation, but CMS has deemed some of the state’s procedures inadequate.

Idaho’s changed requirements have ensnared in red tape many recipients who have no income or are self-employed.

The Affordable Care Act, the Obama administration’s landmark health care policy overhaul, required states to modernize eligibility procedures, and state Medicaid agencies began developing IT systems that could automatically verify recipients’ income. New technology allowed states to avoid asking recipients for new annual paperwork by comparing their reported incomes with state and federal income data.

If the eligibility system found contradictions, the state could then ask for more information. When the data confirmed that recipients’ income fell below the cut off, the systems could automatically renew their coverage without paperwork hassles. This is also called an “ex parte” renewal.

Jennifer Wagner, a senior policy analyst at the Center on Budget and Policy Priorities in Washington, said the shift to verifying income electronically removes many bureaucratic hoops that can penalize qualified recipients unfairly if “they didn’t receive a document, they didn’t send in the right information or the state is overwhelmed and failed to process that renewal timely.”

Many parents learned from their child’s medical provider that they had been dropped from coverage. Others received a final notice informing them they’d been dropped, though they said they never received the initial paperwork.

Many who did receive notices were confused, since the new forms did not clearly explain the changed requirements.

Many state and federal administrators chalked up the trend to an improved economy, which may have helped boost residents’ income so they no longer qualified for Medicaid or led them to jobs with private insurance.

However, the latest census insurance data released in September made clear that a healthier economy was not a blanket reason for declines. As the number of recipients enrolled in Medicaid and CHIP dipped, the number of uninsured residents rose. Meanwhile, those with private insurance coverage remained virtually the same.

Advocates have pointed to a number of Trump administration policies that have driven former recipients away from Medicaid and CHIP. One of the most commonly discussed proposals is the “public charge” rule, which would count immigrants’ reliance on public programs against them if they apply for a green card.

State-driven processes have also contributed. Minnesota’s Medicaid agency recently sent recipients a new form asking for permission to verify their assets, giving them a few weeks to respond before coverage was suspended. The majority of the 70,000 recipients who lost coverage in Missouri in 2018 were removed after failing to return the mailed renewal form.

The Affordable Care Act instructs states to officially renew recipients once a year unless there is a change in circumstances. Under the Trump administration, CMS has encouraged Medicaid agencies to look for those changes more frequently.

For the remaining recipients affected by the change, often the state’s poorest residents who report having no income and the self-employed, CMS does not yet see any reasonable way to confirm their eligibility without requiring additional paperwork.

https://www.propublica.org…

---

Comment:

By Don McCanne, M.D.

The Trump administration has frequently stated that they want to reduce the administrative hassles in our health care financing system. Yet they are increasing administrative complexity for Medicaid beneficiaries which seems to have contributed to the fact that more than a million children are no longer covered by Medicaid and the Children’s Health Insurance Program.

The health care financing system should be designed to help people get the health care that they need. Now we have a system that erects administrative and financial barriers to that care.

If the Trump administration really did care they should adopt a system that greatly reduces administrative complexity and provides automatic equitable financing that would ensure that everyone would have the care they need, such as a single payer Medicare for All program. Instead they use rhetoric such as “Medicare for All means Medicare for none.”

A million children. We should blame ourselves since we have failed to elect government stewards with a heart and a soul. If we can get that right, the rest should follow.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Aaron Carroll, M.D.
JAMA Forum, October 30, 2019

As “Medicare for all” gains steam in the Democratic primary, many physicians are concerned about reduced revenues from the program compared with private insurance. Even an expansion of the program, as many candidates’ plans call for “Medicare for more,” causes angst. Inevitably, some physicians will threaten to opt out of Medicare and refuse to see patients.

Such calls are, for the most part, bluffs. We need only examine how many physicians have followed through on past threats to see that.

For years, the Association of American Physicians and Surgeons claims that it’s simpler for physicians to opt out of Medicare than to stay in. Physicians have not been listening.

It’s important to understand that even when physicians threaten to opt out periodically, very few ever do. In 2010, for the first time ever, the number of physicians who had officially opted out of the program with the Centers for Medicare & Medicaid Services (CMS) reached triple digits—a total of 130. That’s out of the 850 000 or so licensed physicians in the United States that year.

The Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, made it easier for physicians to get out if they wanted to. Before that, physicians needed to re-file with the program every 2 years. After 2015, however, opt-outs could be permanent, lasting until physicians filed affidavits to opt in again. With that, opt-outs climbed to their historically highest level in 2016. Even then, though, there were only 7400.

That number represents fewer than 1% of physicians. And, as a Kaiser Family Foundation infographic in JAMA pointed out, more than 40% of them were psychiatrists.

Today, CMS updates its data on physicians who opt out of Medicare quarterly, and the list of clinicians who have filed affidavits is easily accessed online. As of October 2019, psychiatrists, 3911 of them, remain—by far—the largest group of physicians who choose not to participate in Medicare. They’re followed by clinical psychologists, dentists, oral surgeons, and clinical social workers.

Recently, a study in the Journal of General Internal Medicine delved deeper into the population of psychiatrists who opt out of Medicare. The authors found significant variation in where psychiatrists who opted out practiced. In more than a third of hospital referral regions, none did. California and New York had the highest opt-out rates, but even there, the averages across the state were only 10% and 13% respectively.

Older psychiatrists (those 65 years or older) were most likely to opt out, as were those who identified as female. Those who graduated from a top-20 ranked institution were more likely to leave, and those who graduated from a foreign medical school were much less likely to do so. Perhaps most significantly, psychiatrists were more likely to opt out when there was little competition in their geographic area.

Still, there’s a general sense that we have a shortage of mental health services, including for elderly patients, and it’s not optimal that so many physicians who might see them have chosen not to do so for Medicare beneficiaries. But more concerning are physicians who might serve in a primary care capacity.

There, the numbers who refuse are smaller. Family medicine has only 1544 physicians who opt out. Internal Medicine has only 1003.

Of course, even if physicians choose not to fully opt out of Medicare, they may elect not to accept new patients. A Kaiser Family Foundation analysis (excluding pediatricians) found that only 72% of primary care doctors were willing to accept new patients with Medicare in 2015. Of course, only 80% were willing to accept new patients with private insurance.

Given the overwhelming number of physicians who accept Medicare, it’s ironic that so many people think that they’ll have an easier time finding a physician if they have private insurance coverage. One of the most common ways that private insurance reduces its cost is by establishing networks, and then steering their beneficiaries to physicians in them. Usually, the cheaper the plan, the smaller the network.

Medicare Advantage, the privatized optional form of Medicare, has fewer options than traditional Medicare. Another Kaiser Family Foundation analysis showed that networks of Medicare Advantage plans included, on average, fewer than half of physicians in any county. Too few patients realize this. Even when they do, research shows that they have trouble figuring out which doctors they can really see.

There are plenty of reasons to be concerned about a transition to a Medicare-for-all type of system in the United States. Any big transition, even if it wound up being better than what we had before, would likely cause major disruption. But a mass exodus of doctors from Medicare is unlikely. Physicians need to see patients, and in such a system, all the patients would be covered by one carrier.

Even in a “Medicare for more” system, evidence from the past shows us that the vast majority of physicians are likely to remain. The ones who won’t may be more vocal, but they’ll be the exception, not the norm.

https://newsatjama.jama.com…

---

Comment:

By Don McCanne, M.D.

Some opponents of single payer Medicare for All claim that there would be a mass exodus of physicians if a universal, single payer version of Medicare were enacted and implemented as the sole payment source for health care in America. Aaron Carroll explains why this is highly unlikely.

These predictions fail to understand the nature of the physician. From the earliest days that students decide that they want to become physicians, they know that they are planning to enter a profession (not a “business”) that is dedicated to caring for patients. It is not as if they would try to give this a go and if they didn’t like it they could move on to some other business venture. This isn’t to say that there aren’t those who may identify lucrative opportunities within health care and align themselves in that direction. But even there, the primary concern of the physician (not the medical-industrial complex) would remain the delivery of health care for the benefit of the patient.

It is often claimed that under Medicare for All prices would be reduced to Medicare rates (some proposals even specify this) and that they are too low to sustain physician interest in continuing to work in the profession. First of all, the classic single payer model calls for negotiation of fees or capitation rates. The public stewards would balance their role in preventing overpayment that might excessively enhance the wealth of the physicians, with providing enough monetary resources to ensure adequate capacity in the system while at the same time providing fair margins for the physicians.

But let’s assume that the payment level is at the current Medicare prices. Would that really be too low to sustain physicians’ practices? There would be increased revenues since physicians would no longer have nonpaying charity cases – the system would cover those patients – and there would no longer be unpaid accounts or patient bankruptcies due to uninsured patients being unable to pay their bills. Also there would no longer be losses due to the inability to collect deductibles, coinsurance and copayments since they would go away. More importantly, the profound administrative burden placed on physicians would be lifted under a single payer system, and, assuming the same payment rates, those exorbitant administrative costs would be recovered. For most practices that would be more than enough to fill in the difference between Medicare payment rates and commercial insurance payment rates. Also the experiences in other nations have shown that there is not a net reduction in compensation with expansion of their systems to cover almost everyone.

The predicted physician exodus under Medicare for All is not just a bluff, it is a total myth.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Elizabeth Warren
Medium, November 1, 2019

There are two absolute non-negotiables when it comes to health care:

One: No American should ever, ever die or go bankrupt because of health care costs. No more GoFundMe campaigns to pay for care. No more rationing insulin. No more choosing between medicine and groceries.

Two: Every American should be able to see the doctors they need and get their recommended treatments, without having to figure out who is in-network. No for-profit insurance company should be able to stop anyone from seeing the expert or getting the treatment they need.

Health care is a human right, and we need a system that reflects our values. That system is Medicare for All.

The best way to fight misinformation is with facts. That’s why today, I’m filling in the details and releasing a plan that describes how I would implement the long-term policy prescriptions of the Medicare for All Act and how to pay for it.

Under my plan, Medicare for All will cover the full list of benefits outlined in the Medicare for All Act, including long-term care, audio, vision, and dental benefits. My plan will cover every single person in the U.S., and includes common-sense payment reforms that make Medicare for All possible without spending any more money overall than we spend now.

Option 1: Maintain our current system, which will cost the country $52 trillion over ten years. And under that current system –

• 24 million people won’t have coverage, and millions can’t get long-term care.
• 63 million have coverage gaps or substandard coverage that could break down if they actually get sick. And millions who have health insurance will end up going broke at least in part from medical costs anyway.
• Together, the American people will pay $11 trillion of that bill themselves in the form of premiums, deductibles, copays, out-of-network, and other expensive medical equipment and care they pay for out-of-pocket — all while America’s wealthiest individuals and biggest companies pay far less in taxes than in other major countries.

Option 2: Switch to my approach to Medicare for All, which would cost the country just under $52 trillion over ten years. Under this new system –

• Every person in America — all 331 million people — will have full health coverage, and coverage for long-term care.
• Everybody gets the doctors and the treatments they need, when they need them. No more restrictive provider networks, no more insurance companies denying coverage for prescribed treatments, and no more going broke over medical bills.
• The $11 trillion in household insurance and out-of-pocket expenses projected under our current system goes right back into the pockets of America’s working people. And we make up the difference with targeted spending cuts, new taxes on giant corporations and the richest 1% of Americans, and by cracking down on tax evasion and fraud. Not one penny in middle-class tax increases.

That’s it. That’s the choice. A broken system that leaves millions behind while costs keep going up and insurance companies keep sucking billions of dollars in profits out of the system — or, for about the same amount of money, a new system that drives down overall health costs and, on average, relieves the typical middle class families of $12,400 in insurance premiums and other related health care costs.

No middle class tax increases. $11 trillion in household expenses back in the pockets of American families. That’s substantially larger than the largest tax cut in American history.

---

America’s middle class is facing a crisis. For a generation, wages have remained largely flat while family costs have exploded. I’ve spent decades sounding the alarm about it. I’m running for President to fix it. That means doing whatever we can to reduce the overall strain on family budgets.

Medicare for All can be a huge part of the solution. When fully implemented, my approach to Medicare for All would mark one of the greatest federal expansions of middle class wealth in our history. And if Medicare for All can be financed without any new taxes on the middle class, and instead by asking giant corporations, the wealthy, and the well-connected to pay their fair share, that’s exactly what we should do.

https://medium.com…

---

Comment:

By Don McCanne, M.D.

Elizabeth Warren’s proposal for Medicare for All is helpful because it shows us that we can provide affordable, comprehensive care for everyone without increasing taxes on the middle class. That is possible because of the efficiency features of the single payer model and because income and wealth inequality have provided a revenue source accessible though equitable tax policies.

Like Bernie Sanders, she is advancing a bona fide single payer model of Medicare for All. That is in sharp contrast with those models that perpetuate the current system, including the ACA exchanges, with the addition of a public option such as a Medicare buy-in. An even sharper contrast is found in the models that would begin to disassemble what programs we do have, shifting more of the costs to the patient even if clearly unaffordable. The status quo/public option models leave major deficiencies in place, whereas the models that merely unravel our system leave the majority worse off.

Providing a 44 page explanation of her Medicare for All proposal certainly gives Elizabeth Warren’s opponents plenty of nits to pick. You can almost hear the sound bites already. What is important is that essentially everyone will be better off except that the wealthy are already receiving all the care they need or want. It is true that they might suffer some angst when they look at what would likely be not much more than a footnote on their personal financial statements, but that seems to be a small price to pay for health care justice for all.

PNHP has a mission to educate colleagues and the public at large on single payer health reform, but the organization does not endorse any candidates for political office.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Michelle Andrews
Kaiser Health News, October 29, 2019

Everything old is new again. As open enrollment gets underway for next year’s job-based health insurance coverage, some employees are seeing traditional plans offered alongside or instead of the plans with sky-high deductibles that may have been their only choice in the past.

Some employers say that, in a tight labor market, offering a more generous plan with a deductible that’s less than four figures can be an attractive recruitment tool. Plus, a more traditional plan may appeal to workers who want more predictable out-of-pocket costs, even if the premium is a bit higher.

That said, consumer-directed plans are hardly disappearing. Fifty-eight percent of covered employees worked at companies that offered at least one high-deductible health plan in 2019, according to an annual survey of employer health benefits released by the Kaiser Family Foundation last month. That was second only to the 76% of covered workers who were at firms that offered a PPO plan.

According to the survey by the National Business Group on Health, employers that opted to add more choices to what they offered employees typically chose a traditional PPO plan. Members in these plans generally get the most generous coverage if they use providers in the plan’s network. But if they go out of network, plans often cover that as well, though they pay a smaller proportion of the costs. For the most part, deductibles are lower than the federal minimum for qualified high-deductible plans.

https://khn.org…

---

Comment:

By Don McCanne, M.D.

High deductibles have been a major contributor to underinsurance – exposing individuals and families to financial hardship in spite of being enrolled in an insurance plan. This article indicates that employers are recognizing that offering only high-deductible plans to their employees is no longer wise and thus they are again offering PPO plans that have lower patient cost sharing and some limited out-of-network coverage. This reintroduction of better coverage may not represent altruistic employer concern for the employees but rather merely the recognition of the need to offer better health benefits in a tighter labor market.

Although this may reduce the intensity of the degree of underinsurance, it does not eliminate it. Many individuals find PPO cost sharing to be unaffordable as well. Also PPOs perpetuate the deficiencies of our multi-payer health care financing system, especially the profound administrative waste.

Taking a step back into a system that already cried out for reform does not get business off the hook. They really need to join the bandwagon for a model that would ensure comprehensive, affordable health care for all of their employees and everyone else. Businesses should seriously consider joining the campaign, “Business for Medicare for All,” led by Richard Master and Wendell Potter:

https://www.businessformedicareforall.org

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

The Commonwealth Fund, The New York Times, Harvard T.H. Chan School of Public Health, October 2019

Reforming the U.S. health insurance system has become a major issue in the upcoming presidential election, both in primaries and likely in the general election. There are a number of different health care reform proposals that have been put forth by candidates and parties, but prior studies show that voters in the general public are often not aware of the details of these plans. This suggests that the differentiation voters make between one plan and another is likely based on underlying values, beliefs, and life experiences. This report addresses specifically adults’ views in these three areas, as they relate to health insurance reform proposals supported by the public.

One of the issues that has emerged in recent polling on health insurance reform is that people often report they support more than one type of plan, even though these plans are often very different from each other from a policy perspective. This poll seeks to examine this issue by asking people who are interviewed to choose the plan that they most favor among the three major plans that are being debated currently: (1) Medicare-for-all, (2) improving the existing Affordable Care Act (Obamacare), or (3) replacing the Affordable Care Act with a new law that would give taxpayer funding to states to design their own health insurance systems with fewer federal rules.

Conclusions

This report examines Americans’ current beliefs, values, and experiences, according to their preferences on three major proposals for national health reform. The results point to significant conclusions, which are timely given the importance of health care as an upcoming issue in the Democratic primaries and the 2020 presidential election.

We polled Americans’ values and beliefs across seven different areas: the preferred role of government generally, the preferred role of government in health care, attitudes toward the current U.S. health care system, views on equal treatment in health care, personal experiences with health care, views on the future desired direction of health insurance reform, and public trust in groups trying to improve the U.S. health care system.

Notably, none of the three policies received a majority of Americans’ support as their most-favored plan, suggesting major divisions in preferences on the future of health insurance reform. We found the greatest differences in public opinion are the preferred role of government in health care, attitudes toward the current U.S. health care system, and views on increasing taxes so everyone can have health insurance. Proponents of all three plans showed the greatest similarities in shared values for equality in health care and trust in similar groups trying to improve health care, as well as their personal experiences.

Overall, Americans who prefer Medicare-for-all and those who prefer improving the existing ACA share similar views in several areas that lie in contrast to the views of those who favor replacing the ACA with state health plans. However, proponents of Medicare- for-all and improving the existing ACA also differ in important ways. They are split in their views of the economy, where a slight majority of adults who favor improving the existing ACA have a positive image of capitalism, while a majority of adults who favor Medicare-for-all have a positive image of socialism. Meanwhile, two-thirds of Medicare- for-all proponents prefer more federal government involvement in health care, compared to only a slight majority of proponents of improving the existing ACA. In addition, about two-thirds of adults who favor improving the existing ACA hold favorable opinions about private health insurance provided by employers, compared to only about half of adults favoring Medicare-for-all who share this view.

Among all three groups, there are dramatic differences in views on the preferred role of government involvement in health care. While more than eight in ten adults who favor Medicare-for-all and more than seven in ten adults who favor improving the existing ACA say they think it is the responsibility of the government to make sure all Americans have health insurance coverage, only one in five adults who favor replacing the ACA with state health plans say this. More than seven in ten adults who favor Medicare-for-all and a majority of adults who favor improving the existing ACA prefer a health insurance system run mostly by the government, while only about one in seven adults who favor replacing the ACA with state health plans prefer this approach.

Americans are also divided in their attitudes toward the current U.S. health care system, by their preferences for health reform. While large majorities of adults who are proponents of improving the existing ACA and Medicare-for-all hold favorable opinions of the Affordable Care Act, three-quarters of adults who are proponents of replacing the ACA with state health plans hold unfavorable opinions about it. This suggests major divisions in public opinion, both in how the U.S. health care system is currently operating, as well as the path forward.

Americans also hold opposing views according to their preferences for health reform about increasing taxes so everyone can have health insurance. While large majorities of adults who favor Medicare-for-all and improving the existing ACA favor increasing taxes so everyone can have health insurance, seven in ten adults who favor replacing the ACA with state health plans oppose tax increases.

When it comes to equal treatment in U.S. health care, large majorities of adults favoring all three approaches to health reform share views that while equal treatment is not a current reality, it is an important goal. Americans generally share views on the importance of equal treatment, regardless of income or race.

When it comes to public trust in various groups trying to improve the U.S. health care system, Americans favoring all three plans generally do not trust any interest major groups, with the exception of nurses. This suggests that if outside groups are to play an important role in shaping the future of health reform, they will need to coalesce around a shared vision of what it should look like.

In addition, we found that people’s personal experiences, though important to individuals, do not generally drive opinions about preferences for health reform. While a greater share of adults who favor Medicare-for-all express concerns about health care costs and health care access compared to those who favor improving the existing ACA and those who favor replacing the ACA with state health plans, large majorities of adults preferring all three plans say they are satisfied with their current health insurance coverage.

As we look ahead to the debate over national health insurance reform, it is clear that Americans’ viewpoints on health care issues are heavily driven by their basic beliefs and values. Medicare-for-all is a powerful issue in the Democratic primary, but for Americans who are Republicans or Independents, this approach to health insurance reform does not resonate the same way. These Americans are split in preferences between improving the existing ACA and developing other alternatives.

---

The following responses are grouped based on the plan most preferred by individual respondents:

• Plan A: Medicare for All
• Plan B: Improving the Affordable Care Act
• Plan C: Give taxpayer funding to states to design their own health insurance systems

Q12. In the future, how involved do you think the federal government should be in health care? Should it be (more involved), (less involved), or about as involved as it is now?

• Plan A: 67% MORE involved
• Plan B: 54% MORE involved
• Plan C: 65% LESS involved

Q13. Do you think it is the responsibility of the government to make sure all Americans have health insurance coverage, or is that not the responsibility of the government?

• Plan A: 85% Responsibility
• Plan B: 73% Responsibility
• Plan C: 76% NOT responsibility

Q14. Do you favor or oppose increasing taxes on higher income people so everyone can have health insurance?

• Plan A: 84% Favor
• Plan B: 76% Favor
• Plan C: 70% OPPOSE

Q15. Would you personally be willing or unwilling to pay more in taxes so that everyone can have health insurance in the U.S.?

• Plan A: 79% Willing
• Plan B: 67% Willing
• Plan C: 74% UNWILLING

Q16. Which of the following approaches for providing health insurance in the United States would you prefer–a health insurance system (run mostly by the government), or a system (based mostly on private health insurance)?

• Plan A: 73% Run mostly by the government
• Plan B: 55% Run mostly by the government
• Plan C: 84% Mostly PRIVATE HEALTH INSURANCE

Q27. Do you think all Americans should have a right to health care regardless of ability to pay, or not?

• Plan A: 94% Should have right
• Plan B: 91% Should have right
• Plan C: 60% Should have right

Q29. How important is it to you that all Americans be treated equally in terms of the health care they receive? Very important, somewhat important, not too important, not important at all?

• Plan A: 97% Very or somewhat important
• Plan B: 98% Very or somewhat important
• Plan C: 88% Very or somewhat important

Q30. How important do you think it is that poor American families receive the same quality of health care as rich American families? Is it very important, somewhat important, not too important, or not at all important?

• Plan A: 98% Very or somewhat important
• Plan B: 98% Very or somewhat important
• Plan C: 90% Very or somewhat important

Q31. How important do you think it is that African Americans receive the same quality of health care as white Americans? Is it very important, somewhat important, not too important, or not at all important?

• Plan A: 99% Very or somewhat important
• Plan B: 99% Very or somewhat important
• Plan C: 92% Very or somewhat important

Q32. How much do you trust each of the following groups when it comes to trying to improve the U.S. health care system? How about (INSERT ITEM)? Do you trust them a great deal, a fair amount, not very much, or not at all?

• g. Pharmaceutical companies
• • Plan A: 70% Not very much or not at all
  • Plan B: 72% Not very much or not at all
  • Plan C: 78% Not very much or not at all
• h. Health insurance companies
• • Plan A: 67% Not very much or not at all
  • Plan B: 64% Not very much or not at all
  • Plan C: 53% Not very much or not at all
• i. The federal government
• • Plan A: 48% Not very much or not at all
  • Plan B: 47% Not very much or not at all
  • Plan C: 70% Not very much or not at all

https://cdn1.sph.harvard.edu…

---

Comment:

By Don McCanne, M.D.

This survey confirms, once again, that Americans are divided over the role that government should play in financing our health care system. Those favoring a greater role for government are divided between improving the Affordable Care Act or replacing it with Medicare for All. Those opposing government involvement would prefer that states design their own systems, and they are unwilling to pay more taxes to fund health care.

What is interesting is that those opposed to a greater government role nevertheless do support health care justice in that they agree that health care should be a right regardless of ability to pay, that all Americans be treated equally in terms of the health care that they receive, that poor American families receive the same quality of health care as rich American families, and that African Americans receive the same quality of health care as white Americans.

The report confirms that Democrats are split between the two options of Medicare for All or expanding the Affordable Care Act, Republicans favor turning health care over to the states, and Independents are divided between the three options.

Thus there is a conflict between concepts of health care justice which are supported by all and the three options for reforming health care. Only a single payer Medicare for All program would accomplish the listed goals of social justice. The Republicans have been stumbling around with proposals that would actually further suppress health care justice, while Independents and moderate Democrats support the model we already have that still falls far short of health care justice for all.

Which really is more important? Health care justice for all? Or holding fort in your ideological camp? We are accomplishing the latter but not the former. Shouldn’t we reverse our priorities?

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Committee for a Responsible Federal Budget, October 28, 2019

In the coming months, the Committee for a Responsible Federal Budget will publish a detailed analysis describing numerous ways to finance Medicare for All and the consequences and trade-offs associated with each choice. This paper provides our preliminary estimates of the magnitude of each potential change and a brief discussion of the types of trade-offs policymakers will need to consider.

We find that Medicare for All could be financed with:

• A 32 percent payroll tax
• A 25 percent income surtax
• A 42 percent value-added tax (VAT)
• A mandatory public premium averaging $7,500 per capita – the equivalent of $12,000 per individual not otherwise on public insurance
• More than doubling all individual and corporate income tax rates
• An 80 percent reduction in non-health federal spending
• A 108 percent of Gross Domestic Product (GDP) increase in the national debt
• Impossibly high taxes on high earners, corporations, and the financial sector
• A combination of approaches

Each of these choices would have consequences for the distribution of income, growth in the economy, and ability to raise new revenue. Some of these consequences could be balanced against each other by adopting a combination approach that includes smaller versions of several of the options as well as additional policies.

Consequences could also be mitigated through aggressive efforts to lower per-person health care costs and/or by substantially scaling back the generosity or comprehensiveness of Medicare for All.

While the financing options above are quite large in magnitude, they could be reduced significantly by reducing the cost of Medicare for All itself.

These cost reductions could be achieved in part by reforming or reducing provider payments, improving care coordination, and identifying policies to reduce excessive utilization of care.

From the Conclusion

In deciding how to finance Medicare for All, policymakers must consider the distributional, economic, and policy consequences of replacing premiums and cost sharing with various alternatives. Most of the options we put forward are more progressive on average than current law but would shrink economic output and bring the top tax rate up to its revenue-maximizing level – leaving little capacity for further taxes.

http://www.crfb.org…

---

Comment:

By Don McCanne, M.D.

The Committee for a Responsible Federal Budget is an influential organization that professes to advance bipartisan concepts that would place controls on the federal budget, but if you check the list of Directors (on the first page of their report) you will see that those on the left are predominantly neoliberals, with a stark absence of authorities with more progressive views – at best some may be classified as neutral academics. Understanding this is important because it seems to explain why they selected for this report their unusual framing of the options for financing Medicare for All.

They list eight different options plus a ninth option of combining various approaches. Most of the analysis is an evaluation each option isolated separately with the assumption that it would finance the entire health care system – nearly one-fifth of our economy. On the face of it, these assumptions are ridiculous. Opponents of single payer Medicare for All can take any one of them and hold the concept of trying to finance our entire health care system up to ridicule. As an example, they say that the concept of paying for health care by taxing the rich – high earners, corporations, and the financial sector – is an impossibility because at 100% tax rates there is not enough money there to pay for health care for all. They seem to ignore the fact that nobody has suggested paying for all health care in this manner nor through any of the other financing methods listed when used as the sole source of health care revenues. They end the list with a consideration of enacting a combination of approaches, almost as if it were an afterthought.

In discussing the trade-offs, they caution that most of the options “would shrink the economy,” with the potential of even greater damage to the economy should a decision be made to use deficit-financing for Medicare for All. Also they caution that there is risk that each of these options would bring the top rate close to the “revenue-maximizing rate” beyond which there is not much tax capacity left, reducing the ability of government policymakers to raise revenue in the future.

In spite of the distinguished officers and directors of this organization, this appears to be a hit piece designed to extinguish the flames of the passionate supporters of single payer Medicare for All. This is a preliminary report, and they say that in the coming months they will be publishing more detailed analyses, obviously timed to coincide with the election season. Unfortunately these reports will be suited only for the electronic trash heap, though we must keep our guard up so that they do not gain traction amongst the public at large.

That said, it is imperative that we understand how we can finance Medicare for All so that it works for everyone. Yesterday’s message was on the new book, “The Triumph of Injustice” by Emmanuel Saez and Gabriel Zucman. They describe tax policies that would make health care affordable for absolutely everyone while actually increasing the incomes of those who have been stuck in wage stagnation for the last several decades. If you did not followup on this yesterday, please do so now; health care justice depends on it:

https://pnhp.org…

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Emmanuel Saez and Gabriel Zucman
From Chapter 9: A World of Possibility

Private Health Insurance: A Huge Poll Tax

The other specificity of the United States compared to other advanced economies is that public health insurance is far from universal in America. About half of all health care spending (10% out of 20% of national income) is publicly funded. A large fraction of the population must purchase private insurance. The system of private insurance excludes millions of Americans and imposes a mammoth burden on workers.

As we saw in Chapter 5, private insurance premiums are akin to a huge private tax. Although most workers get insurance through their employers – and thus employers nominally foot the bill – the premiums are a labor cost as much as payroll taxes are. Just like payroll taxes, premiums are ultimately borne by employees. The only difference is they are even more regressive than payroll taxes, because the premiums are unrelated to earnings. They are equal to a fixed amount per employee (and only depend on age and family coverage), just like a poll tax. The secretary literally pays the same dollar amount as an executive.

(Historically, in American colonies and in some US states before 1964, voting registration was conditioned on the payment of “poll” taxes. In this book, we use the classic definition of a poll tax, namely a tax levied on every adult without reference to income or resources.)

Poll taxes, unsurprisingly, are not popular. When Margaret Thatcher imposed a poll tax in 1988 to replace real estate property taxes, she faced an unprecedented revolt and was ousted from office in 1990. No government would out of the blue impose a poll tax to fund health care; it would be a crushing burden on moderate-income families. And yet in essence that’s what the United States does today: employers are administering a huge poll tax on behalf of the government. Since the passage of the Affordable Care Act in 2010, employers with fifty or more employees are legally required to provide health insurance to their workers or pay a penalty of $2,500 per employee in 2019. Given how big the average annual health insurance premium has become ($13,000 per covered worker), this system is unsustainable.

To illustrate the magnitude of this poll tax, let’s look at the distribution of US tax payments once we include mandatory private health insurance premiums. As we saw in the first chapter, considering regular taxes only the US tax system looks like a giant flat tax that becomes regressive at the top. But with the health care poll tax added, it is in fact frankly regressive: once private health insurance is factored in, the average tax rate rises from a bit less than 30% at the bottom of the income distribution to reach close to 40% for the middle class, before collapsing to 23% for billionaires.

The poll tax hammers the working and the middle class. At the bottom of the distribution, it’s not as onerous as sales and payroll taxes. But that’s because many working-class Americans do not get health insurance from their employers. They either face the burden of obtaining coverage themselves, rely on a family member to cover them, enroll into Medicaid, or go uninsured. The Affordable Care Act increased the pool of Americans eligible for Medicaid and subsidized the purchase of private insurance for low-income people who weren’t otherwise covered, but the law still left about 14% of the adult population uninsured in 2019. And it provided no relief for workers who fund their health care through a poll tax whose cost for the middle-class far outweighed that of the income tax.

https://wwnorton.com…

Tax Justice Now: Use the following link to access an interactive website where you can see the current tax system, Triumph of Injustice’s Tax Plan, Joe Biden’s Tax Plan, Bernie Sanders’ Tax Plan, Elizabeth Warren’s Tax Plan, or make your own tax plan.

https://taxjusticenow.org…

---

Comment:

By Don McCanne, M.D.

The Quote of the Day for Friday, October 25 was from an article in The Guardian by Emmanuel Saez and Gabriel Zucman which was adapted from their book, “The Triumph of Injustice.” In that article they explained how single payer Medicare for All would make health care affordable for everyone while also providing a pay raise for most of us.

If you expect to be able to explain to others how we can make health care affordable for everyone through Medicare for All, then it is imperative that you have a clear understanding of the tax policies that would make that possible. The policies are not that complex, but they are not simply intuitive either. So this is why you should read “The Triumph of Injustice.”

The excerpt selected today explains how private health insurance premiums act like a huge poll tax – one of the least fair forms of taxation since it is not based on ability to pay, that is, it is not based on income nor personal resources. Because health care is now close to one-fifth of our economy, that places a very large financial burden on middle-income Americans who are not eligible for government subsidized programs such as Medicaid or ACA subsidies.

Think about what that means for Medicare as a public option. Presumably those eligible for government assistance will be enrolled in Medicaid or a subsidized plan in the ACA exchanges whereas those with middle incomes who do not qualify for subsidization will be paying high premiums for the Medicare public option just like they would with private insurance plans. Once again, this would be like a huge poll tax – very unfair.

If you go to the Tax Justice Now website (link above) and click on “Tax Breakdown” you can see how the revenue sources would vary by income groups under various tax plans, including that of the authors. It would be difficult to see how we could have a more equitable method of funding health care than that devised by the authors, with two of the three presidential candidates’ plans coming close. Compare theirs with the current tax system to see how unfair the status quo would be (private insurance premiums and out-of-pocket cost sharing would fall in the pink “health” section).

As stated in the last message, let’s make America affordable again.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.