PNHP

The Medicare for All bill is a winner

The Medicare for All bill is a winner

By Jeffrey Sachs
CNN, March 1, 2019

Rep. Pramila Jayapal introduced a sweeping Medicare for All (MFA) bill on Wednesday (H.R. 1384), and the national debate on healthcare is bound to intensify through the 2020 election. Voters rank healthcare costs as their second most important priority, just after the economy. The political fate of MFA will likely depend on one key question: Will it reduce healthcare costs while preserving the freedom to choose health providers?

If properly structured, MFA can do that: cut costs while improving choice.

Medicare for All has come a long way since Sen. Bernie Sanders launched his 2016 presidential campaign on that theme, while fellow Democrats ran from the label. Sanders also faced the wrath of mainstream pundits like Paul Krugman, who described Sanders’ healthcare plan as “smoke and mirrors.” Now, every major Democratic Party candidate endorses the label, (though they will certainly differ on the details) and Sanders could well become president in 2021 on the basis of his clear and persistent MFA advocacy.

No doubt the debate will become heated, even shrill. We are talking about serious money, and the largest single sector of the American economy. Healthcare outlays in the United States account for nearly 18% of the country’s gross domestic product. Profits are soaring in the private healthcare and pharmaceutical industries, both of which will fight fiercely against MFA. President Donald Trump has weighed in, declaring that Democrats are “radical socialists who want to model America’s economy after Venezuela.”

While former President Barack Obama spoke out in favor of a single-payer plan, he avoided the battle back in 2009 with the Affordable Care Act. And by making health insurance available to millions more Americans, the Affordable Care Act allowed private industry to raise prices given the increase in demand. The result is that Obamacare expanded overall coverage, and provided hugely popular guaranteed coverage for pre-existing conditions, while avoiding any decisive steps on cost containment.

MFA picks up at that point. Real cost containment will be the critical issue that either makes or breaks each MFA proposal.

Americans currently pay around $10,000 per person per year in health outlays, compared with roughly half that amount in other high-income countries such as Canada, Japan, the Netherlands, or Sweden. The reasons have been debated and studied in detail. Do Americans use more and better healthcare and therefore also pay more? Alas, no. Americans use roughly the same or less healthcare, but pay far more for health services including drugs, hospital stays, and medical procedures such as an MRI.

The Canada comparison

A comparison of healthcare costs between the US and 10 other high-income countries allows a detailed comparison of the US and Canada, the most relevant peer country. According to the comparative data, the US spends 17.8% of GDP compared with Canada’s 10.3%, amounting to $9,403 per person in the US compared with Canada’s $4,641.

All Canadians are covered by the healthcare system, while 10% of Americans lack public or private insurance coverage. Total pharmaceutical spending per person per year averages a whopping $1,443 in the US, compared with $613 in Canada.

For example, the cholesterol drug Crestor is $86 per month in the US, and $32 in Canada; the arthritis drug Humira is $2,505 in the US, compared with $1,164 in Canada. Yet despite the much higher health spending per person, life expectancy in the US is 78.8 years, while in Canada it is 81.7 years.

The article reaches the following conclusion: “The United States spent approximately twice as much as other high-income countries on medical care, yet utilization rates in the United States were largely similar to those in other nations. Prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the United States and other high-income countries.”

Huge private costs in the US

US private health insurance costs are out of sight. A typical US family of four covered by employer-based health insurance pays, in total, around $28,000 per year, taking into account the insurance premium paid for by the employer out of the worker’s total compensation, the premium paid directly by the household, and all of the extra costs, including deductibles, co-payments, and out-of-network payments. The cost of healthcare is crippling working-class families, which may explain why it is at the top of the political agenda.

What is the reason for these extraordinary costs in the US? Astronomical administrative costs, for one, are the result of countless and conflicting payments systems facing almost any patient who visits the doctor’s office or hospital. One study in 2014 suggested that America’s extraordinarily complicated multi-payer system leads to administrative costs for billing and insurance that are five times the costs of a simplified payment system such as Canada’s.

The second is the soaring monopoly profits and sky-high salaries along the entire private supply chain, from drug manufacturers to hospitals. The drug companies use their extraordinary monopoly power, whether due to patents or FDA approvals on out-of-patent drugs, to overcharge Americans with markups that are sometimes hundreds of times the production cost of the medicines. And private providers are a highly concentrated industry in most metropolitan areas.

With the mergers and closures of hospitals during the past 20 years, driven by for-profit medicine, this market power has soared, and so too have monopoly profits and healthcare costs facing consumers.

Check out the CEO compensation of the big systems providers — $59 million for Aetna, and $44 million for Cigna in 2017 — or the salaries of the executives of the “not-for-profit” hospitals in your area, often running several million dollars per year.

For these reasons, healthcare costs in the US could be brought down by cutting three main areas: administrative costs, drug prices, and monopoly profits of private insurers, which in turn could be achieved by much lower reimbursement rates for medical services and more effective contracting. Recent studies (here and here) have shown prospective savings on national health expenditures resulting from Medicare for All would save trillions of dollars over 10 years.

Smart cost control

The Jayapal bill is smart on cost control. It would have Medicare negotiate with pharmaceutical companies to drive drug prices down, with the threat of removing the monopoly rights of patents if the drug company doesn’t reach a reasonable agreement on prices. (Technically, the government would issue a compulsory license to competitors). It would have Medicare set an annual budget with hospital providers. This annual budget would focus on healthcare provision rather than wasted time and expenses on billing. It would not permit astronomical management salaries and super-profits.

By wringing massive administrative costs, monopoly profits, and sky-high salaries out of the healthcare system, costs would be slashed, with the savings passed on to households. Remember, if the US paid the same share of income as our peer countries like Canada, the total saving would be on the order of 6% of GDP (from 18% today to around 10-12% as in the peer countries). With a GDP of around $62,000 per person in the US, 6% of GDP saving comes to a cost saving of around $3,700 per person, or around $14,800 for a family of four.

Such savings wouldn’t be achieved in full, or even in the early years. The pushback from industry against cost-cutting will be fierce. Moreover, the sheer inertia of existing costs, prices, budgets, and administrative systems cannot be doubted. But what can be said with confidence is that a well-designed MFA system would put the US on a path toward the reasonably priced healthcare systems of other comparable countries.

Moreover, MFA would allow us to rethink healthcare delivery to take into account perhaps the biggest feasible benefit in health outcomes. America’s current disease burdens often reflect unhealthy life circumstances — great stress, obesity-inducing diets, lack of exercise, drug dependence, and others. These are social ills turning into medical ills.

A fairer, more balanced, health system based on good health rather than maximum profits would turn its attention to helping Americans live healthier lives.

Getting MFA through the political process won’t be easy. The drug industry is one of America’s top lobbies and campaign contributors, befitting a massive economic sector rolling in profits. Lobbying outlays in 2018 across the health sector are estimated at around $549 million and campaign funding in the 2018 election cycle at $255 million. The industry will be ready to fight an MFA plan with guns blazing, and trot out the usual arguments: stop socialized medicine, save personal choice, don’t put yourself into the hands of government bureaucrats, don’t let American become Venezuela — you name it.

Yet Sanders and Jayapal and their many colleagues who have come on board now (including 106 co-sponsors) have the best chance to prevail in our modern history. Americans know that the healthcare system is rigged, and they will support a new system that convincingly shows the way to fair and reasonable healthcare costs.

Jeffrey Sachs is a professor and director of the Center for Sustainable Development at Columbia University.

https://www.cnn.com…

The special interests behind the Medicare for All bill

The Special Interests Behind Rep. Pramila Jayapal's Medicare for All Bill Are Not the Usual Suspects

By Ryan Grim
The Intercept, February 27, 2019

The Medicare for All legislation unveiled Wednesday by Rep. Pramila Jayapal, a Democrat from Washington state, was written with the help of a broad swath of lobbyists and special interest groups, if perhaps not the kind associated with typical health policy legislation on Capitol Hill.

The key outside groups involved in the drafting included nurses, doctors, disability rights activists, and advocates for the elderly, as well as public interest organizations such as Public Citizen and the Center for Popular Democracy.

Along with Consortium for Citizens with Disabilities, the main groups involved in drafting the legislation were National Nurses United, a major nurses union that has long been on the forefront of the fight for single payer; Physicians for a National Health Program; the Center for Popular Democracy, which organizes poor and marginalized communities; Public Citizen; and Social Security Works, which represents more than a million progressive seniors who support expanding the Medicare coverage they have to the rest of the population.

Meanwhile, the insurance and pharmaceutical industries played little to no role in the drafting process — an anomaly on Capitol Hill. Their marginalization in the process represents a major departure from the approach taken with the Affordable Care Act and reflects the type of bill being drafted: one less concerned about the profits, or even survival, of interest groups like insurers and more concerned with delivering care to the largest amount of people in the most cost-effective way.

Noticeably absent from the central drafting room was the Center for American Progress, the leading center-left think tank, which reflects a reticence by many in the progressive policy community to embrace something as sweeping as Medicare for All. The Center for American Progress, instead, has pushed what it calls “Medicare Extra for All,“ an expanded version of a public option that people could buy into.

https://theintercept.com…

Comment:

By Don McCanne, M.D.

Special interests yes, when that interest is for the all of the people and their health, but we need to keep out the “usual suspects.”

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There’s A New ‘Medicare-For-All’ Bill In The House. Why Does It Matter?

By Shefali Luthra
Kaiser Health News, February 27, 2019

Members of the House on Wednesday offered their version of a “Medicare-for-all” bill that is broader than what’s been put forth by Sen. Bernie Sanders (I-Vt.), whose 2016 presidential run pushed the issue into the political mainstream.

Rep. Pramila Jayapal (D-Wash.) and Rep. Debbie Dingell (D-Mich.) unveiled the “Medicare for All Act of 2019,” which redefines what the change in health care coverage might mean. The specifics included in the bill could play a role in the upcoming Democratic presidential primary campaign because candidates seeking support from the party’s progressive wing leverage the phrase. But often, they use it to mean various things.

Is this bill so different from Medicare-for-all proposals that have come before? And why would those differences matter? Here are the essential takeaways:

In terms of the policy 411, the Jayapal-Dingell bill includes provisions not in other proposals.

In many ways, the proposal sounds familiar: The government would establish a health plan that pays for basically all forms of medical care for all citizens. That’s how it gets the moniker “Medicare-for-all.”

Under this plan, patients would not be responsible for any cost sharing of medical expenses, and the government coverage would include hospitals, doctors, preventive care, prescription meds and dental and vision care. Private insurers would not be allowed to sell plans that compete with the government program.

Senior citizens would be folded into the new Medicare plan, which would be more generous than their current coverage, and the government would make sure any medical care they are getting is not disrupted. The bill leaves two other government health care payers intact: the Veterans Health Administration and the Indian Health Service. Beneficiaries enrolled in these programs would have a choice of enrolling in the new Medicare-for-all plan or sticking with their current coverage.

Just like the Sanders bill, the House legislation covers what it calls “comprehensive reproductive health.” Backers say it is meant to cover abortion — a controversial provision. Right now, government-funded health plans are legally prohibited from providing funds for abortions.

There are differences, too. For one, the transition to the new Medicare-for-all system would take place over two years, which would be a fast turnaround for a substantial task. Sanders’ bill suggested a four-year transition.

The biggest difference: This House vision of Medicare-for-all would also cover long-term care. That isn’t part of the Sanders bill, and it is not covered by Medicare. But for people with disabilities and the elderly, it’s a significant benefit — and one that can get very expensive to pay for out-of-pocket. (The Affordable Care Act included a long-term care provision that was eventually scrapped because of its high cost.)

The House bill also would take a swipe at high prices for prescription drugs by empowering the government to negotiate prices directly with manufacturers and to take away and reissue drug patents if such efforts faltered. This idea, known as “compulsory licensing,” has appeared in drug-pricing bills, but not in other Medicare-for-all legislation.

And the bill wades into one of the hottest Medicare-for-all controversies: the role of private health care. Notably, it permits it. Private plans can cover services not included in the single government health plan. Doctors can also refuse to participate in the program and charge patients cash for medical treatment instead.

“Whether there’s someone out in Beverly Hills who sees the stars and doesn’t partake — that would be possible,” said Dr. Adam Gaffney, a doctor and president of Physicians for a National Health Program, a single-payer advocacy group that supports the legislation. “The way the whole program is structured is to really make it such that that’s a very insignificant overall phenomenon.”

And the legislation takes on wonkier questions, like health care costs — proposing so-called global budgets that set a firm amount the federal government would pay for hospitals, for instance, as a strategy to bring down spending.

Still, the legislation leaves a lot of meaningful details open to interpretation.

Three big ones: what precisely would be covered, what doctors would be paid and how the program would be financed.

Generally, Medicare-for-all would provide “comprehensive benefits,” accounting for health care needs as “medically necessary or appropriate.” That means covering hospital and doctor visits, but also, for instance, mental health, maternity services, addiction treatment, pediatrics and medications.

Where it gets tricky is determining which specific services qualify as “necessary.” Sometimes that’s obvious — insulin for diabetics or a cast for a broken leg.

In other cases, it’s not as clear. Examples include politically controversial treatments, like gender confirmation surgery. Many experts do say the procedure is an important option for people with gender dysphoria. But specific components of it are sometimes deemed cosmetic or unneeded — often by those skeptical of the treatment to begin with.

There are also reconstructive surgeries that provide medical value, but may be deemed cosmetic.

The Department of Health and Human Services would have significant discretion in interpreting what specific services are “medically necessary.” That means political leanings or scientific debates could sway what’s covered, even from administration to administration.

“Reasonable people could disagree on certain things,” Gaffney acknowledged.

The legislation also spells out steps for determining how to pay doctors — a tricky issue, since doctors often complain that traditional Medicare pays them less than does private insurance. But the bill doesn’t set up a reimbursement system.

Of course, there’s the question of how the U.S. pays for the new program. Studies suggest Medicare-for-all would bring down national health care costs. Currently, though, much of that health spending is borne by the private sector. Under the Jayapal-Dingell bill, the money would have to come out of taxpayer dollars.

That would mean new taxes, and that’s a subject that does not appear anywhere in the Jayapal-Dingell bill. (Jayapal has said she will put out a separate list of potential taxes that could finance her single-payer proposal. Sanders also used this strategy — a separate list of “pay-fors” — to make a case for his bill.)

The bill could resonate throughout the 2020 campaign.

The House bill keeps a spotlight on the Medicare-for-all issue — requiring Democratic presidential primary candidates to answer more questions and spell out stances on this particular policy.

That could create some land mines. Medicare-for-all is controversial, and already major health industry groups have ramped up opposition to the broad idea. This bill’s specific provisions, such as its coverage of abortion, would add more adversaries. Its long-term care coverage would further drive up its multitrillion-dollar price tag

But Robert Blendon, a health care pollster at the Harvard T.H. Chan School of Public Health, pointed out that addressing concerns such as the long-term care benefit could add to the measure’s political muscle. It could make the idea more attractive to older voters, who otherwise might be hesitant to change their coverage but who do turn out disproportionately to vote in primaries.

That dynamic, he said, could skew primary results to favor candidates who endorse Medicare-for-all, as opposed to more moderate Democrats who have distanced themselves from the issue. (In a general election, he noted, costs could certainly diminish that support.)

“The long-term care piece is unbelievably significant,” he said. “It surely will help [progressives] with older voters.”

https://khn.org…

PNHP President Dr. Adam Gaffney helps introduce the Medicare for All Act of 2019

Remarks by Adam Gaffney, M.D., M.P.H.
Introductory Press Conference, H.R. 1384, February 27, 2019

I am so happy to be here today, speaking as a representative of Physicians for a National Health Program, an educational and advocacy organization of physicians across the country who know first-hand that a single-payer Medicare for All system is what this country needs.

I’d like to thank Congresswoman Pramila Jayapal for her leadership on this, and everyone here who’s joining together for this critical cause at this crucial moment.

As physicians, we see daily the harm that a for-profit, fragmented, privatized health care system imposes on our patients. We see the uninsured — the 29 million people without any health coverage — who go untreated, who develop unnecessary complications, who even die as a consequence.

We see the under-insured — the 44 million people who have coverage, but with holes and gaps so big it’s as if they’re not covered at all. These are people who go without needed care. People with asthma who don’t take their inhalers because they can’t afford the prescription. People with heart disease who don’t fill their prescription at all because they can’t afford it. People with multiple sclerosis, mental illness, or cancer who can’t get the care they need because the copays and the deductibles are too high.

Meanwhile, as physicians, we are encumbered with never-ending billing tasks and administrative tasks that take us from the bedside, that take us from the patient, from the practice of medicine itself. We see a corporate calculus replacing the fundamental calling of the medical profession and the profit motive superseding medical science and justice.

No longer. A Medicare for All system would guarantee health care for everyone in America, replacing the current welter of fragmented, inadequate plans that deny claims with universal coverage that is not only comprehensive, but first-dollar; not only portable, but seamless over life; that allows you to see the doctors and go to the hospitals that you want, not the ones that your insurance company tells you you have to go to.

At the same time, such a system would allow us as physicians to again focus on the care of patients, away from billing and back to the beside, which is why we became doctors to begin with.

Thank you so much, everyone, for joining together. The time for half-measures is over. Medicare for All, a single-payer universal health care system, is the name of the game and we’re going to win it!

more information on H.R. 1384:
pnhp.org/housebill

House Democrats introduce ‘Medicare for All’ bill

By Robert King
Modern Healthcare, February 27, 2019

House Democrats on Wednesday rolled out an ambitious proposal to extend Medicare to all Americans, eliminate private insurance and drastically overhaul reimbursement for doctors and hospitals.

Rep. Pramila Jayapal (D- Wash.) told reporters that the goal of the Medicare for All Act of 2019, which has more than 100 co-sponsors, is to completely overhaul the U.S. healthcare system and convert it to a government-run entity.

The legislation provides an outline of the thinking of some congressional Democrats on “Medicare for All,” an issue that has been highly debated among Democrats running for president in 2020.

“We believe that the market is broken and that is the core idea that we would like to fix,” She said on a call with reporters Tuesday. “We love to buy our coffee from Starbucks…but there are some things that should not be provided through the for-profit marketplace and we believe healthcare is one of them.”

The legislation would expand Medicare to provide insurance coverage to every American and would ban private insurers from offering any benefits that duplicate the benefits covered by Medicare, likely eliminating most of the private insurance market.

It would also drastically revamp how hospitals and doctors get reimbursed by Medicare.

Each hospital would get an annual prepaid budget to cover all healthcare costs for the facility for the given year. HHS would appoint regional directors that would oversee all hospitals and doctor offices in a specific region.

The director and the hospital would negotiate the budget. Nursing homes, health centers, home health agencies and independent dialysis facilities would also get an annual budget.

The budget would be determined by a host of factors that include the historical volume of services the hospital provided in the area, Jayapal told reporters.

“It is a common practice of most of the developed countries around the world and it has been very successful,” she said of global budgets. “It increases accountability over hospital spending.”

The annual budget could also be changed if there are certain circumstances, Jayapal said.

Doctor offices would still be paid under a fee-for-service model, however some physicians included in certain group practices can opt to get a salary from a hospital or another provider that gets a global budget.

Jayapal expects that around one to two million people would be out of work if the legislation becomes law because of the elimination of most private insurance. She said that 1% of the global budget for hospitals will go to a fund to provide services to displaced workers in the insurance industry.

“This could include pension benefits, include any number of things that would take care of these workers as we transition,” Jayapal said. “I do think there will be a boon to the economy once we get healthcare under control.”

Jayapal added that a private insurance industry could still exist, but they couldn’t cover the same benefits as Medicare, which include coverage of prescription drugs, hospital and physician services and long-term care services. However, an insurers could cover services such as cosmetic surgery or other types of elective benefits.

Healthcare sector lobbyists are expected to put up a vigorous fight against any “Medicare for All” proposal.

America’s Health Insurance Plans, the top lobbying group for the insurance industry, issued a pre-emptive strike on Tuesday in anticipation of the bill’s introduction.

“The vast majority of Americans are satisfied with the coverage they have today,” the group said in a statement. “They have choice and control over their coverage, options, and treatment.”

Jayapal said that money from industry groups would be the biggest obstacle to getting the bill through Congress.

But it’s unclear whether the bill will come up for a vote in the Democratic controlled House. Jayapal said that the legislation will first get a hearing in the House Rules Committee and in the House Budget Committee.

The bill has been referred to the House Energy & Commerce Committee and Ways & Means Committee, which both have healthcare jurisdiction. So far no hearing has been scheduled.

https://www.modernhealthcare.com…

PNHP endorses the Medicare for All Act of 2019

Doctors say Rep. Jayapal’s single-payer House bill is the only way to achieve universal, comprehensive coverage while saving the nation billions in health costs

Physicians for a National Health Program, February 27, 2019

WASHINGTON, D.C. – Physicians for a National Health Program (PNHP), a nonprofit research and education organization whose 23,000 members support single-payer national health insurance, endorses the Medicare for All Act of 2019, filed today by its lead sponsor Rep. Pramila Jayapal (D-Wa.) along with more than 100 co-sponsors.

“Accept no substitutes — only single-payer, Medicare for All can fix the grave dysfunctions and injustices of the American health care system,” said Dr. Adam Gaffney, PNHP’s president and a critical care physician and faculty member at Harvard Medical School. “Congress shouldn’t be distracted with incremental plans like a Medicare buy-in or public option. The only way to achieve universal and comprehensive coverage is to eliminate the profits and waste of the private insurance industry, which drains hundreds of billions of dollars from our health care system each year.”

The Medicare for All Act would improve Medicare by providing comprehensive, first-dollar health benefits inclusive of dental, vision, hearing, mental health, and long-term care, as well as the full spectrum of women’s reproductive health care. It would then expand Medicare to cover everyone living in the U.S., regardless of age, income, or employment. Coverage would be lifelong, portable, and seamless; services would be covered free at the point of service without copays or premiums, which serve only to keep patients from the care they need.

Experts predict that single-payer Medicare for All would would save more than $600 billion annually by slashing the administrative waste of private insurance and the paperwork insurers impose on hospitals and doctors ($504 billion) and bargaining down drug prices ($155 billion). These efficiencies would free up enough money for universal, first-dollar coverage without any overall increase in U.S. health spending, while controlling its growth over time.

Currently, the U.S. spends $3.65 trillion per year on health care, double the per-capita spending of other industrialized nations that provide universal coverage. Without single-payer reform, U.S. health spending is projected to reach $5.96 trillion — 19.4 percent of GDP — by 2027.

“Even single-payer opponents admit that, compared to Medicare for All, the status quo will cost U.S. $2 trillion more over the next decade,” said Dr. Claudia Fegan, a Chicago-based internal medicine physician and PNHP national coordinator. “How do they propose we pay for that?”

Dr. Fegan added that although the Affordable Care Act — which relies on a system of private and employer-provided insurance — expanded coverage to many, it failed to reduce the proportion of bankruptcies driven by medical problems, while doing little to expand the health security of all Americans.

While endorsing the Medicare for All Act as a strong single-payer bill, PNHP notes an area for improvement: Since for-profit providers (including hospitals, dialysis centers, nursing homes, home care agencies, and hospices) have been shown to provide inferior care at inflated prices, PNHP recommends moving to a fully nonprofit health system in addition to the bill’s current constraints on profit-making. To achieve an orderly transition of for-profit providers to nonprofit status, the doctors’ group recommends a bond-funded buyout of investor-owned facilities.

Dr. Gaffney welcomed this moment as a key step forward in the movement towards a sustainable, just health care system for the nation. “The system is failing both physicians and patients,” he said. “We can do better. In fact, we have to: The health and future of our nation hangs in the balance.”

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization whose 23,000 members support single-payer national health insurance.

https://pnhp.org…

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Physicians group endorses the Medicare for All Act of 2019

Doctors say Rep. Jayapal’s single-payer House bill is the only way to achieve universal, comprehensive coverage while saving the nation billions in health costs

FOR IMMEDIATE RELEASE: February 27, 2019

Contact: Clare Fauke, communications specialist, clare@pnhp.org or 312-782-6006

WASHINGTON, D.C. – Physicians for a National Health Program (PNHP), a nonprofit research and education organization whose 23,000 members support single-payer national health insurance, endorses the Medicare for All Act of 2019, filed today by its lead sponsor Rep. Pramila Jayapal (D-Wa.) along with more than 100 co-sponsors.

“Accept no substitutes — only single-payer, Medicare for All can fix the grave dysfunctions and injustices of the American health care system,” said Dr. Adam Gaffney, PNHP’s president and a critical care physician and faculty member at Harvard Medical School. “Congress shouldn’t be distracted with incremental plans like a Medicare buy-in or public option. The only way to achieve universal and comprehensive coverage is to eliminate the profits and waste of the private insurance industry, which drains hundreds of billions of dollars from our health care system each year.”

The Medicare for All Act would improve Medicare by providing comprehensive, first-dollar health benefits inclusive of dental, vision, hearing, mental health, and long-term care, as well as the full spectrum of women’s reproductive health care. It would then expand Medicare to cover everyone living in the U.S., regardless of age, income, or employment. Coverage would be lifelong, portable, and seamless; services would be covered free at the point of service without copays or premiums, which serve only to keep patients from the care they need.

Experts predict that single-payer Medicare for All would would save more than $600 billion annually by slashing the administrative waste of private insurance and the paperwork insurers impose on hospitals and doctors ($504 billion) and bargaining down drug prices ($155 billion). These efficiencies would free up enough money for universal, first-dollar coverage without any overall increase in U.S. health spending, while controlling its growth over time.

Currently, the U.S. spends $3.65 trillion per year on health care, double the per-capita spending of other industrialized nations that provide universal coverage. Without single-payer reform, U.S. health spending is projected to reach $5.96 trillion — 19.4 percent of GDP — by 2027.

“Even single-payer opponents admit that, compared to Medicare for All, the status quo will cost U.S. $2 trillion more over the next decade,” said Dr. Claudia Fegan, a Chicago-based internal medicine physician and PNHP national coordinator. “How do they propose we pay for that?”

Dr. Fegan added that although the Affordable Care Act — which relies on a system of private and employer-provided insurance — expanded coverage to many, it failed to reduce the proportion of bankruptcies driven by medical problems, while doing little to expand the health security of all Americans.

While endorsing the Medicare for All Act as a strong single-payer bill, PNHP notes an area for improvement: Since for-profit providers (including hospitals, dialysis centers, nursing homes, home care agencies, and hospices) have been shown to provide inferior care at inflated prices, PNHP recommends moving to a fully nonprofit health system in addition to the bill’s current constraints on profit-making. To achieve an orderly transition of for-profit providers to nonprofit status, the doctors’ group recommends a bond-funded buyout of investor-owned facilities.

Dr. Gaffney welcomed this moment as a key step forward in the movement towards a sustainable, just health care system for the nation. “The system is failing both physicians and patients,” he said. “We can do better. In fact, we have to: The health and future of our nation hangs in the balance.”

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization whose 23,000 members support single-payer national health insurance.

More than 100 House Democrats to unveil ‘battle-ready’ Medicare-for-all plan as 2020 election looms

By Jeff Stein
The Washington Post, February 26, 2019

More than 100 House Democrats plan to unveil a new “Medicare-for-all” plan Wednesday to provide government health insurance to every American, according to a copy of the bill provided to The Washington Post, as a number of Democratic-leading presidential candidates for 2020 feud over the party’s health-care platform.

Rep. Pramila Jayapal (D-Wash.), co-chair of the Congressional Progressive Caucus, is expected to release legislation Wednesday that incorporates key policy demands of single-payer activists, aiming to overhaul the U.S. health-care system even faster and more dramatically than legislation proposed in 2017 by Sen. Bernie Sanders (I-Vt.).

Jayapal’s Medicare-for-all would move every American onto one government insurer in two years, while providing everyone with medical, vision, dental and long-term care at no cost. Similar proposals have been projected to increase federal expenditures by at least $30 trillion but virtually eradicate individuals’ health spending by eliminating payments such as premiums and deductibles. About 30 million Americans do not have insurance, while tens of millions more are “underinsured,” meaning they cannot afford or do not seek care, according to the nonpartisan Kaiser Family Foundation.

The bill has 106 co-sponsors but essentially no chance of passing the House or Republican-controlled Senate this term. It comes amid a wider debate about the meaning of Medicare-for-all in Democratic policy circles, as some presidential candidates and center-left think tanks have said they support both Medicare-for-all while also aiming to preserve private insurance that currently enrolls about 150 million Americans. Jayapal’s plan would leave only a minimal role for private insurance in the United States, similar to Sanders’s bill in the Senate.

“We have a plan. We have a real plan,” Jayapal told reporters, calling the state of U.S. health care “atrocious” and dominated by a handful of wealthy corporate interests. “Americans are literally dying because they cannot afford insulin and can’t get the cancer treatments they need . . . I think this Medicare-for-all bill makes it clear what we mean by health care for all. We mean a complete transformation of our health-care system.”

The plan is, in a number of ways, more aggressive than the Sanders plan co-sponsored by more than a dozen Democratic senators, including presidential candidates Sens. Cory Booker (D-N.J.), Kamala D. Harris (D-Calif.) and Elizabeth Warren (D-Mass.). It is also significantly more detailed than the previous single-payer bill in the House introduced by then-Rep. John Conyers Jr. (D-Mich.), which at about 30 pages outlined only a set of goals with few legislative specifics.

Tim Faust, a single-payer advocate, said it was the first “comprehensive, battle-ready” single-payer plan to be introduced in Congress.

“The idea of Medicare-for-all has become extremely popular, but it’s at risk of being co-opted by those who want modest, incremental proposals that fall well short of true universal health care,” said Adam Gaffney, president of Physicians for a National Health Program, a group of doctors supporting single-payer that provided input to the Jayapal plan. “What we’re doing here is a big step forward to clarify exactly what Medicare-for-all means.”

Critics say the plan would require impossibly large new taxes, given its estimated $30 trillion price tag, and question the political wisdom of forcing nearly half the country to switch from the current private plan to a public insurer. Conservatives have also argued that a single-payer system could impede quality of care for those who have it, pointing to the potential for longer wait times.

Supporters point out that U.S. health-care spending per capita is more than two times as large as the average for developed nations, even as Americans have below-average life expectancy at birth and lag on a number of other key health outcomes. Single-payer advocates say one government insurer would have the bargaining power to drive down costs, while giving free health care to those who lack coverage.

Jayapal’s plan, about 120 pages, would transition every American to Medicare-for-all over two years, cutting the four-year transition in Sanders’s Senate bill in half. Sanders is currently working on an updated version of his legislation, according to Josh Miller-Lewis, a spokesman for the senator.

Some health policy experts fear that dramatically disrupting the health markets over four years could lead prices to explode in the private market, increasing the urgency of a quicker transition.

Jayapal’s bill also includes two big new provisions left out of the Senate legislation: a crackdown on the pharmaceutical industry aimed at lowering drug prices, and new government-run long-term care to help people with disabilities. It does not specify how it would finance the new legislation.

The number of Americans who require long-term care is expected to explode over the next few decades as the baby-boom generation ages, with the number of Americans with a disability projected to more than double from 2015 to 2065. Jayapal’s new Medicare-for-all bill, unlike the one Sanders introduced in the Senate in 2017, would guarantee free long-term care, including home health care, for Americans with disabilities as part of the single-payer system.

“This one part of it is, in some ways, as complicated and expansive as the Affordable Care Act itself,” said Harold Pollack, a University of Chicago health expert. “It’s an unbelievably complicated and fraught issue.”

Jayapal’s bill will include a proposal from Rep. Lloyd Doggett (D-Tex.) aimed at bringing down prescription drug prices by allowing Medicare to negotiate the price of drugs. The bill would give the government the ability to issue a generic license to produce the medication if negotiations fail, a provision known as “compulsory licensing.”

The previous version of the Medicare-for-all bill called for the elimination of all for-profit hospitals, and it called on the government to give financial compensation to providers that would be forced to become nonprofits. That provision was removed from the new Jayapal bill, in part because House aides feared it would lead the government to compensate hospital shareholders. In December 2018, Politico reported that hospitals, insurance companies and other health-care lobbies had launched a unified front to beat back the push for Medicare-for-all, raising the political stakes for Democrats who embrace the plan.

The new bill specifies that funds from the government’s Medicare-for-all could not be used “for profit,” union-busting, marketing or federal campaign contributions. Many hospitals with the biggest budget surpluses are also nonprofit, which seems to diminish the case for converting all hospitals to that model.

Jayapal also said between 1 million and 2 million people currently work in the private health insurance system, and that 1 percent of the new Medicare-for-all fund would go to a five-year transition program to pay for pension benefits, job training programs and other assistance for affected workers.

Congressional Democrats have proposed a number of incremental health reform provisions recently, including a plan by Sen. Debbie Stabenow (D-Mich.) and Tammy Baldwin (D-Wis.) that would create a public option for Americans from ages 50 to 64 to buy into Medicare. Sen. Brian Schatz (D-Hawaii) has proposed a Medicaid expansion via a state-based buy-in program. The recent push leftward on single-payer has made those plans, which would still use the federal government to expand health insurance to millions of people, seem more modest by comparison.

“Even though it’s still extremely unlikely to pass, Medicare-for-all has moved the political landscape so suddenly, it’s created a window for these other proposals to seem quite feasible,” said Pollack, a single-payer skeptic.

Hearings on the legislation are expected to begin later this year.

https://www.washingtonpost.com…

Livestream launch of single payer bill Wed., Feb. 27, 11:15 a.m. EST, 8:15 PST

PNHP, Feb. 26, 2019

Dear colleague,

After months of dialogue with single-payer advocates, Rep. Pramila Jayapal will file the Medicare for All Act of 2019 in the U.S. House of Representatives on Wednesday, Feb. 27. The PNHP Board of Directors has endorsed this legislation, which would achieve both the universal coverage and long-term cost control needed to fix our broken health care system.

Tomorrow, I will join Rep. Jayapal in a press conference announcing the new bill. PNHP will broadcast the press conference via Facebook Live, and will also live-tweet the event.

Watch the press conference LIVE, Wednesday at 11:15am EST.

I hope you can join us for this historic moment, and are inspired to continue pushing for single-payer reform.

Onward,

Adam Gaffney, M.D., M.P.H.
President

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

Did the Affordable Care Act reduce amenable mortality?

The Effect of Health Insurance on Mortality: Power Analysis and What We Can Learn from the Affordable Care Act Coverage Expansions; NBER Working Paper No. 25568

By Bernard Black, Alex Hollingsworth, Leticia Nunes, and Kosali Simon
National Bureau of Economic Research, February 2019

Abstract

A large literature examines the effect of health insurance on mortality. We contribute by emphasizing two challenges in using the Affordable Care Act (ACA)’s quasi-experimental variation to study mortality. The first is non-parallel pretreatment trends. Rising mortality in Medicaid non-expansion relative to expansion states prior to Medicaid expansion makes it difficult to estimate the effect of insurance using difference-in-differences (DD). We use various DD, triple difference, age-discontinuity and synthetic control approaches, but are unable to satisfactorily address this concern. Our estimates are not statistically significant, but are imprecise enough to be consistent with both no effect and a large effect of insurance on amenable mortality over the first three post-ACA years. Thus, our results should not be interpreted as evidence that health insurance has no effect on mortality for this age group, especially in light of the literature documenting greater health care use as a result of the ACA. Second, we provide a simulation-based power analysis, showing that even the nationwide natural experiment provided by the ACA is underpowered to detect plausibly sized mortality effects in available datasets, and discuss data needs for the literature to advance. Our simulated pseudo-shocks power analysis approach is broadly applicable to other natural-experiment studies.

From the Introduction

We do not find a statistically significant pattern of results consistent with Medicaid expansion causing mortality changes, but we also cannot rule out large effects in either direction. We note here that prior evidence on the effects of insurance expansion on mortality lead one to expect modest effects of incremental insurance expansions on mortality. Reasons for modest overall effects include: many of those in greatest need of healthcare are already insured; and many uninsured persons already receive substantial healthcare. One reason for our “null result” is that the first stage on insurance coverage is weak: our principal identifying variation (the relative change in uninsurance rates for Medicaid expansion versus non-expansion states) amounts to a very small fraction of the population. The average increase in health insurance coverage attributable to Medicaid expansion over 2014-2016 is only around 1.1% for persons aged 50-64, and only around 4% even when we hone in on low-educated populations; precise income measures used to determine ACA eligibility are unavailable in mortality data. A second reason for failure to reject the null of no effect is a high level of “noise” – substantial background variation in mortality, and mortality trends, across states and demographic groups. A third reason is that mortality is a low-frequency outcome. We note too that effects of health insurance on mortality are more likely to emerge over a long time frame.

Our second contribution is to highlight that observational studies can often benefit from performing and reporting power analyses. We use a simulation-based power analysis, in which we impose treatment effects of varying sizes on actual data during the pre-treatment period, and assess whether ACA expansion effects on mortality of plausible size can be detected with our data. We conclude that even the nationwide natural experiment provided by the ACA is severely underpowered to detect effects on mortality of plausible size in county-level death certificate data. To reliably detect effects of insurance coverage on mortality, one would need very large-sample panel data on individuals, which is not currently available. Such data could include information on health, income, and insurance status, which would allow the study to focus on subsamples with a larger first stage and/or higher sensitivity of health and mortality to healthcare use. Even with such hypothetical data, it is likely that only fairly large effects of health insurance on mortality could be reliably detected.

From the Discussion

In this paper, we examine the relationship between mortality and health insurance, principally using the DD research design used in many prior ACA studies. This design exploits the natural experiment created by variation between those states that expanded Medicaid insurance and those that did not. We also exploit variation that results from counties having varying uninsurance or poverty levels prior to 2014. We focus on persons aged 55-64 years, whose mortality rates are the most likely to be affected by health insurance. We study effects of the first three years after expansion by type of mortality (healthcare amenable vs non amenable), demographics (gender, race, and ethnicity), education level, cause of death, and residence in counties most likely to gain from the ACA expansion).

We find large confidence intervals with no statistically significant evidence of an ACA- induced decline in mortality in Medicaid expansion states. Instead, there are important non-parallel pre-treatment trends, and standard errors are far too large to allow detection of effects of plausible sizes. We confirm lack of power through a formal, simulation-based power analysis.

While it is possible that the mortality effect of the ACA health insurance expansion variation we study may materialize with more time, other factors make it unlikely they too could be statistically detected; lengthening the study period would increase likelihood that other sources of variation, including cross-border moves, the instability of insurance status over time, and the underlying causes of the non-parallel pre-treatment trends we observe, will pose challenges for credible causal inference. Moreover, our power analysis implies that an extra few years would still be insufficient to attain reasonable power, given plausible effect sizes.

https://www.nber.org…

Comment:

By Don McCanne, M.D.

This meticulous, technically complex, 187 page economic paper attempted to look at changes in amenable mortality (mortality that could be reduced by beneficial interventions) from implementation of the Affordable Care Act. Their somewhat shocking result: “Our estimates are not statistically significant, but are imprecise enough to be consistent with both no effect and a large effect of insurance on amenable mortality over the first three post-ACA years.”

Before discussing this further, it is important to take note of the authors’ caveat: “Thus, our results should not be interpreted as evidence that health insurance has no effect on mortality for this age group, especially in light of the literature documenting greater health care use as a result of the ACA,” and keep this in mind when others report that this study failed to show any benefit of ACA. Stating that the study showed no statistically significant benefit is not the same as stating that there was no benefit.

Could it be that health care provides no benefit? Clearly not. Management of major trauma, use of antibiotics for potentially lethal diseases, surgical interventions for potentially disabling of lethal disorders, preventive measures that reduce the risk of chronic diseases, and vaccines that prevent epidemics of serious diseases are just a few examples of the benefits of modern health care. Of course, health care is dynamic in that new beneficial measures are continually introduced and measures that prove to be detrimental are abandoned.

So can it be that health insurance provides no benefit? The answer here is a little bit more complicated. Health insurance is clearly beneficial when it prevents financial hardship for individuals who clearly need health care. Yet it can be detrimental when it erects financial barriers to care or when it impairs access by denying care outside of the insurer’s provider networks. Also wasting funds on administrative excesses can be detrimental when those funds could have been diverted to more beneficial purposes.

In the case of the implementation of ACA, some people did benefit by gaining insurance protection while avoiding financial hardship through government subsidies or through enrollment in Medicaid. On the other hand, some faced greater financial risk by being shifted to plans with lower actuarial value (paying a lower percentage on the medical bills), plus some lost access to their usual health care because of narrow provider networks. There is some suggestion that care was impaired for many Medicaid beneficiaries who were transferred to private Medicaid managed care plans that seemed to be more concerned about cost containment rather than care provision.

Could these deficient policies of ACA have resulted in the failure to come to statistically significant conclusions on the impact of ACA on amenable mortality? Although that is highly unlikely it would be interesting to compare the impact of a well designed single payer Medicare for All system on amenable mortality since such a system is crafted to benefit patients and not designed to enhance the market success of insurers and other sectors of the medical-industrial complex. But then, amenable mortality should not be the sole criterion for judging the beneficial effects a health care financing system. Good health outcomes and financial security also matter.

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Fixing Our Health Care System

By Claudia Fegan, M.D.
The New York Times, Letters, Feb. 24, 2019

To the Editor:

Re: “What’s Good Health Care Worth?” (editorial, Feb. 17):

Thirty-six thousand Americans die prematurely each year because they are uninsured. And more than half a million households declare bankruptcy each year because of illness or medical bills. Who could possibly benefit from such an inhumane system?

Private insurers.

High deductibles and co-pays, narrow networks of doctors, and prior authorization paperwork keep patients from getting the care they need, while funneling more money into the pockets of insurance companies. Private insurers add nothing of value to our health care system and drain billions of dollars that should be spent on patient care.

A single-payer “Medicare for all” system would end this needless loss of life and life savings.

Dr. Claudia Fegan is the chief medical officer of Cook County Health and the national coordinator of Physicians for a National Health Program.

https://www.nytimes.com…

Soaring insulin costs are a symptom of our bigger health care crisis

By the Editorial Board
St. Louis Post-Dispatch, February 24, 2019

Soaring insulin prices are a genuine emergency in America. Many diabetics, suddenly unable to afford their prescribed doses, are self-rationing or using expired supplies. In the world’s most advanced nation, some are dying because they can’t afford a simple injection.

Critics allege artificial price inflation by the insulin industry. Congress finally is conducting hearings to rein it in.

But on this medical topic and so many others, the underlying problem is a health care system obsessed with profit, even if it means suffering or death for patients who can’t pay the asking price. The insulin crisis is one symptom of a wider emergency that won’t end until America fundamentally changes its health care delivery system.

Type 1 diabetes develops when a person’s pancreas stops producing insulin, which regulates blood sugar. Diabetes was virtually always fatal until, almost 100 years ago, scientists discovered how to process injectable insulin from animal pancreases. Synthetic insulin followed.

Type 1 diabetes still can’t be cured, but that it can be managed remains one of medical science’s greatest achievements. For the 1.25 million Americans living with type 1 diabetes today — and for many of the roughly 30 million more living with the less severe type 2 — consistent access to insulin is a matter of life or death.

Insulin prices have skyrocketed recently, far beyond rates of inflation or most other prescription drugs. One vial of insulin that sold for $31 in 2001 now costs $270. One father told a congressional hearing in December that the cost of his 13-year-old son’s three-month supply rose from $300 to more than $900 in one year.

Uninsured diabetics, or those with high insurance deductibles, have responded by using less insulin than they’re supposed to, tempting a range of health hazards. Victims include people like Alec Smith, 26, of Minneapolis, who died in 2017, weeks after aging out of his parents’ insurance coverage. He couldn’t afford a $1,300 insulin refill and tried to self-ration his existing supply.

The causes of the price spikes are maddeningly unclear. Major insulin manufacturers like Eli Lilly have blamed supply chains, the insurance industry and others. Critics allege the manufacturers engage in underhanded strategies to fix prices, obfuscate pricing methods and keep generic insulin out of the U.S. market. Congressional Democrats and some Republicans have vowed to get to the bottom of it. They must; lives depend on it.

But the insulin crisis is just one element of a broader problem: America’s entire health care system is far more expensive and far less accessible than in other developed countries. The claim that market-based medical care works just fine grows more dubious by the day.

When otherwise healthy 26-year-olds are dying because of the terms of insurance policies, it’s time to look seriously at alternatives closer to the “Medicare for all” model.

https://www.stltoday.com…