PNHP

How would Medicare for All work?

How would Medicare for All work?

Interview with Drs. Margaret Flowers and Ana Malinow

By Rose Aguilar and Laura Wenus
KALW (San Francisco) Public Radio, Jan. 8, 2019

House Democrats have promised to hold public hearings on single-payer healthcare proposals, which have been sidelined for years. According to the Washington Post, between 58 and 70 percent of Americans support some form of Medicare for All. We’ll discuss details of existing proposals and how they seek to fix a healthcare system that leaves so many behind. What would it take to provide all Americans comprehensive and affordable healthcare?

full audio:
https://www.kalw.org…

Dr. Margaret Flowers is a pediatrician, national board adviser for Physicians for a National Health Program (PNHP), and coordinator with the Health Over Profit for Everyone campaign.

Dr. Ana Malinow is a primary care pediatrician in San Francisco and past President of PNHP.

Lee Stanfield is a steering committee member of Health Over Profit for Everyone, and founder of Single Payer Now Tucson.

Gov. Newsom calls on the federal government to empower California to enact a single payer system

In First Act as Governor, Gavin Newsom Takes on Cost of Prescription Drugs & Fights for Health Care for All

Office of Governor Gavin Newsom, January 7, 2019

In his first act as California’s 40th Governor, Governor Gavin Newsom announced a series of major, first-in-the-nation executive actions and budget proposals to lower prescription drug and health care costs for all California families and move California closer to the goal of health care for all.

(The Governor) Calls on the federal government to empower California to truly innovate: Governor Newsom has long said California should be the national leader in health care innovation. However, instead of cultivating and rewarding good ideas, current federal law hinders truly transformative innovation, such as a single-payer health care system. Governor Newsom sent a letter today to President Trump and Congressional leaders calling on the federal government to lift these limitations and, instead, empower states like California to enact transformative change that would allow California to develop a single-payer health system to achieve universal coverage, contain costs, and promote quality and affordability.

https://www.gov.ca.gov…

Office of the Governor, Letter, January 7, 2019

The Honorable Donald J. Trump
The Honorable Mitch McConnell
The Honorable Charles E. Schumer
The Honorable Nancy Pelosi
The Honorable Kevin McCarthy

(Brief excerpts from a 6 page letter)

Existing law permits only limited, piecemeal innovation – not the comprehensive reform necessary to address the myriad challenges that Californians face when navigating today’s health care system.

However, to address this ongoing cost crisis in health care in the most effective way, we must have the federal tools to support California’s ability to provide quality healthcare for everyone, financed through a single-payer model like Medicare. We must have the tools to innovate and expand the Affordable Care Act. even as we build towards a more comprehensive, universal system that works for patients, providers, and taxpayers alike.

A comprehensive solution to affordable health care will require both wisdom and courage, with States and the federal government working together as partners. First and foremost, I ask that you amend federal law to enable States to apply for Transformational Cost and Universal Coverage Waivers, empowering California to pursue transformative health care reform, such as a single-payer system. Further, I ask that you build on the progress of the Affordable Care Act, especially by bolstering the affordability provisions of the law.

Sincerely,

Gavin Newsom, Governor of California

https://www.gov.ca.gov…

Comment:

By Don McCanne, M.D.

Various federal policies and programs have prevented states from accomplishing transition into a state-level single payer system. In his first action, moments after his inauguration, Governor Gavin Newsom signed an executive order to create the largest single purchaser for prescription drugs and allow private employers to join the state in negotiating drug prices. Immediately after that, he signed a letter to the President and Congress asking that federal law be amended to permit a single payer financing system, like Medicare, in California. The letter also requested numerous innovations that would build on the progress of the Affordable Care Act.

There should be no confusion about priorities here. The political climate has improved for enactment of a national Medicare for All program, though not until after the next elections. Every effort should be made to set the stage for such an outcome. Because of the uncertainties of being able to accomplish that goal, willing states like California should move ahead with efforts to establish their own single payer systems, such as Saskatchewan did in Canada before the Canada Health Act was enacted. Since there are also uncertainties about the politics of establishing state single payer programs, it is appropriate to move forward with efforts to strengthen the benefits of the Affordable Care Act on a transitional basis. The primary caveat is that that we cannot allow lesser efforts to diminish in the least our resolve to establish a national Single Payer Medicare for All program. If the politics are not aligned, we need to change them.

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Single-payer advocacy group elects Dr. Adam Gaffney as 2019 president

Dr. Gaffney to lead national physicians group through an “exciting but dangerous moment” for improved Medicare for all

FOR IMMEDIATE RELEASE: January 8, 2019
Contact: Clare Fauke, PNHP communications specialist, clare@pnhp.org

Physicians for a National Health Program (PNHP), a nonprofit research and educational organization, welcomes Dr. Adam Gaffney as its new president for 2019. Dr. Gaffney was unanimously elected at PNHP’s national meeting in November. PNHP now includes 22,000 members across 55 local chapters, as well as 65 chapters of the group’s student arm, Students for a National Health Program (SNaHP).

Dr. Gaffney is a pulmonary specialist at Cambridge Health Alliance / Harvard Medical School. He earned his bachelor’s and medical degrees from New York University, and a master’s in public health degree from the Harvard T.H. Chan School of Public Health. Dr. Gaffney completed his residency in internal medicine at Columbia University Medical Center, where he spent a year as chief resident. He also completed a clinical and research fellowship in pulmonary and critical care medicine at Massachusetts General Hospital.

Dr. Gaffney has led several major research and advocacy efforts within the single-payer movement. In 2016, Dr. Gaffney co-chaired the working group that developed the “Physicians’ proposal for single-payer health care reform.” He also co-chaired the Pharmaceutical Policy Reform Working Group which published “Healing an ailing pharmaceutical system: prescription for reform” in 2018.

Dr. Gaffney is a prolific writer and has published articles in prestigious medical and academic journals such as The Lancet, The BMJ (British Medical Journal), Chest, the European Respiratory Journal, and the Journal of Policy Analysis and Management, as well as mainstream news outlets such as the Washington Post, Guardian U.S., New Republic, Los Angeles Review of Books, Fortune, USA Today, Salon, CNN.com, Dissent, U.S. News & World Report, and Jacobin. His first book, “To Heal Humankind: The Right to Health in History” was published by Routledge in 2017.

“I’m honored to be taking on the role of PNHP president at such an exciting—but also dangerous—moment in the history of the single-payer movement,” said Dr. Gaffney.

Even though 70% of Americans support Medicare for all (including a majority of doctors), Dr. Gaffney expressed concern about political leaders undermining the policy goals of single-payer Medicare for all.

“We’ve been so successful in popularizing the idea of ‘Medicare for all’ that everybody wants in on the slogan—even if they have something completely different in mind, like a public option,” he said. “But tweaks won’t solve the fundamental problems of American health care: persistently high uninsurance, rising underinsurance, unaffordable drugs, narrow provider networks, and the growing corporate domination of health care that prioritizes profits over patients.”

Dr. Gaffney emphasized that an improved Medicare for all system cannot include a role for the bloated, profit-driven private insurance industry, which would undermine the goal of universal coverage. “The only way to achieve universal and comprehensive coverage is to eliminate the profits and administrative waste of the private insurance industry, which drains hundreds of billions of dollars from our health care system each year.”

A physician’s case for a single-payer health care

By John Perryman, M.D.
Daily Herald (Arlington Heights, Ill.), Jan. 8, 2019

Shane Patrick Boyle, a Type 1 diabetic living in Texas, had to move to Arkansas to care for his sick mother. His health insurance did not provide coverage in that state, so he set up a GoFundMe page to help cover his medical expenses until he could obtain new insurance. He got within $50 of his goal, rationing his insulin until he could obtain more.

Then he died from complications of his diabetes.

This tragedy and many others like it demonstrate some of the many failings of American health care.

The United States spends more on health care than every other nation on earth, yet is the only rich country that does not guarantee it for its citizens. Our high costs put incredible strains on patients, their families, businesses and the economy. Medical costs are a leading cause of personal bankruptcy and mortgage foreclosures.

In 2017, the U.S. spent $3.5 trillion on health care, or about $10,700 per person. This represents 18 percent of GDP, or one dollar of every six spent in the American economy. And costs continue to rise.

One might be comforted if we had the best health care in the world. While this is true for some of us, the performance of our system as a whole is severely lacking. Based on reports from the Organization for Economic Cooperation and Development for the year 2017, we ranked 26th in the world in life expectancy, 31st in infant mortality and 26th in maternal mortality. We are the only wealthy nation where our new moms are dying at increasing rates.

Even with passage of the now endangered Affordable Care Act, we still have 28 million uninsured Americans. Based on reports in medical literature, this leads to over 36,000 deaths a year. Tens of millions more are underinsured, meaning that they can’t afford the high out-of-pocket costs of their insurance plan. When faced with a serious illness or injury, they have the choices of going into debt, going broke or going without care. Meanwhile, insurers make billions in profits.

We pay more, but we get less. Where is the money going?

One place where we spend more than other nations is on administrative costs and insurer profits. Commercial insurers have overhead of 12-20 percent, compared to traditional Medicare, which is around 3 percent. All told, higher administrative costs add hundreds of billions a year to our health care tab.

High drug prices are another major contributor. If we negotiated and paid what most other nations do for medicines, we would save about $150 billion a year. The pharmaceutical industry has been raising drug prices relentlessly and made over $40 billion in profits in 2017.

Rising insulin prices killed Shane.

Faced with all of these considerations; the costs, the suffering and death, it is clear that something fundamental needs to change.

A single-payer, improved Medicare for All system provides the best way forward.

Under such a plan, as proposed in house bill HR 676, a government funded, national health insurance system is created. Providers would remain private. All people are provided comprehensive coverage from birth to death for medical, drug, dental, vision and long-term care. Mental health and addiction treatment are covered.

Additionally, there are no out-of-pocket expenses; no co-pays, deductibles or co-insurance.

One might logically ask how we could afford such a system. When factoring in administrative savings from reduced overhead, lower drug costs brought about by negotiating with pharmaceutical companies and other cost reductions, many studies indicate that our health care expenditures would actually be less than what we pay now.

Further evidence of this is demonstrated by what other nations with guaranteed coverage pay. Most of them spend around 11-12 percent of GDP, versus our 18 percent. If we were spending 12 percent of GDP, that would represent a trillion-dollar reduction per year.

More importantly, no one would be financially ruined by illness. No one would die because of a lack of coverage.

These are goals worthy of America. A single-payer system is the best way to achieve them.

Dr. Perryman is a physician in the Rockford area and co-president of the northern Illinois branch of Physicians for a National Health Program.

https://www.dailyherald.com…

Ocasio-Cortez explains how we pay for Medicare for All

Alexandria Ocasio-Cortez slams critics calling her agenda too radical

By Mark Moore
New York Post, January 6, 2019

Rookie Rep. Alexandria Ocasio-Cortez shot back at critics who say her progressive agenda is too radical and expensive, saying there’s nothing revolutionary about providing people with good jobs, health care and an education.

“When you can’t provide for your kids working a full-time job, working two full-time jobs. When you can’t have health care. That is not dignified,” Ocasio-Cortez told CBS’ “60 Minutes” in an interview that aired Sunday.

The 29-year-old newly minted House member is entering office with an ambitious agenda — including Medicare for all, tuition-free public college, and sweeping environmental protections.

“How are you going to pay for all that?” CBS’ Anderson Cooper asked her.

“No one asks how we’re going to pay for this Space Force. No one asked how we paid for a $2 trillion tax cut,” she said. “We only ask how we pay for it on issues of housing, health care and education. How do we pay for it? With the same exact mechanisms that we pay for military increases for this Space Force.”

https://nypost.com…

Selected prior analyses of single payer financing proposals:
https://pnhp.org…

Comment:

By Don McCanne, M.D.

We tend to try to provide an overly detailed answer when people ask how we would pay for health care for everyone through a single payer Medicare for All program. The appropriate answer in most circumstances is that we would pay for it like we do for all other publicly-financed programs – through equitable tax policies which would be affordable for each of us, less than most of us are paying now.

For more specific details, over the past three decades many single payer financing proposals have been analyzed (see link above). The recent Pollin PERI study is another example. They all show that the single payer model covers everyone while making health care affordable for each of us. That is what people need to know. Inevitably, opponents ferret out isolated details, which vary in each proposal, that are used to claim that the system is unaffordable while they fail to mention details of the fundamental design that, in fact, show that health care actually would be affordable for all.

Regardless, we should avoid dead end arguments over the specific details of these reports. We should hold firm on the general position that the efficiencies of a single payer system would offset the additional costs of covering everyone, and that it would be affordable for each of us through equitable public financing. Like Alexandria Ocasio-Cortez says, “we pay for it with the same exact mechanisms that we pay for (any other government program).”

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

Northern Illinois Doctor Believes Single Payer Is The Answer

Interview with John Perryman, M.D.

By Jenna Dooley
Northern Public Radio, January 4, 2019

John Perryman is a pediatrician with Mercyhealth in Roscoe. He sees patients struggling to afford medications. Some families, he says, disappear for stretches of time when they fall off an insurance plan. On this week’s Friday Forum, Jenna Dooley talks with Perryman about his view as well as from a major opponent of the idea.

Perryman is northern Illinois co-president of Physicians for National Health Program, or PNHP. The organization supports single payer insurance, also known as “Medicare for all.” In this scenario, the government handles the expenses so private plans become obsolete.

Perryman says the issue wasn’t on his radar until the Bernie Sanders campaign. As he did more research, he found the data compelling. Sanders didn’t make it to the White House but pieces of legislation remain calling for an overhaul of the U.S. healthcare system.

“It’s, I shouldn’t say perfect,” Perryman said. “It’s just so much better than what we have now in terms of outcomes, cost control, things of that nature.”

But implementing such a system could cost trillions of dollars.

Perryman argues the country is already spending more than the rest of the globe for healthcare and the outcomes don’t always compare well.

“You would be shifting funding from many private insurers to the government, but even now government spending accounts for about two thirds of healthcare spending already,” Perryman argues. “So we’re about two thirds of the way there already. When you factor in the efficiencies that single payer brings, the administrative efficacies, which are massive, savings on drug costs, savings on certain types of medical service costs, the savings will either equal or exceed the expenditure with adding more people and offering more services.”

Perryman notes there are major insurance companies and pharmaceutical companies with clout in Washington that do not support the single payer proposals and will stall anything that tries to make major changes.

There are a lot of jobs associated with those entities; Perryman acknowledges it is a significant number of workers.

“The number of jobs you’re talking about, I believe it’s about 1.7 million jobs,” Perryman acknowledged.  “But it’s about the number of people who get fired every month in this economy. And there are supports in place for those people, so they won’t just be left high and dry.”

There’s also the complexity of explaining a new system to patients. Perryman says the easiest way to explain the benefits of a single payer system is that is gives more control to patients.

“They could choose to see whoever they want to,” Perryman said. “The second is no out of pocket expenses. They don’t have a copay, they don’t have a deductible, anything like that. And that’s really important because that ends up limiting the amount of care that’s used when out pocket expenses are too high. So the two big practical things for them would be they don’t have to pay anything out of pocket and they can go where they want.”

So who or what pays for single payer?

“Taxes would have to make up for it,” Perryman said. “But with what we pay now in payroll taxes, we are already a good chunk of the way there. There would need to be some additional tax revenue somewhere. There are a variety of ideas in terms of what they would be. Perhaps a more graduated payroll tax, taxes on unearned income such as capital gains, state taxes, transaction taxes and stocks, things like that.”

Perryman says not overhauling the system leads to preventable deaths every day.

“What happens is [patients] don’t get the services they need. They don’t fill the prescriptions, they don’t go see the doctor. And there are tens of millions of people who fall into that category. So what ends up happening now with what we have is we have many people die and many people who suffer needlessly, or people who are bankrupted because of healthcare. So that’s why it has to change.”

But not everyone agrees that single payer is the magic bullet.

Robert Moffit is a senior fellow in Domestic Policy Studies at the Heritage Foundation, a conservative think-tank based in Washington D.C. He says it is a mammoth consideration because it would transfer all major decision making over healthcare to federal officials.

“In other words, there’s no alternative,” Moffit said. “If healthcare is an entitlement at the point of service, then, basically, government officials are going to make all the key decisions about who gets care, how they get care, when they get care, and under what circumstances they get care. So the key decisions in such a system are invariably political decisions.”

He fears medical decisions will be driven by budgets or government pricing outside of any kind of independent market.

“I think that that is likely to result in a highly impersonal and bureaucratic system of care delivery,” Moffit said.

Moffit acknowledges criticisms of corporate medicine, and says consumers should have more of a say in their healthcare plan.

“The fact of the matter is most Americans, for example, don’t pick their own health insurance plan or the benefits or the treatments or the medical procedures available to them,” Moffit said. “These decisions are all made by third parties.”

He argues that is the direct result of government policy which allows private insurers to make key decisions in what plans employers can offer.

“One of the arguments that my colleagues at the Heritage Foundation make is that we ought to basically change the fundamental structure of the system so people can pick and choose the kind of healthcare they want and carry it with them from job to job without a tax or a regulatory penalty,” Moffit said. “But the argument against third party payments is a good argument. The problem is that the Medicare bureaucracy is no more sensitive to consumer wants or needs than corporate health insurance.”

Moffit doubts any major overhaul will come in a single piece of legislation.

“The idea that you can solve the problems of the healthcare sector of the economy which is $3.5 trillion in one big bill — which is what President Obama really tried to do — is a huge mistake.” he said. “I don’t think that you can do it. I think the system is too big, it’s too complex to kind of try to do that. I do think we could make some very, very direct changes right now that would loosen things up a little bit and give people more options than they have today.”

For him, that includes giving states authority over insurance.

“Frankly, if California or Vermont or New York want to have a single payer system then they can do it,” he said. “But it will mean though that they’re not going to force the rest of us to finance it or bail them out.”

Moffit also belives individuals and families should have individual tax relief so they can purchase health insurance.

“And they can pick and choose the plan they want without a tax or a regulatory penalty, whether that plan is offered through their employer, or a trade association, or a religious organization, or any other type of group that would offer health insurance like a union or a fraternal organization,” Moffit said.

More consumer control, Moffit argues, would improve trust in the healthcare system.

“They can’t trust politicians. And I don’t think they can trust corporate executives,” Moffit said. “I think they should trust themselves and they should have the authority and the power over their own healthcare dollars and their own healthcare decisions. That’s a radical shift from what we have today where in fact you have no control over any of that.”

Like Perryman, Moffit says there are major obstacles to changing the existing structure.

“An awful lot of people do very well by defending and protecting the status quo,” Moffit said. “If you do not have to face intense competition for goods and services that you’re providing, that’s a pretty good situation.”

Both men agree systemic change is needed, but admit it will be difficult to achieve in a single sweep given competing interests in Washington D.C.

full audio:
https://www.northernpublicradio.org…

Pelosi supports holding hearings on ‘Medicare for all’

By Peter Sullivan
The Hill, January 3, 2019

Speaker Nancy Pelosi (D-Calif.) supports holding hearings on “Medicare for all,” her spokesman said Thursday, marking a major step forward for supporters of a single-payer health system.

Some Democrats have been talking about holding hearings on the issue, but Pelosi’s backing is seen as a boost for those efforts.

Pelosi had said last year only that Medicare for all would “have to be evaluated” and is “on the table.”

Rep. Pramila Jayapal (D-Wash.), the main sponsor of Medicare for all in the House, said Thursday that hearings would likely start in the Rules and Budget committees.

That would leave out the main committees with jurisdiction over the issue: Energy and Commerce and Ways and Means. The chairmen of those committees have not given their backing to Medicare for all, while the chairmen of Rules and Budget have.

Jayapal has been working to update the Medicare for all legislation and said Thursday she hopes to have draft text available “in the next week or two.”

She said she is hoping to eventually have hearings in the Energy and Commerce Committee, and has spoken to its chairman, Rep. Frank Pallone Jr. (D-N.J.), but that he has yet to give a commitment to hold hearings.

“He hasn’t committed that to me but I have the Speaker’s commitment that she will help me to do this,” Jayapal said. “And I spoke to Pallone and Pallone is not opposed, he just hasn’t said yes yet.”

Pallone threw cold water on the idea in November, but that was before Pelosi’s support for hearings.

“I’ve always been an advocate for Medicare for all or single-payer, but I just don’t think that the votes would be there for that, so I think our priority has to be stabilizing the Affordable Care Act, preventing the sabotage that the Trump administration has initiated,” Pallone said in November.

Jayapal said that the bill she is working on will not spell out how the measure would be paid for or which taxes will increase.

“This is really going to be a bill on what the system looks like,” she said.

Some lawmakers are awaiting the details of the new version.

Rep. Joe Kennedy III (D-Mass.) told The Hill in November that he was “hopeful” he could support the new version if issues with last year’s bill were worked out.

(In an 11/30/18 article in The Hill, Kennedy said that the bill needs more vetting and detail, but that he “absolutely” supports the idea of single-payer health insurance, which has the government provide health insurance for everyone. “There’s no doubt that our country needs to continue this progress towards making sure that everybody gets access to health care that you need, when you need it, at a price you can afford,” he said. “That has been something that’s one of the big driving motivators for me in my work here, it’s been something that obviously members of my family have been working on for a very long time.”)

Rep. John Yarmuth (D-Ky.), the chairman of the Budget Committee, said last year that he planned to hold hearings on Medicare for all.

“Chairman Yarmuth plans to hold a hearing this Congress on the various approaches to expanding coverage and making health care more affordable, which would include different Medicare for All options,” spokesman Sam Lau said Thursday.

Rep. Richard Neal (D-Mass.), the Ways and Means chairman, has been more open to the idea, saying in December that Medicare for all deserved “a conversation.”

Democrats, however, face pressure from their left wing on the issue, not only from Jayapal but from a class of new members including incoming Rep. Alexandria Ocasio-Cortez (D-N.Y.).

https://thehill.com…

Comment:

By Don McCanne, M.D.

The political process is evolving as it should. Every seat in the House was open for the midterm election, and the voters placed control of the House in the hands of a majority that supports comprehensive health reform, with many supporting specifically Medicare for All. It is entirely appropriate for the House to now initiate hearings on Medicare for All. Many voters and certainly several members of Congress would like to have more details on what Single Payer Medicare for All would look like and how it would work. The hearings thus can serve an important role in educating Congress and the public at large.

Since President Trump and the majority in the Senate state that they oppose Medicare for All, it is unrealistic to expect that such a program could be enacted in this session of Congress. But the next election is less than two years away and that is a very short time to inform and mobilize the political forces that would be essential for enabling enactment of Medicare for All.

The hearings will be part of the process, but it is important that we continue with our other advocacy activities as well. Special targets should include politicians who do not yet seem to understand why single payer is an imperative, and politicians who profess to be advocates but who could be swayed to support detrimental reform policies in a perversion of the process of political compromise. We need to continue to work with politicians who are already fully on board, but we should also continue our efforts to educate those who say they are opposed, if, for no other reason, they might accept defeat more readily were they to understand the clear social benefit of Medicare for All. Also we cannot let up in the least in our efforts to educate the public at large. Grassroots efforts will continue to be an essential component of the reform effort.

As a 501(c)(3) organization, PNHP does not support any individual politician or political party. We encourage all politicians, regardless of political affiliation, to learn about and support a single payer national health program, an improved Medicare for all, that would ensure comprehensive, affordable health care for everyone.

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Coverage Denied: Medicaid Patients Suffer As Layers Of Private Companies Profit

By Chad Terhune
Kaiser Health News, January 3, 2019

Marcela Villa isn’t a big name in health care — but she played a crucial role in the lives of thousands of Medicaid patients in California. Her official title: denial nurse.

Each week, dozens of requests for treatment landed on her desk after preliminary rejections. Her job, with the assistance of a part-time medical director, was to conclusively determine whether the care — from doctor visits to cancer treatment — should be covered under the nation’s health insurance program for low-income Americans.

She was drowning in requests, she said, and felt pressed to uphold most of the denials she saw. “If it was a high-dollar case, they tried to deny it,” Villa said. “I told them you can’t deny it just because it’s going to cost $20,000.”

Villa, 32, did not work for the government. She did not even work for an insurer under contract with the government. She worked for a company now called Agilon Health. Owned by a private equity firm, it’s among the legion of private subcontractors looking to profit from Medicaid patients.

California’s Medicaid program, known as Medi-Cal, has determined that the Long Beach company, which was paid to coordinate care for about 400,000 patients, improperly denied or delayed care for at least 1,400 of them, state officials confirmed. The state Department of Managed Health Care is investigating further.

The state findings, along with internal company documents and a whistleblower complaint obtained by Kaiser Health News, shine a light on the potential dangers of outsourcing care for poor people. Government oversight, not rigorous to begin with, fades as taxpayer money filters down through layers of companies eager to seize on Medicaid’s substantial growth under the Affordable Care Act. Medicaid officials say they have authority only over the health plans, not their subcontractors.

Skimping On Services?

Nearly three-quarters of the 73 million low-income Americans on Medicaid are now in managed care, in which states pay health insurers fixed monthly amounts for each enrollee to cover the range of services they need.

Under this system, keeping patients as healthy as possible is one way to make money. Another is to deny or skimp on services.

Increasingly, Medicaid plans outsource the work of managing patients’ health and medical treatment to subcontractors like Agilon — passing along a share of the government money coupled with the financial risk posed by a fixed budget.

These firms can be powerful gatekeepers. They run physician groups, bear responsibility for forming doctor networks and judge whether a request for care is necessary.

Agilon is a big player in California — doing business with insurers such as Molina Healthcare and Blue Shield of California.

Agilon’s June report depicts an operation that was often stretched thin: Nurses were handling 120 to 200 requests for care per day, on average, with no full-time medical director to review the findings.

From 2014 until May, the company relied on a family physician who was working 10 to 12 hours a day running his own medical practice, according to the report.

Ultimately, Agilon’s internal investigation found that patient care may have been denied 439 times since 2014 without a physician’s review of the medical records — a potential violation of state law. Under California law, only a licensed physician or health care professional who is “competent to evaluate the specific clinical issues involved” can determine medical necessity.

“These private entities get very little oversight,” said Linda Nguy, a policy advocate at the Western Center on Law & Poverty in Sacramento, “and there’s real harm being done to patients.”

https://khn.org…

Comment:

By Don McCanne, M.D.

Private Medicaid managed care companies using private subcontractors to appropriate to themselves our public funds by denying health care – need we say more?

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Medicare for All now supported by even more evidence

By Donald R. Frey, M.D.
Omaha World-Herald, December 27, 2018

In the frenzy of the last election cycle, it was easy to overlook the release of America’s most recent health care data. But the picture this information painted was anything but pretty.

Our life expectancy continues to decline while the rest of the world improves. Maternal mortality is increasing, the number of children who are uninsured is growing and, while the rest of the world has seen a 29 percent reduction in suicide rates, America’s has grown by 18 percent.

Despite a reduction of 20 million uninsured Americans since the passage of the Affordable Care Act, 30 million others continue to be uninsured, and still others struggle with medical expenses.

The situation has become so critical that even conservative pundits have felt compelled to offer suggestions. According to a recent Tom Purcell column ( Dec. 1, More Commentary), the answer is to spend hundreds of out-of-pocket dollars on tests of questionable value, then join an “association” where your care will be decided by the association’s religious beliefs. Ben Shapiro (Nov. 28, More Commentary) has an even more novel approach. Can’t pay for health care? Start a Go Fund Me page. And by now, we’ve all seen the television commercial where a business owner describes how he can afford to offer health insurance to his employees because of his credit card rebate.

So whether you can get health insurance now depends on your boss’s credit card?

As a physician, I first began writing about the inefficiencies and disparities I was seeing in American health care over 30 years ago. At that time, conventional wisdom held that our health care was the “best in the world,” our outcomes were superior and every country that offered universal health care would soon collapse.

Earlier this year, amid much fanfare, the Koch-funded Mercatus Institute at George Mason University released a 24-page analysis of Medicare for all and declared that it would add $28 trillion to the federal budget over the next 10 years. This news was splashed all across conservative media outlets.

Then, just as suddenly, the discussion went radio silent.

What happened? Buried in the study was this inconvenient truth — under Medicare for all, not only would all Americans gain insurance coverage, but total health care spending would actually drop by $2 trillion over 10 years.

In other words, that $28 trillion that made such headlines? The truth is, we are already paying those costs through high premiums, co-pays, deductibles and uncovered expenses. Medicare for all would simply spend the same money more effectively.

And now, this conclusion has been further confirmed by a much more robust Political Economy Research Institute Study released by the University of Massachusetts. In a rigorous 200 page analysis, the study also demonstrates that Medicare for all would provide coverage for all Americans but calculates the savings at $5 trillion. Another analysis by Physicians for a National Health Program places the savings closer to $10 trillion.

Conservative study. Liberal study. Physicians’ study. It doesn’t matter. Each one shows that Medicare for all covers everyone and saves money in the process.

Both Presidents Teddy Roosevelt and Harry Truman were adamant that America needed a universal health care system. Both hoped they would see it in their lifetime. It’s high time we carried their dreams to fruition.

Or maybe not. Instead, we can always just cross our fingers and keep taking our chances on Go Fund Me pages and our boss’s credit card.

Dr. Frey is professor of family medicine at the Creighton University School of Medicine.

https://www.omaha.com…

Interview of Robert Pollin, lead author of PERI analysis of Medicare for All

Medicare Will Be Good for Everyone — Except CEOs: An Interview with Robert Pollin

By Doug Henwood
Jacobin, December 26, 2018

How much will universal health coverage cost? The Mercatus Institute, a Koch-funded free-market think tank at George Mason University, recently put it at $32 trillion over the next decade. That sounds like a lot, but is it?

Well, the study also estimated that the cost was $2 trillion less than it would cost to do just the same thing as we are now — which is surprising considering the source, but much less interesting to mainstream reporters.

But the Political Economy Research Institute at the University of Massachusetts has its own estimates. Its long and rigorous study shows we could cover everyone in the United States with no copays and cut overall health spending by almost a fifth. Lead author Robert Pollin, professor of economics at the University of Massachusetts and co-director of PERI, recently spoke with Doug Henwood for his Jacobin podcast Behind the News.

Doug Henwood: You’re projecting over the long-term that US health care expenditure would stabilize around 15 percent or 16 percent of GDP. Which is still well above what we see in Canada and Britain, and quite above also Germany and France, who spend more than Canada and Britain.

We’re talking about a difference of a trillion or more dollars, which is enough to save the climate and have enough left over for dessert. Why can’t we get down to those levels?

Robert Pollin: Very good question. We really wanted this study to be really heavily peer reviewed. One reviewer was Jeffrey Sachs, who was extremely active and very helpful, and was quite critical in some points. This was his main question. “If we’re going to do all of this, we end up with a system that is going to cost 16 percent of GDP. Why can’t we do better, if Canada and the others are 11 percent, 10 percent, 9 percent?”

Some of the other reviewers I have were pushing on the other side, saying, “You can’t make these cuts. It’s unrealistic to think you’re going to get this level of savings.” On balance, this is where I think is realistically we can get to.

Henwood: We have this coalition now developing in Congress of Democrats opposed to any idea of single-payer, so not obvious at this point.

Pollin: Well, not obvious. But 70 percent of the population says they’re for it.

The argument was for a long time, “Yeah, you may be for it, but you don’t know what the hell it is and you can’t pay for it.” I hope that my study and other people’s studies have demonstrated that that simply isn’t true. It was obvious all along that it wasn’t true — other countries are paying a lot less, and they have some equivalent to Medicare for All.

But in the US case, now we have these various studies, including ours, that make it blindingly clear that this is completely practical, and the financing works. It works way better for almost everybody in society. It relieves people of all the anxieties they have about how they cover themselves when they have health problems. It’s a much better way to run a health care system.

On the other side, you have people making tons of money off of a bad health care system. That’s what we are going to struggle over.

https://www.jacobinmag.com…

U MASS PERI Analysis:
https://www.peri.umass.edu…

Reviewer Assessments, including that of PNHP’s Woolhandler, Himmelstein, and Gaffney:
https://www.peri.umass.edu…

Comment:

By Don McCanne, M.D.

Those passionate about single payer have been energized by the expanding public support for Medicare for All and by recent policy studies such as that by U MASS-Amherst Professor Robert Pollin and his colleagues, and also particularly by the fact that legislative models are in development on both the state and federal levels. But there are disputes about both policy and process.

Once you exclude those who oppose a government role in ensuring health care for all, the primary disagreement on policy is whether we want to build on our current dysfunctional model of financing health care or if we want to move forward with Single Payer Medicare for All. There is really no contest since the single payer model wins out based on effectiveness, efficiency, accessibility in a system that is both affordable and equitable. Building on the current system by measures such as adding a public option or Medicare buy-in doesn’t come close; lack of insurance, underinsurance, impaired access, and financial hardship would be perpetuated. There are still some differences of opinion regarding details of the single payer model, but this can be worked out cooperatively. What is clear is that expanding the current system is not adequate.

What about process? Above all we need to work with legislators and their staffs and others in the policy community who will be providing input into the legislative process. But in our passion it is essential that we not forget about the importance of civility.

Before Pollin’s team released their analysis, they had it reviewed by several other noted individuals from the policy community (link above). Although not all differences were resolved, the various opinions were advanced for consideration by the community at large. This process includes the crucial ingredient of civility. Without it, the process breaks down, as our highly polarized members of Congress demonstrate repeatedly.

When the legislation needs to be protected against flawed or harmful policies, working together with our colleagues to educate the legislative staffs will get us much further than bombarding them with what appears to them to be the product of uncooperative dissidents. Again, when we are clearly in the right, civility will pave the way.

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Medicare for All Explained Podcast: Episode 3

Interview with Dr. Nicte Mejia

January 1, 2019

Dr. Mejia practices in a state where many people are insured (Massachusetts) but says single payer would be a dramatic improvement because it would eliminate copays and deductibles, and fully cover long-term care. Hosted by Joseph Sparks. Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Is ‘Medicare Advantage for All’ just around the corner?

‘Medicare for All’ Gains Favor With Democrats Looking Ahead to 2020

By Robert Pear
The New York Times, December 29, 2018

More and more Democrats, fed up with private health insurance companies, are endorsing the goal of a government-run, single-payer system like Medicare for all Americans. But they have discovered a problem. More than one-third of Medicare beneficiaries are in Medicare Advantage plans, run not by the government but by private insurers.

Whether to allow younger Americans to enroll in such private Medicare plans has become a hotly debated political question as Democrats look to 2020.

When liberal Democrats started advocating “Medicare for all” more than 25 years ago, Medicare was the original fee-for-service program run by the government. Since then, it has changed in big ways. More than 20 million of the 60 million beneficiaries are in comprehensive Medicare Advantage plans sold by private insurers like UnitedHealth, Humana, Kaiser Permanente and Blue Cross and Blue Shield.

“Medicare for all” has become a rallying cry for progressive Democrats, though it means different things to different people. Supporters generally agree that it is a way to achieve universal coverage with a system of national health insurance in which a single public program would pay most of the bills, but care would still be delivered by private doctors and hospitals.

Billy Wynne, a health care lobbyist who used to work for Senate Democrats, said: “The literal meaning of ‘Medicare for all’ would include Medicare Advantage. But that is not what most supporters of Medicare for all have in mind.”

The champions of Medicare for all generally see insurance companies as part of the problem, not the solution.

“There are a lot of insurance companies and medical companies that are advocating for their own best interests, and those best interests are usually money, and not people’s health,” Representative-elect Deb Haaland, Democrat of New Mexico and a supporter of Medicare for all, said in an interview.

President Trump and other Republicans have mocked the idea of Medicare for all, saying it could ruin the program for older Americans and generate huge costs for the federal government. It would “come at a staggering cost to taxpayers,” said Alex M. Azar II, the secretary of health and human services.

Asked if his vision of Medicare for all included private Medicare Advantage plans, Adam Green, a founder of the Progressive Change Campaign Committee, an advocacy group, said: “No, absolutely not. Why would it? Medicare for all, in the end, means fundamental systemic change. People would no longer be at the mercy of for-profit insurers that make money by denying people care.”

Mr. Sanders and Representative Pramila Jayapal, Democrat of Washington and a chairwoman of the Medicare for All Caucus in Congress, see no need for private Medicare Advantage plans.

Vedant Patel, a spokesman for Ms. Jayapal, said her vision of Medicare for all was the traditional Medicare program, not private plans. “The purpose of Medicare for all is defeated if there are other plans people can buy into,” he said.

Josh Miller Lewis, a spokesman for Mr. Sanders, said: “We would get rid of duplicative health insurance. Our version of Medicare would cover most procedures. There would be no need for a Medicare Advantage program.”

Other lawmakers support expanding Medicare, but do not want to disrupt coverage for consumers who like the insurance they have.

Josh Miller Lewis, a spokesman for Mr. Sanders, said: “We would get rid of duplicative health insurance. Our version of Medicare would cover most procedures. There would be no need for a Medicare Advantage program.”

Other lawmakers support expanding Medicare, but do not want to disrupt coverage for consumers who like the insurance they have.

“Millions of Americans who rely on employer-sponsored insurance and Medicare Advantage are satisfied with their coverage,” said Representative Rosa DeLauro, Democrat of Connecticut.

Some health policy experts have suggested building a national health insurance program on Medicare Advantage rather than on the traditional fee-for-service Medicare program.

“Medicare Advantage for all — that would be a much more politically feasible and a uniquely American spin on single payer,” said John K. Gorman, a former Medicare official who is a consultant to many insurers. “It would be Medicare paying all the bills, but it would be privately administered by heavily regulated plans that would effectively serve as utilities.”

https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

As we move into the next year, we should be celebrating the fact that “Medicare for All” has gained traction and now has widespread support throughout the United States. But can we? Any celebration has to be tempered by the fact that a multitude of very powerful forces are hijacking the “Medicare for All” label and using it to advance their own agendas based on ideology and especially greed.

What has crept into the national dialogue more recently is an emphasis that Medicare is not just the traditional public program but it also includes the private Medicare Advantage plans. The latter are being promoted by those in the insurance industry camp as the ideal model for expanding the Medicare program, whether by reducing the eligibility age, or by offering Medicare Advantage as a ready-to-go “public option” (that is actually private), or by opening up the ACA exchanges to include private Medicare Advantage plans (as a devious route to premium support – using ACA subsidies to support privatized Medicare).

Whatever, it is clear that the private insurance industry is going to continue to do all it can to capture the present and future versions of the Medicare program, and they are doing it with the help not only of the conservatives but also the neoliberals who have infiltrated the progressive camp. We will likely be hearing much more about Medicare Advantage for All.

It is going to be a rough year.

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