PNHP

Uninsured rate at four-year high

Uninsured rate at four-year high

U.S. Uninsured Rate Rises to Four-Year High

By Dan Witters
GALLUP, January 23, 2019

The U.S. adult uninsured rate stood at 13.7% in the fourth quarter of 2018, according to Americans’ reports of their own health insurance coverage, its highest level since the first quarter of 2014. While still below the 18% high point recorded before implementation of the Affordable Care Act’s individual health insurance mandate in 2014, today’s level is the highest in more than four years, and well above the low point of 10.9% reached in 2016. The 2.8-percentage-point increase since that low represents a net increase of about seven million adults without health insurance.

https://news.gallup.com…

Comment:

By Don McCanne, M.D.

According to this GALLUP survey, the uninsured rate declined from 18 percent just before implementation of the Affordable Care Act down to 10.9 percent in 2016. It has since increased to the current level of 13.7 percent, a net increase of about seven million adults now without health insurance since its 2016 low.

This is the program that was enacted after an intensive political effort that began with rejection of the single payer model that would have reduced the uninsured rate to zero percent.

A majority of the nation now understands that we need to enact and implement Single Payer Medicare for All – a program in which everyone is automatically enrolled for life. Yet where are our politicians headed? The Republicans support only guaranteeing access to coverage for individuals with preexisting disorders, yet they offer no practical plan for making that happen. The Democrats campaigned on Medicare for All, yet they want to take us back down the same ACA pathway, leaving tens of millions uninsured and many millions more underinsured.

The original goal supposedly was to make health care affordable and accessible for everyone. The Affordable Care Act, even with the various proposed tweaks, cannot possibly ever get us there because of its unrectifiable design defects. In contrast, the Single Payer Medicare for All model is specifically designed to accomplish that goal, and it would actually work.

So the numbers of uninsured have recently again increased by seven million, and the politicians want more of that system? Shall we ask those seven million uninsured people what they think of it? Or do we even care? (How could anyone ask that last question? But…)

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

More nuanced views of health care reform

KFF Health Tracking Poll – January 2019: The Public On Next Steps For The ACA And Proposals To Expand Coverage

By Ashley Kirzinger, Cailey Muñana, and Mollyann Brodie
Kaiser Family Foundation, January 23, 2019

This month’s KFF Health Tracking Poll continues to find majority support (driven by Democrats and independents) for the federal government doing more to help provide health insurance for more Americans. One way for lawmakers to expand coverage is by broadening the role of public programs. Nearly six in ten (56 percent) favor a national Medicare-for-all plan, but overall net favorability towards such a plan ranges as high as +45 and as low as -44 after people hear common arguments about this proposal.

Larger majorities of the public favor more incremental changes to the health care system such as a Medicare buy-in plan for adults between the ages of 50 and 64 (77 percent), a Medicaid buy-in plan for individuals who don’t receive health coverage through their employer (75 percent), and an optional program similar to Medicare for those who want it (74 percent). Both the Medicare buy-in plan and Medicaid buy-in plan also garner majority support from Republicans (69 percent and 64 percent­).

Moving forward, half of Democrats would rather see the new Democratic majority in the U.S. House of Representatives focus their efforts on improving and protecting the ACA (51 percent), while about four in ten want them to focus on passing a national Medicare-for-all plan (38 percent).

Malleability in attitudes towards national health plan and lingering confusion about possible impacts

This month’s KFF Health Tracking Poll finds the net favorability of attitudes towards a national Medicare-for-all plan can swing significantly, depending on what arguments the public hears.

Net favorability towards a national Medicare-for-all plan (measured as the share in favor minus the share opposed) starts at +14 percentage points and ranges as high as +45 percentage points when people hear the argument that this type of plan would guarantee health insurance as a right for all Americans. Net favorability is also high (+37 percentage points) when people hear that this type of plan would eliminate all premiums and reduce out-of-pocket costs. Yet, on the other side of the debate, net favorability drops as low as -44 percentage points when people hear the argument that this would lead to delays in some people getting some medical tests and treatments. Net favorability is also negative if people hear it would threaten the current Medicare program (-28 percentage points), require most Americans to pay more in taxes (-23 percentage points), or eliminate private health insurance companies (-21 percentage points).

While most Americans (77 percent) are aware they would have to pay more in taxes to cover the cost of health insurance if a national Medicare-for-all plan was put into place, there is some confusion about whether people would be able to keep their current health insurance. Most people under the age of 65 and who currently have employer-sponsored insurance say that if a national health plan was put into place, they would be able to keep their current coverage (55 percent) while about four in ten (37 percent) are aware they would not be able to keep their current coverage.

And while majorities say low-income people and people who currently don’t have health insurance would be “better off” if a national Medicare-for-all plan was put into place, there is less certainty among the public about how much it would impact them, personally. Across demographic groups, about four in ten say that if a national Medicare-for-all plan was put into place it “would not have much impact” on them.

Medicare-for-All and seniors

Overall, a larger share of the public say a Medicare-for-all plan will “not have much impact” on seniors (39 percent) or say that they would be “better off” (33 percent) than say seniors would be “worse off” (21 percent).

Democrats want Democratic lawmakers to focus on ACA rather than Medicare-for-All

Despite the recent attention on proposals to expand Medicare or Medicaid, when asked to choose Democrats would rather the new Democratic majority in the U.S. House of Representatives focus their efforts on “improving and protecting the ACA” rather than “passing a national Medicare-for-all plan.” Half (51 percent) of Democrats say House Democrats should focus on the ACA while four in ten (38 percent) say they should focus on passing a national Medicare-for-all plan. The share of Democrats who want Congress to focus on passing a national Medicare-for-all plan is down 10 percentage points from March 2018.

Partisans have different health priorities for Congress

When forced to choose the top Congressional health care priorities, the public chooses continuing the ACA’s pre-existing condition protections (21 percent) and lowering prescription drug cost (20 percent) as the most important priorities for Congress to work on. Smaller shares choose implementing a national Medicare-for-all plan (11 percent), repealing and replacing the ACA (11 percent), or protecting people from surprise medical bills (9 percent) as a top priority. One-fourth said none of these health care issues was their top priority for Congress to work on.

Continuing the ACA’s pre-existing condition protections is the top priority for Democrats (31 percent) and ranks among the top priorities for independents (24 percent) along with lowering prescription drug costs, but ranks lower among Republicans (11 percent). Similar to previous KFF Tracking Polls, repealing and replacing the ACA remains one of the top priority for Republicans (27 percent) along with prescription drug costs (20 percent).

The Role of independents in the Democratic health care debate

One of the major narratives coming out of the 2018 midterm elections was the role that health care was playing in giving Democratic candidates the advantage in close Congressional races. Consistently throughout the election cycle, KFF polling found health care as the top campaign issue for both Democratic and independent voters. While a majority of Democrats want the new Democratic majority in the U.S. House of Representatives to focus on improving and protecting the ACA, Democratic-leaning independents have more divided opinions of the future of 2010 health care law. These individuals – who tend to be younger and male – would rather Democrats in Congress focus efforts on passing a national Medicare-for-all plan (54 percent) than improving the ACA (39 percent) – which is counter to what Democrats overall report. In addition, when asked whether House Democrats owe it to their voters to begin debating proposals aimed at passing a national health plan or work on health care legislation that can be passed with a divided Congress and a Republican President, Democrats are divided (49 percent v. 44 percent) while Democratic-leaning independents prioritize House Democrats working on bipartisan health care legislation (53 percent) over debating national health plan proposals (39 percent).

https://www.kff.org…

Comment:

By Don McCanne, M.D.

Medicare for All now has more public support than ever before, but this highly credible poll reminds us that some are still confused on the policy issues, and many are swayed by rhetoric and framing of those who are supporting alternative visions of reform, especially from the neoliberal and conservative ranks.

When poll results like this are released, there is a tendency to criticize the pollsters for failing to ask the right questions and then to dismiss the results. On the contrary, we should use the perceptions of those polled to refine our own messages. The lesson is that we still have a long way to go on educating the public at large on health policies that would benefit us all – those of the Single Payer Medicare for All model.

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

Progressives Warn Against Democrats Pushing ‘Diluted’ Half-Measures as Alternative to Medicare for All

"Improved Medicare for All has support from an overwhelming majority of Democratic voters, so why the sudden proliferation of public option proposals? We should be very skeptical of these sorts of bills."

By Jake Johnson
Common Dreams, January 22, 2019

A Medicare buy-in. A Medicaid buy-in. Medicare for retiring police officers and firefighters under the age of 65. Defend and strengthen Obamacare.

With Medicare for All polling at an unprecedented 70 percent support among the American public and headed toward its first-ever congressional hearing, Politico on Tuesday reported that there is a growing effort among congressional Democrats—including some 2020 presidential hopefuls—to “water down” the grassroots push for a transformative single-payer program by offering up more incremental approaches to solving America’s for-profit healthcare crisis.

The proposals listed above, which Politico encapsulated with the term “Medicare for More,” are just a handful of ideas Democratic lawmakers have put forth as ostensibly more “pragmatic” paths to achieving a humane healthcare system.

But grassroots Medicare for All advocates and campaigners—whose voices were absent from Politico‘s report—strongly objected to any plan that leaves intact central elements of a status quo that has produced enormous profits for the insurance and pharmaceutical industries, while leaving millions of Americans with soaring costs or entirely uninsured.

“Improved Medicare for All has support from an overwhelming majority of Democratic voters, so why the sudden proliferation of public option proposals? We should be very skeptical of these sorts of bills,” Dr. Adam Gaffney, president of Physicians for a National Health Program (PNHP), told Common Dreams.

“They would not solve the fundamental problems of the American healthcare system, such as uninsurance, underinsurance, enormous administrative waste, or sky-high drug prices,” Gaffney added. “Only improved Medicare for All, aka single-payer, could accomplish those goals, reining in costs while achieving first-dollar universal coverage for everyone in the nation. This should be the moment that lawmakers coalesce behind the single-payer bills in the House and the Senate.”

According to Politico, Democratic leaders as well as rank-and-file lawmakers like Sens. Sherrod Brown, Tim Kaine, and others are refusing to throw their support behind Medicare for All, instead backing plans that “range from modest Medicare reforms to more ambitious restructurings that would extend government-run care to millions of new patients—an array of options that fall short of campaign trail promises for full Medicare for All.”

Michael Lighty, a founding fellow of the Sanders Institute, told Common Dreams that such incremental approaches completely fail to address the fundamental crises at the heart of the U.S. healthcare system, which is the most inefficient and ineffective in the industrialized world.

“The dilution of improved Medicare for All remains the greatest threat to guaranteeing healthcare for all,” Lighty said. “Without eliminating all barriers to care—starting with the huge out-of-pocket costs workers must pay—we cannot create a just healthcare system. We cannot reduce the huge administrative costs if we continue a fragmented system dominated by commercial insurance companies. This diluted approach would institutionalize big profits, high executive salaries, and political clout for the healthcare industry.”

Lighty concluded that Democrats should stop pushing half-measures and work to “improve Medicare for everybody.”

In addition to efforts by some Democrats to undercut Medicare for All with non-universal plans that critics say would fail to deliver badly needed results, the insurance industry and major business lobbying groups like the Chamber of Commerce are ramping up their own campaigns to crush single-payer before it gets off the ground.

Thomas Donohue, the president and CEO of the Chamber of Commerce, vowed earlier this month to use all of the resources at his disposal to “combat” Medicare for All.

As part of the effort to overcome this deep-pocketed opposition, National Nurses United (NNU) is holding nationwide Medicare for All “barnstorms” next month to help “build the mass collective action we know we’ll need to win.”

In a Tuesday op-ed on Common Dreams, essayist Thomas Neuburger wrote that Democrats will soon be forced to pick a side in the immensely consequential fight over the future of the American healthcare system.

“When Medicare for All becomes a bill, the fight will be a cage match with the bright lights on,” Neuburger noted. “What will the Democratic Party (in the aggregate) do in response? Will it support, whole-heartedly and by its actions, the health and welfare of the American people, or continue the abuse of the American people by supporting those who extract wealth from suffering?”

https://www.commondreams.org…

More Trump administration abuse through the rule-making process

Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2020

Health and Human Services Department, Proposed Rule, January 17, 2019

Summary

This proposed rule sets forth payment parameters and provisions related to the risk adjustment and risk adjustment data validation programs; cost-sharing parameters; and user fees for Federally-facilitated Exchanges (FFEs) and State-based Exchanges on the Federal Platform (SBE-FPs). It proposes changes that would allow greater flexibility related to the duties and training requirements for the Navigator program and proposes changes that would provide greater flexibility for direct enrollment entities, while strengthening program integrity oversight over those entities. It proposes policies that are intended to reduce the costs of prescription drugs. It includes proposed changes to Exchange standards related to eligibility and enrollment; exemptions; and other related topics.

https://www.federalregister.gov…

Unpublished rule – 331 pages:
https://www.federalregister.gov…

This document is scheduled to be published in the Federal Register on 01/24/2019 and available online at:
https://federalregister.gov…

Fact Sheet – 4 pages:
https://www.cms.gov…

By Katie Keith
Health Affairs Blog

The 2020 Proposed Payment Notice, Part 1: Insurer And Exchange Provisions:
https://www.healthaffairs.org…

The 2020 Proposed Payment Notice, Part 2: Risk Adjustment:
https://www.healthaffairs.org…

Trump Proposals Could Increase Health Costs for Consumers

By Robert Pear
The New York Times, January 21, 2019

Consumers who use expensive brand-name prescription drugs when cheaper alternatives are available could face higher costs under a new policy being proposed by the Trump administration.

The proposal, to be published this week in the Federal Register, would apply to health insurance plans sold under the Affordable Care Act.

The administration is proposing several other changes that could increase costs for consumers.

Under the proposal, fewer people would qualify for federal subsidies, and those who qualify could be required to spend a larger share of their income on insurance premiums.

The Trump administration estimated that the changes would save the government $900 million annually in subsidies in 2020 and 2021 and $1 billion a year in 2022 and 2023. In addition, it predicted that 100,000 fewer people would have coverage through the insurance exchanges created under the Affordable Care Act.

The administration said that some of the 100,000 people might buy short-term insurance policies, which do not have to cover pre-existing conditions or provide all the benefits required by the health law. But, it said, most are “likely to become uninsured.”

Either way, the administration said, “these individuals will be bearing a larger share of the costs of their own health care consumption.”

Senator Ron Wyden of Oregon, the senior Democrat on the Finance Committee, described the new proposed rule as “Trump’s latest attempt to sabotage health care.”

https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

The federal process of making arcane rules is somewhat elaborate, requiring publication of the proposed rule in the Federal Register to provide an opportunity for public comment. Since none of us read the rules, the process favors the vested interests that do provide input. More importantly, it is used by the administration to change the rules so that they are more com[pliant with their ideological preferences.

Although the title of this particular rule indicates that it is about benefit and payment parameters under ACA, you really should quickly skim-read the four-page fact sheet if you want to get an idea of the extent of the rule changes. If you want to better understand some of the rule changes, the two articles in the Health Affairs Blog by Katie Keith can be helpful, though they are heavy on academic rhetoric. We’ll mention only two topics here.

One of the major defects of the Affordable Care Act is that it relies heavily on private health insurance plans. Thus the risk pool is split amongst the various insurers. The insurance industry is notorious for adopting policies that manipulate the risk pool to improve their bottom lines. Thus risk adjustment has become essential to transfer funds from insurers that had healthier patients and thus paid out less in health benefits to insurers that had to pay out more because of greater “losses” because their clients had greater needs. Decades of experience have shown that the program administrators cannot get risk adjustment right. The proposed rule on “recalibrating the risk adjustment models using a blended average from 2017 MarketScan® data and 2016 and 2017 enrollee-level EDGE data” and on “Risk Adjustment Data Validation (RADV) Audits” may convince you that they will never get it right.

The obvious solution is that we need to get rid of the fragmented system of private insurers and establish one single risk pool that covers everyone. This, of course, is what a Single Payer Medicare for All program would do.

The other topic to be mentioned regards the prescription drug benefit. Without discussing here any of the specific proposals in the rule, Robert Pear, in his New York Times article writes, “fewer people would qualify for federal subsidies, and those who qualify could be required to spend a larger share of their income on insurance premiums.” Also, most of the 100,000 who would lose their ACA coverage are “likely to become uninsured.” Pear also reports that Senator Ron Wyden described the new proposed rule as “Trump’s latest attempt to sabotage health care,” and it does.

There would certainly be rule-making under Single Payer Medicare for All, but the rules would be designed to benefit patients rather than designed to satisfy the whims of the right-wing, anti-government ideologues who are also rewarding their friends in the health care corporate world with our tax funds.

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

Martin Luther King Jr. on the myth of time

By Dr. Martin Luther King Jr.
City Temple, London, England, December 7, 1964

Now I would like to mention one or two ideas that circulate in our society—and they probably circulate in your society and all over the world—that keep us from developing the kind of action programs necessary to get rid of discrimination and segregation. One is what I refer to as the myth of time. There are those individuals who argue that only time can solve the problem of racial injustice in the United States, in South Africa or anywhere else; you’ve got to wait on time. And I know they’ve said to us so often in the States and to our allies in the white community, “Just be nice and be patient and continue to pray, and in 100 or 200 years the problem will work itself out.” We have heard and we have lived with the myth of time. The only answer that I can give to that myth is that time is neutral. It can be used either constructively or destructively. And I must honestly say to you that I’m convinced that the forces of ill will have often used time much more effectively than the forces of goodwill. And we may have to repent in this generation, not merely for the vitriolic words and the violent actions of the bad people, but for the appalling silence and indifference of the good people who sit around saying, “Wait on time.”

And somewhere along the way it is necessary to see that human progress never rolls in on the wheels of inevitability. It comes through the tireless efforts and the persistent work of dedicated individuals who are willing to be co-workers with God. And without this hard work, time itself becomes an ally of the primitive forces of social stagnation. And so we must help time, and we must realize that the time is always ripe to do right. This is so vital, and this is so necessary.

Democracy Now! MLK Day Special: Rediscovered 1965 King Speech on Civil Rights, Segregation & Apartheid South Africa:
https://www.democracynow.org…

Comment:

By Don McCanne, M.D.

And they are telling us, “We don’t have time for Medicare for All. We’ll be too busy trying to fine tune the Affordable Care Act.”

We don’t have time to enact and implement a health care financing system that is truly universal, affordable, efficient, effective and equitable because we have to use that time refining a system that has none of these features? We have time to expand the health care business model in order to enhance the returns of the medical-industrial complex, the private insurers and the pharmaceutical industry, but we can’t use that same time to ensure health care justice for all?

Maybe we should read once again Martin Luther King’s words on the myth of time.

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

Your Health Care is a Business Opportunity?

By Brad Cotton, M.D.
Circleville (Ohio) Herald, January 20, 2019

The floodlight lit Cleveland Clinic at night towered over Cleveland’s dirt poor east side like an Egyptian pyramid. As a paramedic on those desperate streets I could see the plush helicopters chauffeuring the Arab oil sheiks in for their cardiac bypass grafts. Some say this is proof America has the best health care system in the world. I say it means we have the best health care system that oil money could buy. My patients that I took to the ERs at Charity, Sinai and St Luke’s didn’t get good health care. The ER was their only refuge. They lived sick and died young while the plush helicopters landed at the walled-off shining white pyramid.

American physician Dr. James Peter Warbasse understood the problem over a hundred years ago saying in 1918: “Among the wealthy there now is a surfeit of doctors; among the poor, too few… I believe that the wives of coal miners and iron workers are as worthy of the best of the best scientific attention and tenderest care in the hour in the hours of their need as are the wives of the the rich. I believe that they should have it, not as a charity or welfare enterprise, but as a matter of social justice. It is their right.”

I have been told that my intensity and passion in these columns has been disturbing to some. I do believe we have to allow facts to guide our ideology, rather than ideology blinding us to the facts. Business and markets do not work for health care. My passion, even anger, stems from being face to face and heart to heart with the intense suffering, pain, even death visited upon our good, hard-working neighbors who are abandoned by health care business and markets. They have nowhere else to go but the ER.

My professional association, the American College of Emergency Physicians (ACEP) reports that 81 percent of its’ members report seeing patients seriously harmed by lack of health insurance. I submit that the 19 percent who do not report such either work in extremely affluent areas or are so focused on pulling drowning patients out of the river, that they are too busy to look upstream to note that it is business and markets ideology that is throwing their patients in the river in first place. ACEP is actively suing Anthem for protecting its’ profits by denying payment retroactively for ER visits it deems ( deems as a “Monday morning quarterback”) to have been unnecessary, thus forcing patients to try and wait out a potential stroke, heart attack or appendicitis at home out of fear for the cost. Proud to pay my dues to ACEP!

My friend and fellow activist member of the Ohio Single Payer Action Network (join us at www.spanohio.org!) Dr. Jonathan Ross is eminently quotable :

“Americans have an almost religious belief that market forces can solve any problem. Narrow physician networks (my parentheses: narrow networks is your insurer limits Docs you can see) are at the heart of the ProMedica vs. Aetna dispute. Narrow networks are supposed to create competition that will control costs and improve quality. Instead, they create out of network price gouging by providers. This is not the first bad idea promoted by the acolytes of market forces in health care. We have tried privatization of Medicare through competing Medicare Advantage plans, privatization of Medicaid by competing HMOs, privatizing facilities like nursing homes, home care, hospices and dialysis. We have tried insurance reforms such as marketplace exchanges like those of Obamacare, the federal employee health benefit system, high risk pools to reduce insurer risk, and expanding insurance markets across state lines. We have tried putting providers and patients at risk through HMOs, PPOs, ACOs, capitation, health savings accounts, high deductible health plans, bundled payments, pay for performance, narrow networks, and the Holy Grail for doctors—-malpractice reforms. All have failed to control cost, improve outcomes, or expand access.”

Dr. Ross goes on to note that Winston Churchill said that Americans can always be counted on to do the right thing, after we have tried to do everything the wrong way first. We are the only advanced nation in the world that believes that having business and profit, MBAs and pin-striped financiers at the bedside is the best for our health. Many are afraid of “government health care”, really, are you afraid of Medicare? I am afraid of Wall Street corporate health insurers and Big Pharma—I see every day the harm they wreak upon my innocent neighbors. It is time for single payer improved and expanded “Medicare for All”. We shall continue to explore on these pages both the moral underpinnings as well as the precise specifics of how “Medicare for All” is not only safe and compassionate but is cost-effective, saving you and your family large sums of real money.

https://www.circlevilleherald.com…

Hospital readmission reduction program does not live up to its hype

Decreases In Readmissions Credited To Medicare’s Program To Reduce Hospital Readmissions Have Been Overstated

By Christopher Ody, Lucy Msall, Leemore S. Dafny, David C. Grabowski, and David M. Cutler
Health Affairs, January 2019

Abstract

Medicare’s Hospital Readmissions Reduction Program (HRRP) has been credited with lowering risk-adjusted readmission rates for targeted conditions at general acute care hospitals. However, these reductions appear to be illusory or overstated. This is because a concurrent change in electronic transaction standards allowed hospitals to document a larger number of diagnoses per claim, which had the effect of reducing risk-adjusted patient readmission rates. Prior studies of the HRRP relied upon control groups’ having lower baseline readmission rates, which could falsely create the appearance that readmission rates are changing more in the treatment than in the control group. Accounting for the revised standards reduced the decline in risk-adjusted readmission rates for targeted conditions by 48 percent. After further adjusting for differences in pre-HRRP readmission rates across samples, we found that declines for targeted conditions at general acute care hospitals were statistically indistinguishable from declines in two control samples. Either the HRRP had no effect on readmissions, or it led to a systemwide reduction in readmissions that was roughly half as large as prior estimates have suggested.

From the Discussion

The Hospital Readmissions Reduction Program has been cited as one of the successes of value-based payment, which fosters the view that targeted financial incentives can lead to large changes in behavior. However, altering two seemingly small details related to data and methodology meaningfully weakens the evidence that the HRRP lowered risk-adjusted readmission rates for targeted conditions and targeted hospitals. By coincidence, the HRRP was implemented just before a change in electronic transaction standards that increased diagnostic coding and therefore created the illusion that risk-adjusted readmission rates had decreased. Furthermore, given the higher rate of readmissions for targeted conditions at targeted hospitals than at nontargeted hospitals and nontargeted conditions, the decreases in readmission rates for targeted conditions and targeted hospitals were not atypically large.

This set of findings can be interpreted in two ways. One is that the HRRP had no effect on readmissions. The second is that the HRRP may have led to a systemwide reduction in readmissions (that is, a reduction not limited to targeted conditions and targeted hospitals) that was roughly half as large as prior estimates have suggested. Distinguishing between these conclusions remains an important topic for research.

We note in closing that if the HRRP has not lowered readmission rates, then the rationale for the program’s existence becomes substantially weaker. To see why, note that pay-for-performance programs have at least two potential downsides. First, participants may engage in undesirable efforts to game the system. In the case of the HRRP, many observers have raised concerns that hospitals may have been less willing to readmit patients after implementation of the program, which could have increased the use of care that was not counted as a readmission (such as emergency department visits or observation stays) or prevented patients from receiving needed care, possibly harming care quality. Second, pay-for-performance schemes expose participants to the risk of unstable funding, in ways that may seem unfair or contrary to other social goals. In the case of the HRRP, the program was found to have initially penalized hospitals that cared predominantly for patients of low socioeconomic status—hospitals that are more likely to be safety-net providers already operating on tight budgets.

In a successful pay-for-performance program, these two potential downsides must be more than made up for by robust improvements in performance. Our study suggests that any salutary effects of the HRRP are smaller than earlier estimates have suggested.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

Medicare’s Hospital Readmissions Reduction Program (HRRP) has been used extensively as an example of how changing incentives (P4P – paying more, or at least not penalizing, based on performance) can lower costs. Yet this study shows that, at a minimum, the benefits of penalizing hospitals for readmitting patients have been tremendously overstated.

An additional concern is that patients are often held on observation status rather than being readmitted, sometimes to avoid the readmission penalties. This can significantly increase out-of-pocket costs for the patient since they are billed as outpatients (Part B), with greater cost-sharing, rather than as inpatients (Part A). More importantly, there is also the risk that the patient may receive less care as an outpatient when the patient’s condition warrants full inpatient services. Thus the readmission reduction program may be causing significant patient harm, both physically and fiscally.

The government bureaucrats and the policy community are fixated on these various programs that they just thought up out of the blue that supposedly would control spending, even though their track record overall is dismal. Yet they keep avoiding a proven solution that would reduce our uniquely outrageous administrative waste that costs hundreds of billions of dollars. That solution is a single payer national health program, an improved Medicare that would cover everyone. We should at least enact that and then we could examine other innovations as long as they are designed to truly benefit patients.

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

What to Make of Hospital Price Lists?

By Ken Lefkowitz
The New York Times, Jan. 17, 2019

To the Editor:

Your article (“Hospitals Post Their Prices. Just Try to Decipher Them,” Jan. 14) outlines how regulations requiring hospitals to post their prices have resulted in data that is incomprehensible and unusable by consumers because of the complexity and inconsistency inherent in our health care system. In fact, this is also the issue with the lack of our system’s cost-effectiveness.

American health care is financed through a free market, which is ineffective in controlling costs because it requires transparency so consumers can compare prices. But the dizzying complexity of both medical care and insurance plan design precludes the consumer from making informed choices.

Primary-care doctors strongly influence choice, and insurance company provider networks limit choices even further.

Rather, single-payer universal health care is quite cost-effective. Expressed as a percentage of gross domestic product, it has proved to be less costly in many other countries. It will wring out the duplicative and wasteful administrative costs of the free marketplace and provide negotiating leverage to stabilize medical provider and pharmacy costs.

A University of Massachusetts study demonstrated that a single-payer system can cover all citizens, including today’s uninsured, eliminating deductibles and co-pays, and still save $592 billion. For employers, reduced absenteeism and increased labor productivity will be an additional cost advantage.

The writer is a former senior director of compensation and benefits, including health plans, for major companies.

https://www.nytimes.com…

Medicare for all

By George Bohmfalk, M.D.
Dallas Morning News, Letters, January 17, 2019

Re: “Our painful reality — We uninsured Texans must cobble together health care; no wonder we end up in the ER,” by Destiny Herndon-De La Rosa, Sunday Points.

Herndon-De La Rosa says she doesn’t have a solution to our very broken system. I do: improved Medicare for all. One registration (not even application, as everyone will be accepted) for life. Zero deductible. No anxiety about rate changes. No cobbling. It’s simple, sensible and proudly American. Everyone wins, except the manipulative insurance companies.

(I practiced neurosurgery and lived in Texarkana for 30 years.)

https://www.dallasnews.com…

That promise of Medicare for All hearings?

Pelosi Backs Medicare for All Hearings

By William Davis
The Daily Caller, January 3, 2019

Soon-to-be Democratic Speaker of the House Nancy Pelosi is willing to test the waters on an important grassroots progressive issue.

The new speaker announced her support for “Medicare for All” hearings through a spokesperson, according to The Hill. The creation of a single-payer healthcare system has been key issue for many on Pelosi’s left flank.

While Pelosi has never endorsed the legislation, she has previously promised that it would be ‘evaluated,’ if Democrats took control of the House.

According to a report from The Washington Post, a group of House Democrats are planning to re-introduce the bill at the start of the 116th Congress. The Rules Committee and the Budget Committee are expected to conduct hearings on “Medicare for All” legislation early in the caucus.

https://dailycaller.com…

Health committees finalized in new Congress

By Dan Diamond
POLITICO Pulse, January 17, 2019

Rep. Lloyd Doggett (D-Texas) was announced Wednesday to lead the Ways and Means Health Subcommittee, the last unfilled seat among the Hill’s health leadership positions.

Anna Eshoo walks back vow on Medicare-for-all hearing. The Energy and Commerce Health Subcommittee chair told reporters Wednesday afternoon she’d hold a hearing on Democrats’ Medicare for All proposals — a seeming break with Committee Chairman Frank Pallone (D-N.J.) that would mark a significant victory for the party’s progressive wing.

But by Wednesday evening, the California Democrat was having second thoughts, telling POLITICO’s Adam Cancryn that her subcommittee needed to prioritize shoring up Obamacare and crafting sweeping drug price reforms.

Only after the committee gets done with those issues, Eshoo said, will she see if there’s any “spare time” to tackle Medicare for All — an outcome that she suggested was unlikely.

https://www.politico.com…

Comment:

By Don McCanne, M.D.

Through a spokesperson, Speaker Nancy Pelosi announced her support for “Medicare for All” hearings, which pleased the single payer Medicare for All advocacy community.

The two subcommittees of the House of Representatives that introduce major health legislation are those of the Ways and Means Committee and the Energy and Commerce Committee. So who has the leadership appointed to chair these committees, and what are their positions on the issue?

Rep. Lloyd Doggett was appointed Chair of the Ways and Means Health Subcommittee. Though he has been a member of the House since 1995, he has never become a co-sponsor of HR 676 – The Expanded and Improved Medicare for All Act. Also he has not joined the House Medicare for All caucus. Regarding health care, he has stated that he was “committed to individual choices” (Wikipedia), which sounds like an endorsement of our fragmented, multi-payer health care system. Do not look for a Medicare for All hearing before his committee.

Rep. Anna Eshoo has been appointed Chair of the Energy and Commerce Health Subcommittee. We were pleased when she announced yesterday that she would hold a hearing on Medicare for All. But by last evening, barely enough time for the leadership to contact her, she announced that the priorities of shoring up Obamacare would make it unlikely that there would be enough time for a Medicare for All hearing.

Rep. Pramila Jayapal is expected to release very shortly her extensively revised version of HR 676, the Medicare for All Act of 2019. If it receives a hearing at all, it will likely be in the Budget Committee as a token concession to supporters. Don’t hold your breath waiting for the media coverage.

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GoFundMe CEO on funding health care

‘Gigantic Gaps’ In Health System Showing Up In Crowdfunding

By Rachel Bluth
Kaiser Health News, January 16, 2019

Scrolling through the GoFundMe website reveals seemingly an endless number of people who need help or community support. A common theme: the cost of health care.

Of the $5 billion the company says it has raised (in eight years), about a third has been for medical expenses from more than 250,000 medical campaigns conducted annually.

The prominence of the medical category is the symptom of a broken system, according to CEO Rob Solomon. He said he never realized how hard it was for some people to pay their bills: “I needed to understand the gigantic gaps in the system.”

Solomon talked to Kaiser Health News’ Rachel Bluth about his company’s role in financing health care and what it says about the system when so many people rely on the kindness of strangers to get treatment.

Q: KHN and other news outlets have reported that hospitals often advise patients to crowdfund their transplants. It’s become almost institutionalized to use GoFundMe. How do you feel about that?

It saddens me that this is a reality. Every single day on GoFundMe we see the huge challenges people face. Their stories are heartbreaking.

Some progress has been made here and there with the Affordable Care Act, and it’s under fire, but there’s ever-widening gaps in coverage for treatment, for prescriptions, for everything related to health care costs. Even patients who have insurance and supposedly decent insurance [come up short].

I would love nothing more than for “medical” to not be a category on GoFundMe. The reality is, though, that access to health care is connected to the ability to pay for it. If you can’t do that, people die. People suffer. We feel good that our platform is there when people need it.

Q: What have you learned that you didn’t know before?

I guess what I realized [when I came] to this job is that I had no notion of how severe the problem is. You read about the debate about single-payer health care and all the issues, the partisan politics. What I really learned is the health care system in the United States is really broken. Way too many people fall through the cracks.

The government is supposed to be there and sometimes they are. The health care companies are supposed to be there and sometimes they are. But for literally millions of people they’re not. The only thing you can really do is rely on the kindness of friends and family and community. That’s where GoFundMe comes in.

Q: But what does this say about the system?

The system is terrible. It needs to be rethought and retooled. Politicians are failing us. Health care companies are failing us. Those are realities. I don’t want to mince words here. We are facing a huge potential tragedy. We provide relief for a lot of people. But there are people who are not getting relief from us or from the institutions that are supposed to be there. We shouldn’t be the solution to a complex set of systemic problems. They should be solved by the government working properly, and by health care companies working with their constituents. We firmly believe that access to comprehensive health care is a right and things have to be fixed at the local, state and federal levels of government to make this a reality.

https://khn.org…

Comment:

By Don McCanne, M.D.

We’ve all heard stories about how individuals were referred to the GoFundMe crowdsourcing website when they were unable to pay for their medical care. What we don’t hear is how much of the unmet need can be filled by GoFundMe. Based on the numbers in this article, they have collected an average of about $200 million a year for health care costs. That is about 00.006 percent of our $3.5 trillion annual health care expenditures – a bit short of the need. Charity just won’t do it; the bill is too big.

Although we certainly admire the efforts of GoFundMe CEO Rob Solomon, he is the first to say, “access to comprehensive health care is a right and things have to be fixed at the local, state and federal levels of government to make this a reality.” It seems like this cries out for Single Payer Medicare for All, federally funded and administered on a regional and local basis. Nothing like good ol’ egalitarian solidarity.

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Can States Fix the Disaster of American Health Care?

The governor of California has proposed some big ideas. Who knows whether he can pull them off, but there’s reason for hope.

By Elisabeth Rosenthal
The New York Times, January 16, 2019

Last week, California’s new governor, Gavin Newsom, promised to pursue a smorgasbord of changes to his state’s health care system: state negotiation of drug prices; a requirement that every Californian have health insurance; more assistance to help middle-class Californians afford it; and health care for undocumented immigrants up to age 26.

The proposals fell short of the sweeping government-run single-payer plan Mr. Newsom had supported during his campaign — a system in which the state government would pay all the bills and effectively control the rates paid for services. (Many California politicians before him had flirted with such an idea, before backing off when it was estimated that it could cost $400 billion a year.) But in firing off this opening salvo, Mr. Newsom has challenged the notion that states can’t meaningfully tackle health care on their own. And he’s not alone.

A day later, Gov. Jay Inslee of Washington proposed that his state offer a public plan, with rates tied to those of Medicare, to compete with private offerings.

New Mexico is considering a plan that would allow any resident to buy into the state’s Medicaid program. And this month, Mayor Bill de Blasio of New York announced a plan to expand health care access to uninsured, low-income residents of the city, including undocumented immigrants.

For over a decade, we’ve been waiting for Washington to solve our health care woes, with endless political wrangling and mixed results. Around 70 percent of Americans have said that health care is “in a state of crisis” or has “major problems.” Now, with Washington in total dysfunction, state and local politicians are taking up the baton.

The legalization of gay marriage began in a few states and quickly became national policy. Marijuana legalization seems to be headed in the same direction. Could reforming health care follow the same trajectory?

States have always cared about health care costs, but mostly insofar as they related to Medicaid, since that comes from state budgets. “The interesting new frontier is how states can use state power to change the health care system,” said Joshua Sharfstein, a vice dean at Johns Hopkins Bloomberg School of Public Health and a former secretary of the Maryland Department of Health and Mental Hygiene. He added that the new proposals “open the conversation about using the power of the state to leverage lower prices in health care generally.”

Already states have proved to be a good crucible for experimentation. Massachusetts introduced “Romneycare,” a system credited as the model for the Affordable Care Act, in 2006. It now has the lowest uninsured rate in the nation, under 4 percent. Maryland has successfully regulated hospital prices based on an “all payer” system.

It remains to be seen how far the West Coast governors can take their proposals. Businesses — pharmaceutical companies, hospitals, doctors’ groups — are likely to fight every step of the way to protect their financial interests. These are powerful constituents, with lobbyists and cash to throw around.

The California Hospital Association came out in full support of Mr. Newsom’s proposals to expand insurance (after all, this would be good for hospitals’ bottom lines). It offered a slightly less enthusiastic endorsement for the drug negotiation program (which is less certain to help their budgets), calling it a “welcome” development. It’s notable that his proposals didn’t directly take on hospital pricing, even though many of the state’s medical centers are notoriously expensive.

Giving the state power to negotiate drug prices for the more than 13 million patients either covered by Medicaid or employed by the state is likely to yield better prices for some. But pharma is an agile adversary and may well respond by charging those with private insurance more. The governor’s plan will eventually allow some employers to join in the negotiating bloc. But how that might happen remains unclear.

The proposal by Governor Inslee of Washington to tie payment under the public option plans to Medicare’s rates drew “deep concern” from the Washington State Medical Association, which called those rates “artificially low, arbitrary and subject to the political whims of Washington, D.C.”

On the bright side, if Governor Newsom or Governor Inslee succeeds in making health care more affordable and accessible for all with a new model, it will probably be replicated one by one in other states. That’s why I’m hopeful.

In 2004, the Canadian Broadcasting Corporation conducted an exhaustive nationwide poll to select the greatest Canadian of all time. The top-10 list included Wayne Gretzky, Alexander Graham Bell and Pierre Trudeau. No. 1 is someone most Americans have never heard of: Tommy Douglas.

Tommy Douglas, a Baptist Minister and left-wing politician, was premier of Saskatchewan from 1944 to 1961. Considered the father of Canada’s health system, he arduously built up the components of universal health care in that province, even in the face of an infamous 23-day doctors’ strike.

In 1962, the province implemented a single-payer program of universal, publicly funded health insurance. Within a decade, all of Canada had adopted it.

The United States will presumably, sooner or later, find a model for health care that suits its values and its needs. But 2019 may be a time to look to the states for ideas rather than to the nation’s capital. Whichever state official pioneers such a system will certainly be regarded as a great American.

Dr. Elisabeth Rosenthal was an emergency room doctor before becoming a journalist. A former New York Times correspondent, she is the editor in chief of Kaiser Health News and the author of “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back.”

https://www.nytimes.com…