By Theodore R. Marmor
Journal of Health Politics, Policy and Law, December 2018

Abstract

Social insurance, like commercial insurance, is about protection against financial risk. In the United States, Medicare and the Social Security Administration’s programs for retirement, disability, worker’s compensation, and worker’s life insurance have become dominant features of American public policy, amounting to more than 41 percent of the federal budget. Yet their fiscal centrality does not rest on anything like an understanding of what makes social insurance social—or why that is so important to American political life. This essay seeks to clarify the crucial differences between social and commercial insurance and elaborates on the conceptual justifications and distinctive operational features of America’s social insurance programs.

What Is Social about Social Insurance?

Social insurance, like commercial insurance, is about protection against financial risk. It is “insurance” in the sense that people contribute to a fund to protect themselves against unpredictable financial risks. These include outliving one’s savings in old age, the early death of a breadwinner, the onset of disability that makes work difficult if not impossible, the high costs of illness, involuntary unemployment, and work-related injury. Contributions are not prices in a market and so, unlike commercial insurance, are not higher or lower depending on the customer’s risk profile. Instead of a commercial insurance contract between enrollee and insurer, social insurance is for shared protection among participants in which they agree that each should pay for that protection according to their work income. The “insurer”—a government agency or, originally in Europe, a corporate body with a joint labor/management board—is the agent of the contributing enrollees. The social insurance contract, once created, cannot be voluntary and survive long. By law contributions are required, because otherwise adverse selection would be financially disabling.

Social insurance, then, spreads the costs of coverage according to a different logic than that of commercial insurers. In commercial insurance, price must reflect risk. Social insurance, by contrast, operates on the premise that contributions are calculated according to one’s income and benefits are related to one’s needs. But the central political feature of social insurance is that the contributors are also beneficiaries. This is not the case with social assistance programs with means-tested eligibility standards. As important as such programs are for those who experience poverty, taxpayers do not in general identify with welfare beneficiaries. And, finally, private insurers, unlike governments, cannot tax citizens to make up for losses. But private insurers do routinely try to select customers with an eye to signing up those least likely to experience the risk the insurance policy is to mitigate. That’s why fire insurance is more expensive in poorer neighborhoods, not because insurance firms are racist.

Medicaid, Medicare, and Social Insurance

Medicaid’s very structure is ill designed for broad expansion. Its means-tested mode of eligibility creates a fiscal cliff. That is the term for when an additional dollar of a beneficiary’s income means the loss of a program’s benefit.5 No wealthy democracy has found a way to set the cliff at a point where some other arrangement and a means-tested program can combine to create universal health care. The design problems are particularly evident in the supposedly more middle-class part of the program, long-term care. The means testing and asset testing create cliffs and incentives for fraud. Quality problems can be severe, and yet many people go without needed services

There is little to say about Medicare in the context of conflict over the ACA. Democrats did not rely on expanding Medicare, save for a brief dalliance with voluntary coverage for Americans fifty-five to sixty-five years of age. The “public option” relied on Medicare’s ability to limit prices but not on explicit social insurance principles.6 Indeed, there was no serious discussion of how social insurance ideas were relevant, even though they were important in fact. The regulatory innovations of Obamacare represent earnest efforts to regulate commercial health insurance to become more like social insurance. Requiring insurers to guarantee issue at a fixed price regardless of preexisting conditions would reduce risk selection that social insurance eliminates directly. Requiring commercial insurers to offer a basic benefit plan also moves toward the common coverage that social health insurance offers automatically. The partial measures in the ACA appealed to the values underlying social insurance, but almost no connection was made between these measures and a principled vision of social insurance.

https://read.dukeupress.edu…

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Our Lost Vocabulary of Social Insurance

By Theodore R. Marmor
Niskanen Center, December 10, 2018

Social Insurance, Our Neglected Heritage

There are at least two plausible criticisms of this essay’s argument about the importance of relearning the appeal of social insurance principles. One is that the world has changed dramatically since the birth of social insurance in the late 19th century, let alone since the 1934-35 Committee on Economic Security provided a blueprint for expanding social insurance in American public life. The other is that changes in long-standing European social insurance programs show that major adjustments in the American programs are required as well.

The claim that the world has changed does not necessarily mean that the economic risks against which social insurance programs offer protection have been fundamentally altered. Consider every one of the risks noted in this essay — outliving one’s savings, involuntary unemployment, medical costs, and disability. Not one has disappeared, and social insurance programs for each have been implemented in wealthy democracies. I doubt, in other words, whether social insurance is in any conceptual trouble.

But that does not mean social insurance programs don’t need to adapt to contemporary circumstances. The spread of contract employment has been particularly challenging for European countries where social insurance is a function of trade unions and other sector-level organizations. It is equally obvious in the US that employer-provided health insurance puts a damper on labor market flexibility. Reduced employment in regular jobs with health coverage will demand the search for other sources of provision. These and other realities of our changing economy will only bring to the fore the central claim of this essay: Social insurance programs dominate American social policy but what that means for our politics is too little understood or explained. And that criticism extends not only to harried reporters but to a significant amount of the public policy community, as well.

https://niskanencenter.org…

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Comment:

By Don McCanne, M.D.

From Repeal and Replace to Medicare for All, with heavy doses of health care financing policy such as accountable care organizations, other alternative payment models, and the public option, we are being inundated with messages intended to ignite much needed improvements in our health care financing system. What seems to have slid out of these discussions is the crucial importance of policy design based on a solid foundation of social insurance.

Ted Marmor has provided us with an excellent account of the principles and paradoxes of social insurance as it has played out, or rather failed to play out fully, in the United States. Rather than reading comments here that I might make, it would be more important to download his article from the Journal of Health Politics, Policy and Law. The publisher has kindly removed the paywall, allowing free access to this article, available at the link above. A modified version has also been published by the Niskanen Center. Reading both versions can clarify any points that might not be clear on your first reading.

I believe that this is one of those landmark articles that should be in your health policy library file, whether you are an academic, activist, or simply someone who really cares about our health care system and the people who receive its services. Whatever we do, it is imperative that our future system be imbued with the principles of social insurance. Actually the principles are already there in our model of a universal single-payer improved-Medicare-for-all national health program. But people have to feel it.

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

By Ralph Nader
Common Dreams, December 26, 2018

Costly complexity is baked into Obamacare. No health insurance system is without problems but Canadian-style single-payer— full Medicare for all— is simple, affordable, comprehensive and universal.

Below please find 25 ways the Canadian health care system is better than the chaotic U.S. system.

Replace it with the much more efficient Medicare-for-all: everybody in, nobody out, free choice of doctor and hospital. It will produce far less anxiety, dread, and fear.

Number 25:

• In Canada, everyone is covered automatically at birth – everybody in, nobody out.
• In the United States, under Obamacare, 28 million Americans (9 percent) are still uninsured and 85 million Americans (26 percent) are underinsured.

Number 24:

• In Canada, the health system is designed to put people, not profits, first.
• In the United States, Obamacare has done little to curb insurance industry profits and in fact has increased the concentrated insurance industry’s massive profits.

Number 23:

• In Canada, coverage is not tied to a job or dependent on your income – rich and poor are in the same system, the best guaranty of quality.
• In the United States, under Obamacare, much still depends on your job or income. Lose your job or lose your income, and you might lose your existing health insurance or have to settle for lesser coverage.

Number 22:

• In Canada, health care coverage stays with you for your entire life.
• In the United States, under Obamacare, for tens of millions of Americans, health care coverage stays with you for as long as you can afford your insurance.

Number 21:

• In Canada, you can freely choose your doctors and hospitals and keep them. There are no lists of “in-network” vendors and no extra hidden charges for going “out of network.”
• In the United States, under Obamacare, the in-network list of places where you can get treated is shrinking – thus restricting freedom of choice – and if you want to go out of network, you pay dearly for it.

Number 20:

• In Canada, the health care system is funded by income, sales and corporate taxes that, combined, are much lower than what Americans pay in insurance premiums directly and indirectly per employer.
• In the United States, under Obamacare, for thousands of Americans, it’s pay or die – if you can’t pay, you die. That’s why many thousands will still die every year under Obamacare from lack of health insurance to get diagnosed and treated in time.

Number 19:

• In Canada, there are no complex hospital or doctor bills. In fact, usually you don’t even see a bill.
• In the United States, under Obamacare, hospital and doctor bills are terribly complex, making it very difficult to discover the many costly overcharges or massive billing fraud.

Number 18:

• In Canada, costs are controlled. Canada pays 10 percent of its GDP for its health care system, covering everyone.
• In the United States, under Obamacare, costs continue to skyrocket. The U.S. currently pays 17.9 percent of its GDP and still doesn’t cover tens of millions of people.

Number 17:

• In Canada, it is unheard of for anyone to go bankrupt due to health care costs.
• In the United States, health-care-driven bankruptcy will continue to plague Americans.

Number 16:

• In Canada, simplicity leads to major savings in administrative costs and overhead.
• In the United States, under Obamacare, often staggering complexity leads to ratcheting up huge administrative costs and overhead.

Number 15:

• In Canada, when you go to a doctor or hospital the first thing they ask you is: “What’s wrong?”
• In the United States, the first thing they ask you is: “What kind of insurance do you have?”

Number 14:

• In Canada, the government negotiates drug prices so they are more affordable.
• In the United States, under Obamacare, Congress made it specifically illegal for the government to negotiate drug prices for volume purchases, so they remain unaffordable and skyrocketing.

Number 13:

• In Canada, the government health care funds are not profitably diverted to the top one percent.
• In the United States, under Obamacare, health care funds will continue to flow to the top. In 2017, the CEO of Aetna alone made a whopping $59 million.

Number 12:

• In Canada, there are no required co-pays or deductibles in inscrutable contracts.
• In the United States, under Obamacare, the deductibles and co-pays will continue to be unaffordable for many millions of Americans.

Number 11:

• In Canada, the health care system contributes to social solidarity and national pride.
• In the United States, Obamacare is divisive, with rich and poor in different systems and tens of millions left out or with sorely limited benefits.

Number 10:

• In Canada, delays in health care are not due to the cost of insurance.
• In the United States, under Obamacare, patients without health insurance or who are underinsured will continue to delay or forgo care and put their lives at risk.

Number 9:

• In Canada, nobody dies due to lack of health insurance.
• In the United States, tens of thousands of Americans will continue to die every year due to lack of health insurance and much higher prices for drugs, medical devices, and health care itself.

Number 8:

• In Canada, health care on average costs half as much, per person, as in the United States. And in Canada, everyone is covered.
• In the United States, a majority support Medicare-for-all.

Number 7:

• In Canada, the tax payments to fund the health care system are modestly progressive – the lowest 20 percent pays 6 percent of income into the system while the highest 20 percent pays 8 percent.
• In the United States, under Obamacare, the poor pay a larger share of their income for health care than the affluent.

Number 6:

• In Canada, people use GoFundMe to start new businesses.
• In the United States, fully one in three GoFundMe fundraisers are now to raise money to pay medical bills. Recently, one American was rejected for a heart transplant because she couldn’t afford the follow-up care. Her insurance company suggested she raise the money through GoFundMe.

Number 5:

• In Canada, people avoid prison at all costs.
• In the United States, some Americans commit minor crimes so that they can get to prison and get free health care.

Number 4:

• In Canada, people look forward to the benefits of early retirement.
• In the United States, people delay retirement to 65 to avoid being uninsured.

Number 3:

• In Canada, Nobel Prize winners hold on to their medal and pass it down to their children and grandchildren.
• In the United States, Nobel Prize winners sell their medals to pay for their medical bills. Leon Lederman won a Nobel Prize in 1988 for his pioneering physics research. But in 2015, the physicist, who passed away in November 2018, sold his Nobel Prize medal for $765,000 to pay his mounting medical bills. According to a report in Vox, the University of Chicago professor began to suffer from memory loss in 2011, and died in an Idaho nursing home.

Number 2:

• In Canada, the system is simple. You get a health care card when you are born. And you swipe it when you go to a doctor or hospital. End of story.
• In the United States, Obamacare’s 2,500 pages plus regulations (the Canadian Medicare Bill was 13 pages) is so complex that then Speaker of the House Nancy Pelosi said before passage “we have to pass the bill so that you can find out what is in it, away from the fog of the controversy.”

Number 1:

• In Canada, the majority of citizens love their health care system.
• In the United States, a growing majority of citizens, physicians, and nurses prefer the Canadian type system – Medicare-for-all, free choice of doctor and hospital , everybody in, nobody out and far less expensive.

https://www.commondreams.org…

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Comment:

By Don McCanne, M.D.

As if we needed a reminder.

Would it be that Number 11 would gain traction in the United States: “In Canada, the health care system contributes to social solidarity and national pride.”

We should share at least that much with our Canadian brethren.

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

By Austin Frakt
The New York Times, December 24, 2018

One of the original justifications for Medicare — which kicks in at age 65 — is that older people have much higher health care needs and expenses.

But there are a few common misunderstandings about health costs when people are older, including the idea that money can easily be saved by reducing wasteful end-of-life spending.

Total health care spending for Americans 65 and older is about $15,000 per year, on average, nearly three times that of working-age Americans.

A widely held view is that much spending is wasted on “heroic” measures taken at the end of life. Are all the resources devoted to Medicare and Medicaid really necessary?

First, let’s get one misunderstanding out of the way. The proportion of health spending at the end of life in the United States is lower than in many other wealthy countries.

Still, it’s a tempting area to look for savings. Only 5 percent of Medicare beneficiaries die each year, but 25 percent of all Medicare spending is on individuals within one year of death. However, the big challenge in reducing end-of-life spending, highlighted by a recent study in Science, is that it is hard to know which patients are in their final year.

The study used all the data available from Medicare records to make predictions: For each beneficiary, it assigned a probability of death within a year. Of those with the very highest probability of dying — the top 1 percent — fewer than half actually died.

“This shows that it’s just very hard to know in advance who will die soon with much certainty,” said Amy Finkelstein, an M.I.T. economist and an author of the study. “That makes it infeasible to make a big dent in health care spending by cutting spending on patients who are almost certain to die soon.”

“There absolutely is waste in the system,” said Ashish Jha, director of the Harvard Global Health Institute. But, he argues, waste is present throughout the life span, not just at the end of life: “We have confused that spending as end-of-life spending is somehow wasteful. But that’s not right because we are terrible at predicting who is going to die.”

Of course, beyond any statistical analysis, there are actual people involved, and wrenching individual decisions that need to be made.

“We should do all we can to push waste out of the system,” Dr. Jha said. “But spending more money on people who are suffering from an illness is appropriate, even if they die.”

Austin Frakt is director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health. He blogs at The Incidental Economist.

https://www.nytimes.com…

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NYT Reader Comment:

By Don McCanne, M.D.

I am a retired physician who writes a daily commentary on health policy (PNHP, Quote of the Day), believing that everyone should have affordable access to beneficial health care services when needed (i.e., I support Single Payer Medicare for All). I am also an octogenarian undergoing an evaluation for a medical problem that may well have a guarded prognosis. Believe me, I am very tuned in to this article on late-life care written by one of my favorite health policy analysts, Austin Frakt.

Should an old man like me have a workup for a condition for which there may be no beneficial intervention (though that is uncertain because of the lack of a definitive diagnosis at this point)? Can society afford to fund such care? Well, there is extensive literature that indicates that we can, in fact, afford to fund essentially all truly beneficial health care services for everyone as long as those services are priced reasonably. The line we should not cross is when diagnostic and therapeutic health care interventions become futile, but then that is precisely why we have palliative/hospice care.

The goals of health care should be to prevent premature death when possible, and to maintain quality of life as best we can while we are here. Studies have confirmed that such care would be affordable for society with a well designed, improved version of Medicare that covered everyone – a system that’s efficient, effective and equitable – a system that places the patient first.

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

By Kathryn Elena Woolhandler Himmelstein, M.D., M.S.Ed. and Atheendar S. Venkataramani, M.D., Ph.D.
American Journal of Public Health, December 20, 2018 (published online ahead of print)

Abstract

Objectives: To investigate racial/ethnic and gender inequities in the compensation and benefits of US health care workers and assess the potential impact of a $15-per-hour minimum wage on their economic well-being.

Methods: Using the 2017 Annual Social and Economic Supplement to the Current Population Survey, we compared earnings, insurance coverage, public benefits usage, and occupational distribution of male and female health care workers of different races/ethnicities. We modeled the impact of raising the minimum wage to $15 per hour with different scenarios for labor demand.

Results: Of female health care workers, 34.9% earned less than $15 per hour. Nearly half of Black and Latina female health care workers earned less than $15 per hour, and more than 10% lacked health insurance. A total of 1.7 million female health care workers and their children lived in poverty. Raising the minimum wage to $15 per hour would reduce poverty rates among female health care workers by 27.1% to 50.3%.

Conclusions: Many US female health care workers, particularly women of color, suffer economic privation and lack health insurance. Achieving economic, gender, and racial/ethnic justice will require significant changes to the compensation structure of health care.

(Am J Public Health. Published online ahead of print December 20, 2018: e1–e8. doi:10.2105/AJPH.2018.304801)

https://ajph.aphapublications.org…

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Comment:

By Don McCanne, M.D.

On Christmas Eve, regardless of your religious affiliations, it seems appropriate to consider what Jesus might have had to say about the economic vulnerability of US female health care workers. The lead author of this study, heir and namesake of the co-founders of PNHP, has helped us by providing objective data and an analysis of the plight of female health care workers.

At a time that our political leadership has decided to furlough workers just in time for Christmas, it seems that we should give more thought as to what is wrong and how we can find the moral pathway forward.

Really.

Peace.

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

By Seema Verma, Administrator
Centers for Medicare and Medicaid Services, Blog, December 21, 2018

Today the Trump Administration announced our overhaul of the program for Accountable Care Organizations, or “ACOs,” in Medicare. ACOs serve a large number of Medicare beneficiaries – over 10.4 million individuals in Fee-for-Service Medicare (of the 38 million total Fee-for-Service beneficiaries) receive care from providers participating in a Medicare ACO. Before getting into the specifics of our new policy, let’s take a step back and put today’s announcement in a broader context.

The Trump Administration has put a high priority on accelerating a value-based transformation of America’s healthcare system – which is the move from paying for the volume of services to paying for outcomes and health. CMS is hard at work to move to a value-based system, not just because we want to, but because the American healthcare system is on an unsustainable trajectory, with one in five dollars spent in our economy projected to be spent on healthcare by 2026. Therefore, it is incumbent on our agency to not just pay for healthcare services as they are billed but rather to ensure that patients are getting value for the care that is provided. To this end, we are developing and testing new payment models to transform our payment system, and today’s changes to Medicare’s ACO program are a critical component of that transformation.

ACOs are groups of healthcare providers that take responsibility for the total cost and quality of care for their patients. In exchange for this, ACOs are able to receive a portion of the savings that they achieve as long as they meet quality standards. The program for ACOs in Medicare has been in operation for six years, and from these years of experience, CMS has gleaned key insights about what works and what doesn’t within the program.

CMS issues waivers to ACOs of specific fraud and abuse laws in order to provide the regulatory relief needed to innovate, including waivers of provisions of the Stark Law and the Federal Anti-Kickback Statute. In exchange for this flexibility, today’s rule ensures that ACOs have strong incentives to provide high-quality care and generate savings. Most Medicare ACOs do not currently face financial consequences when costs increase, but a review of the data on ACO performance shows that overtime those ACOs that take accountability for costs perform better than those that do not.

Today’s final rule drives towards greater savings and quality for Medicare’s ACO program. The rule is projected to achieve $2.9 billion in savings over ten years. The final policy is responsive to feedback about the need for incentives to bring healthcare providers into the ACO program, while ensuring the transition to value protects taxpayers and includes patients.

One key element of today’s rule is a reduction in the amount of time that an ACO can remain in the program without taking accountability for healthcare spending. The allowed period of time is decreasing from six years to, at most, three years for new “low-revenue” or physician-led ACOs, two years for all other new ACOs, and one year for existing one-sided ACOs. We are setting the shared savings rate at 40 percent for ACOs not assuming risk for healthcare costs and 50 percent for ACOs at all levels of risk, to strengthen the on-ramp to the program while rewarding ACOs that take on greater risk with higher shared savings rates.

Smaller, physician-led or “low revenue” ACOs – many of which are in rural areas – have shown greater success in controlling costs than hospital-led ACOs, which is an example of why CMS is focused on promoting competition in healthcare marketplaces and ensuring that patients have choices of where to obtain care. We have heard that establishing a physician-led ACO can provide practices with a means of remaining independent from consolidated hospital systems. Today’s rule bolsters the option for physicians to form ACOs while ensuring that all ACOs are generating savings for patients and taxpayers.

Today’s rule also increases flexibility for certain performance-based risk ACOs to encourage innovation and expand access to high-quality services that are convenient for patients, including telehealth services provided at a patient’s place of residence. This is part of our holistic review of policies aimed at driving innovation and efficiency and to ensure regulations are not hindering the development of new ways of delivering care.

In all that we do at CMS, we aim to put patients first and ensure that they have the information they need to make decisions about their care. To this end, today’s rule requires ACOs to provide beneficiaries in an ACO with a written notice in person or electronically through email or a patient portal that they are participating in this new approach to care delivery, and it must also explain what participating in an ACO means for their care.

Pathways to Success also allows risk-based ACOs to offer new incentive payments to beneficiaries for taking steps to achieve good health such as obtaining primary care services and necessary follow-up care. This way patients are aligned with providers on the drive to value.

Finally, to ensure rigorous financial benchmarking for ACOs, we are incorporating regional spending factors in establishing an ACO’s target spending during all agreement periods, providing a more accurate point of comparison for evaluating ACO performance. Our changes to the benchmarking process for ACOs also promote greater alignment between the ACO program and Medicare Advantage.

In connection with the program redesign announced today, and to ensure providers have time to review and assess the new options, CMS is offering an ACO application cycle for a special one-time new agreement period start date of July 1, 2019. We are encouraged that 90 percent of eligible ACOs with participation agreements expiring on December 31, 2018 elected to extend their agreements for six months, so now they will have the option to renew their agreement under the new policies and continue to participate in the program uninterrupted.

As you can see, the Trump Administration is absolutely committed to the value-based transformation of America’s healthcare system. Today’s final rule for Medicare’s ACOs accelerates that transformation while promoting patient engagement and ensuring high-quality care. This is a positive step forward for our healthcare system, one that we hope to continue building on in the future.

CMS Blog:
https://www.cms.gov…

Rule: Medicare Shared Savings Program; Accountable Care Organizations Pathways to Success and Extreme and Uncontrollable Circumstances Policies for Performance Year 2017 (957 pages):
https://www.federalregister.gov…

Fact sheet:
https://www.cms.gov…

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Comment:

By Don McCanne, M.D.

When the government releases on a Friday an important, complex, thousand page document, especially just before the start of a busy holiday week, you can be fairly confident that they do not want it to be at the top of a news cycle. So what is this that CMS released on such a day as today?

They released the final Rule, “Medicare Shared Savings Program; Accountable Care Organizations Pathways to Success and Extreme and Uncontrollable Circumstances Policies for Performance Year 2017.” In typical bureaucratic fashion it includes not only the rule changes for the Medicare Shared Savings Programs and for Accountable Care Organizations, but it also includes considerable information overload by discussing “Extreme and Uncontrollable Circumstances Policies” through events such as hurricanes and California’s wildfires, just to ensure that hardly anyone will read the entire 957 pages.

So what is it they are doing with Medicare that they would prefer be consigned to obscurity as they implement the changes? In answering this question, I am going to take liberties in my interpretation in order to provide a more accurate perspective.

• The ACO rule applies to the traditional Medicare fee-for-service program and not the already privatized Medicare Advantage program.
• Medicare ACOs are groups of healthcare providers that take responsibility for the total cost and quality of care for their patients. Thus, much like the private Medicare Advantage plans, Medicare ACOs are serving an insurance function by assuming the risk of the costs of health care that will be delivered.
• CMS will share limited risk with the ACOs in that they will share the savings (i.e., unspent funds left over after providing the care – funds which might be better categorized as “profits”).
• CMS contends that “ACO performance shows that over time those ACOs that take accountability for costs perform better than those that do not,” and thus they have decided by this Rule to force provider groups into ACOs. Numerous CMS citations of greater Medicare savings with ACOs suggests that their primary criterion for “better performance” is spending less, apparently ignoring potential motivation for pecuniary gain.
• CMS will provide waivers of provisions of the Stark Law (designed to prevent conflict-of-interest self-referrals) and the Federal Anti-Kickback Statute, placing unprincipled business interests below the higher ethical plane of optimal patient service and value.
• Seema Verma writes, “the Trump Administration is absolutely committed to the value-based transformation of America’s healthcare system.” With this Rule, they are moving forward with the dubious “value-based” models of MACRA and its alternative payment models even though there is considerable evidence that they are a major source of dissatisfaction and burnout of health care professionals – the opposite of what you should expect in a high-performance health care delivery system.
• They push the old saw about delivering innovation in health care as if the goal of innovation were to improve patient care as opposed to the usual goal of improving the business model.
• The ACO model, as originally designed, assigned patients to ACOs for accountability purposes only, without telling the patients of their assignment. The new Rule now requires that the patient be notified, thus largely formally duplicating the managed care/HMO/Medicare Advantage model of privatized health care financing, but with government funds.
• CMS “also allows risk-based ACOs to offer new incentive payments to beneficiaries for taking steps to achieve good health such as obtaining primary care services and necessary follow-up care.” Buying patients? What kind of ethical trap door does this open? Since this is Medicare money, should taxpayer funds really be used for such activities that have a great potential for nefarious conversion?
• Finally, “Our changes to the benchmarking process for ACOs also promote greater alignment between the ACO program and Medicare Advantage.”

Alignment between the ACO program and Medicare Advantage! This is the final Rule, so the ACO program is already indelibly privatized!

It is now urgent that we dump our entire health care financing system and replace it by enacting and implementing a Single Payer Medicare for All program. Or would you rather put up with another generation of insurer/managed care intermediaries that have made ours the most expensive and one of the least efficient health care financing systems in the world?

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

By Prof. Ibrahim Abubakar, FRCP; Robert W. Aldridge, PhD; Delan Devakumar, PhD; Miriam Orcutt, MSc; Rachel Burns, MSc; Prof. Mauricio L. Barreto, MD; et al.
The Lancet, December 5, 2018

From the Executive Summary

With one billion people on the move or having moved in 2018, migration is a global reality, which has also become a political lightning rod. Although estimates indicate that the majority of global migration occurs within low-income and middle-income countries (LMICs), the most prominent dialogue focuses almost exclusively on migration from LMICs to high-income countries (HICs). Nowadays, populist discourse demonises the very same individuals who uphold economies, bolster social services, and contribute to health services in both origin and destination locations. Those in positions of political and economic power continue to restrict or publicly condemn migration to promote their own interests. Meanwhile nationalist movements assert so-called cultural sovereignty by delineating an us versus them rhetoric, creating a moral emergency.

In response to these issues, the UCL-Lancet Commission on Migration and Health was convened to articulate evidence-based approaches to inform public discourse and policy. The Commission undertook analyses and consulted widely, with diverse international evidence and expertise spanning sociology, politics, public health science, law, humanitarianism, and anthropology. The result of this work is a report that aims to be a call to action for civil society, health leaders, academics, and policy makers to maximise the benefits and reduce the costs of migration on health locally and globally. The outputs of our work relate to five overarching goals that we thread throughout the report.

First, we provide the latest evidence on migration and health outcomes. This evidence challenges common myths and highlights the diversity, dynamics, and benefits of modern migration and how it relates to population and individual health.

Second, we examine multisector determinants of health and consider the implication of the current sector-siloed approaches.

Third, we critically review key challenges to healthy migration. Population mobility provides economic, social, and cultural dividends for those who migrate and their host communities. Furthermore, the right to the highest attainable standard of health, regardless of location or migration status, is enshrined in numerous human rights instruments. However, national sovereignty concerns overshadow these benefits and legal norms.

Fourth, we examine equity in access to health and health services and offer evidence-based solutions to improve the health of migrants. Migrants should be explicitly included in universal health coverage commitments.

Finally, we look ahead to outline how our evidence can contribute to synergistic and equitable health, social, and economic policies, and feasible strategies to inform and inspire action by migrants, policy makers, and civil society. We conclude that migration should be treated as a central feature of 21st century health and development.

From the Conclusion

Migration should be urgently treated as a core determinant of health and wellbeing and addressed as a global health priority of the 21st century. Migration and global health are both defining issues of our time. How the world addresses human mobility will determine public health and social cohesion for decades to come. Our work for this Commission aimed to provide robust evidence on migration and health to examine the structures, systems, and contexts at the intersection of human mobility and individual and population health. By systematically presenting evidence on what is known about health and migration, it has been our intention to dispel populist myths about a perceived “other” and to suggest promising strategies for a highly mobile world. Amid international dialogues about safer, healthier migration, substantial gains can be achieved towards multiple SDGs (Sustainable Development Goals) by resisting the turbulence of nationalist xenophobic discourse.

In summary, our findings highlight that modern migration is a diverse and dynamic phenomenon, and the health of people who migrate generally reflects the circumstances of migration. Our evidence indicates that, with sufficient political will, the international community, states, and local providers have the knowledge and resources necessary to ensure that individuals who are most vulnerable to harm are not health-marginalised. But, at the same time, our findings suggest that attitudes, misperceptions, and cynical political motivations can hinder rights-based approaches to health for migrants, especially for people seeking safety and economic security for themselves and their family. We must ensure that a migrant’s equal right to health is respected and implemented.

Our multiple analyses also contradict myths about who is migrating where and the health burden of migration on recipient locations. Data for migration tell us that more people from LMICs are migrating within their own countries and region than across HIC borders, even if vocal political rhetoric implies otherwise. Additionally, migrants are, on average, healthier, better educated, and employed at higher rates than individuals in destination locations. However, many men and women who migrate are subjected to laws, restrictions, and discrimination that put them at risk of ill health. Particular mobile subgroups are especially likely to be exposed to migration-related harm and excluded from care, such as trafficking victims, irregular migrants, low wage workers, and asylum seekers. These highly vulnerable migrant subgroups are also frequently individuals who have been forced to move because of global economic and political forces well beyond their control. These global economic and political forces also apply to the populations left behind, when family members migrate for work or groups who are unable to flee from conflict areas or environmental dangers. The evidence indicates that through targeted rights-based laws; inclusive, migrant-friendly health systems; and mobile medical services, it is possible to reduce migration-related risks and increase peoples’ access and use of health services. Migration-informed laws, services, and public perceptions can increase determinants of good health. These determinants include social inclusion, safe employment with fair wages, good nutrition, decent housing and hygiene, and universally accessible health systems that do not result in potentially catastrophic costs for families.

Moreover, multiple opportunities exist to intervene to address health throughout the phases of a migrant’s journey. We believe that now is the time to call on our humanity and to take advantage of worldwide mobility to secure global health, especially for migrant groups who are most at risk of exclusion. We have the evidence, tools, and potential international political will via the UN Global Compact for Migration and the Global Compact on Refugees, and the SDGs.

The Commissioners have reviewed a mass of data collected by researchers from around the world. These data describe the scale and nature of migration and the many threats to the health of men and women and their families who are migrating. However, it is impossible to capture the entire distressing picture on the pages of a scientific journal. That would require the many individual accounts of tragedy, of children drowning in parents’ arms or dying by the wayside, or of individual heroism of people who risk their own lives to rescue them. For such stark realities, we can look to the few journalists and humanitarian organisations who have recorded these accounts, such as the now unforgettable picture of the lifeless body of Alan Kurdi being lifted from a Turkish beach. Anyone viewing these images should surely ask why the international community has done so little to live up to its commitments to advance the health of migrating populations, and especially individuals who have been forced to migrate. How can we explain this inertia?

There are no simple answers to these questions, but one indisputable reality is that, in the discourse on migration, health is far down the list of priorities. International meetings on migration are instead dominated by other considerations, such as domestic politics, national security, international trade, and commerce—especially when politicians ruthlessly exploit migration for their own purposes. These considerations almost always take precedence over the health needs of migrants. Indeed, if health is discussed at all, it is often unjustifiably framed as the migrant posing a threat to the population in the destination country, either as a vector for infections or a terrorist risk. Health and migration have competing, if not conflicting, policy goals. Health goals are inclusive (eg, better health for all, the Hippocratic oath) and international migration policy goals are exclusionary (secure borders, national trade). The other key challenges include financial issues and leadership.

Investing in the health of populations and individuals is generally an expensive long-term commitment, such as providing medical services over lifetimes. However, for state budgets, protecting borders and arranging deportation can seem a lesser investment for greater political gain often contrary to the more positive actual and perceived contributions of migrants by the public. Health leadership in the realm of migration policy making often seems to be considered as less important than other policy interests. Why are health leaders absent from the top table, engaging proactively in high level debates on migration? Instead, the health sector is often left to pick up the pieces of migration policies that leave the lives of migrants in tatters. Additionally, because the health sector will remain dedicated to these humanitarian ideals, policy makers can continue to prioritise security, exclusion, and trade, while discriminatory rhetoric re-enforces the neglect and abuse of migrants. A second, much simpler question is why do some migrants have better health and health services than others? The answer is quite obviously related to the individual’s social and economic status and the power this wields. Therefore, perhaps the greatest challenge to achieving health equity for disadvantaged migrating populations will be promoting rights and empowerment that enable individuals to assert their own rights to health.

https://www.thelancet.com…

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Comment:

By Don McCanne, M.D.

Immigration and health are two often interrelated issues that appropriately command much attention, not only from political leaders but also by the public at large in nations throughout the world and especially here in the United States. The University College London-Lancet Commission on Migration and Health has provided us with a report that casts much needed light on the issues, providing an objective basis for discourse as we move forward with addressing the problems presented.

Leaders of other nations reading this report must be perplexed by the policy discussions in the United States. Here we spend far more money per capita on health care than any other nation, and yet we fall far short on access, equity and outcomes. Yet much of our political dialogue is on “the wall” – a physical barrier between the United States and Mexico that is irrational, expensive and not particular effective, but, worse, is not based the least on an understanding of the truth about migration and its social and moral ramifications.

What is particularly ironic is that we already understand the policy principles that would establish a firm foundation for beginning to address the problematic health hallmarks of immigration. Those principles are found in another hot political topic of today – Single Payer Medicare for All. Under such a program, all residents, including immigrants, receive the health care that they need, and all contribute their fair share into the system, including the immigrants as they are melded into our economy.

So simple. So why do we have to keep hearing about the wall? Any why does President Trump continue to listen to Stephen Miller?

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By Alicia Ault
Medscape, December 18, 2018

As many of the newly elected and newly empowered Democrats in Congress are vowing to push for what they are calling “Medicare for all,” a majority of US healthcare professionals recently surveyed said they support a single-payer system, according to a Medscape Medical News reader poll.

Sixty-eight percent said they supported — with 52% strongly supporting — the United States moving to single-payer healthcare, while 21% said they strongly opposed such a move.

More than two thirds of the 2503 US respondents who participated in the Medscape poll were older than 55, but the support for single-payer care came from respondents of all ages. Nurses and advanced practice nurses made up the majority of respondents, followed by physicians and administrators.

Sixty-six percent of physicians who responded said they favored a single-payer system, compared to 68% of administrators and 69% of nurses. About a quarter of respondents among those three professions opposed single-payer healthcare.

https://www.medscape.com…

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Poll: Do you favor or oppose the United States moving to a single-payer healthcare system?

52% – Strongly favor
17% – Favor
4% – Neither favor nor oppose
7% – Oppose
20% – Strongly oppose

https://www.medscape.com…

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Comment:

By Don McCanne, M.D.

Opponents of Single Payer Medicare for All often claim that most doctors and nurses are opposed. Numerous polls refute that, including this current Medscape reader poll of health care professionals (not technically scientifically valid, but nevertheless informative – two-thirds of physicians, nurses and administrators responding support single payer).

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By Diana Farrell, Fiona Greig, Amar Hamoudi, JPMorgan Chase Institute
Health Affairs, Health Policy Brief, December 13, 2018

Consumer health care spending is sensitive to cash flow fluctuations, causing patients to defer health care.

Key Points

• Bank transaction data reveal that in any given year, one in six families makes an extraordinary health care payment of roughly $2,000 in a single month. They time such payments to coincide with positive cash flow events, yet they have not recovered financially even a year later, as evidenced by a lower level of liquid assets and higher credit card debt.
• Consumers increase health care spending by 60 percent in the week after receiving a tax refund, and the majority of these payments are made in person—likely for care received on that day. This increase is much larger for people in the lowest quintile of account balances.
• Health care spending is sensitive to a wide range of cash flow events, including job loss and the end of unemployment insurance, natural disasters, and mortgage interest rate changes.
• The findings suggest that many consumers make decisions about when to pay for and receive health care based on whether they have cash on hand. Further efforts are needed to reduce out-of-pocket spending for families and encourage and enable them to save. The health care system should promote cost transparency and support discussions between providers and patients about the costs of care.

A large body of literature documents the relationship between health care spending and consumer finance, including the impact of such spending on long-term debt, poverty, and use of health services.

This brief highlights the health care–finance connection… by exploring how short-term changes in household cash flow influence consumer decisions about whether and when to seek medical care. The JPMorgan Chase Institute brings to these questions new empirical evidence based on high-frequency banking transaction data for large samples of Chase checking account customers.

Our data show that consumers immediately increase their use of health services after they receive large infusions of cash. This finding suggests that consumers make health decisions — some of which have long-term consequences — based on short-term financial factors. Far from affecting only low-income people, immediate cash shortages cause people at all income levels to delay care. This behavior is especially concerning in the context of rising out-of-pocket health care spending.

Policy Implications

The trend toward increased consumer cost sharing for health care shows no signs of slowing. It has substantial support from both government regulators and health care payers, based largely on the belief that asking consumers to pay for more of the cost of their health care will cause them to seek care only when they need it, evaluate providers using price as one consideration, and avoid unnecessary treatments. Yet that is not what we see. Instead, our findings suggest that health care consumers are rationalizing consumption, but not in the ways that stakeholders expected. Consumers are making decisions based on whether they have cash in their pocket right now, not based on a longer-term view of what they could afford over time. Assuming that at least some of the delays in care are for necessary services, which is consistent with the findings of others, these delays have the potential to increase long-term costs for the entire health care system, since poorly managed chronic conditions often result in health care costs many times higher than well-managed conditions do.

Our findings also point to the importance of tools that encourage people to save. People who have cash reserves fare better when faced with an extraordinary expense, in that their finances do not show the same persistent adverse consequences of large payments. The health savings accounts and other savings vehicles that are often paired with CDHPs are a positive innovation in that regard. Yet consumers clearly do not have enough savings in them to cope with health costs. If they did, they would put cash into them when they had a cash infusion and spend money in them when they had a health need, which means that we wouldn’t see as large health care spending spikes as we do.

There are many reasons why families don’t save. They may not have the financial slack, or there may be a mismatch in timing between when they have a reserve and when they have a health need. In addition, health savings and reimbursement accounts can be used only for health expenses, which may discourage their use among people who need more flexibility. For these reasons, consumers need savings tools that are automatic, low risk, and uncomplicated.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

This study of cash flow dynamics in health care spending is a little bit different from most other health policy studies in that it uses banking data from JPMorgan Chase rather than data from the health care industry. Although it is understandable that JPMorgan Chase would focus on money management, it must be kept in mind that the application of money management to access and affordability of health care can have a significant effect on health care outcomes.

Although, in our current system, some attention might naturally be given to money management tools, at today’s more advanced state of health policy science, directing attention to our health care financing system that uses cost sharing (deductibles, copayments, coinsurance) should lead to policy decisions that would be more beneficial in ensuring that people receive the health care that they should have.

Cost sharing has been clearly shown to impair access to beneficial health care services. One reason can be that the individual may lack ready cash reserves. The solution here is easy. Eliminate cost sharing. Provide care with no additional payments required at the time of service. Instead, pay for the entire health care system in advance, using progressive tax policies so that individuals automatically pay only what they can afford. Readers already know that’s exactly the way Single Payer Medicare for All is designed to work. There are plenty of other legitimate roles for banking without intruding unnecessarily into the personal financing of health care.

Another important conclusion that can be gleaned from this report is that the highly touted health savings account (HSA) falls far short of being an ideal tool for cash management in health care. Regarding HSAs and other savings vehicles that are often paired with high-deductible health plans, the authors state, “consumers clearly do not have enough savings in them to cope with health costs. If they did, they would put cash into them when they had a cash infusion and spend money in them when they had a health need, which means that we wouldn’t see as large health care spending spikes as we do.” Also, families “may not have the financial slack, or there may be a mismatch in timing between when they have a reserve and when they have a health need. In addition, health savings and reimbursement accounts can be used only for health expenses, which may discourage their use among people who need more flexibility.”

It’s fine to have savings vehicles that earn income, if you can manage to fund them, but we should not have to rely on them as a ticket to accessing health care. Single Payer Medicare for All would take care of that need for all of us just fine.

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By Nicholas Bagley
The Washington Post, December 15, 2018

Late Friday night, a district court in Texas declared the entire Affordable Care Act unconstitutional — lock, stock and barrel. That includes not only the individual mandate and the protections for people with preexisting conditions, but also the entire Medicaid expansion as well as a host of other ACA rules without any connection at all to health insurance.

The logic of the ruling is as difficult to follow as it is to defend, and it sets the stage for yet another round of high-stakes constitutional litigation over the future of health care in the United States.

As part of their 2017 tax reform package, congressional Republicans amended the ACA to eliminate the tax penalty. Because they couldn’t summon a filibuster-proof majority necessary to make substantive amendments, they zeroed the penalty out without also eliminating the naked instruction to buy insurance. And they trumpeted to anyone who would listen that they repealed the individual mandate — which, for all practical purposes, is precisely what they did.

But that’s not how U.S. District Judge Reed O’Connor saw it. In his view, the penalty-free mandate still amounted to a coercive exercise of government power. That meant that two individuals who’d been conscripted by red states as plaintiffs had standing to sue.

To put it bluntly, that makes zero sense. The judge asserted — without any support — that the penalty-free mandate “requires [the plaintiffs] to purchase and maintain certain health-insurance coverage.” But that’s not right. An unenforceable instruction to purchase insurance is not coercive in the slightest.

We know what Congress wanted to do in 2017: repeal the mandate and leave the rest of the act intact. Its judgment could not have been plainer.

That’s not how O’Connor sees it. In perhaps the most remarkable passage in a remarkable opinion, he wrote that the 2017 Congress “intended to preserve the Individual Mandate because the 2017 Congress, like the 2010 Congress, knew that provision is essential to the ACA.”

Your jaw should be on the floor. On no account did Congress in 2017 “intend to preserve” the individual mandate. It meant to get rid of the loathed mandate — and it did, by eliminating the penalty that gave it force and effect.

In his contempt for the ACA, O’Connor blinded himself to all this. Instead, he decided that what Congress “really” wanted was to invalidate the entire ACA.

What happens next? California has already said it will appeal, and the decision won’t take effect while that appeal is pending.

So nothing changes for the time being. And nothing should change.

This case is different; it’s an exercise of raw judicial activism. Don’t for a moment mistake it for the rule of law.

Nicholas Bagley is a professor of law at the University of Michigan Law School.

https://www.washingtonpost.com…

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The Texas ruling against Obamacare is a boon to Medicare-for-all

By Ezra Klein
Vox, December 14, 2018

The Texas ruling finding the Affordable Care Act unconstitutional is ludicrous in its reasoning and unlikely to survive appeal. It argues, in short, that since Congress removed the penalty from the individual mandate, the individual mandate is no longer a tax; because the individual mandate is not a tax, it is no longer constitutional; and if the mandate is no longer constitutional, the entire law must be judged unconstitutional.

But if you want to know why Democrats are suddenly dotting the landscape with new proposals for Medicare-for-all and Medicaid-for-all, this ruling is a useful artifact. The basic idea behind Obamacare was that a public-private system based on Mitt Romney’s Massachusetts reforms would command some Republican support, or at least acceptance, and thus be easier to pass and to expand.

Republicans have proven that theory wrong. Instead, the private-public construction of Obamacare has given opportunistic Republicans their most effective attacks on the bill. Those attacks have been legal, like this assault on the regulations governing private insurance purchase, and political, like the attacks on high deductibles and complex shopping schemes.

But with Obamacare under constant threat, Republicans have refocused Democrats on building what they failed to build in 2010: a universal health care system simple enough and popular enough that it is safe from constant political and legal assault. And that means some version of Medicare-for-all.

But nearly a decade of constant and cynical assault on what was supposed to be a compromise bill has pushed the Democratic Party left on health care policy, and persuaded Democrats everywhere that trying to compromise or placate Republicans is foolish. The legacy of the GOP’s Obamacare repeal strategy won’t be the Affordable Care Act’s destruction, but Medicare-for-all’s construction.

https://www.vox.com…

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Comment:

By Don McCanne, M.D.

There is nobody more knowledgeable on the Republican state attorneys general challenge of the Affordable Care Act (ACA) than Michigan law professor Nicholas Bagley. He describes the ridiculousness of the arguments made by U.S. District Judge Reed O’Connor in his act of judicial activism designed to declare the entire Affordable Care Act unconstitutional and thus invalid.

Briefly, Bagley refutes the judge’s two leading arguments: 1) That Congress’ cancellation of the penalty to fail to comply with the individual mandate to purchase health insurance removes this penalty as a federal tax which then he uses to invalidate, as not being applicable, the previous Supreme Court finding that the penalty is a legitimate federal tax that upholds the constitutionality of the individual mandate, and 2) That the mandate is essential to the entire legislation which would otherwise fall apart without it, and thus it is not severable; that is, he rules that removing the mandate invalidates the entire act. As Bagley says, this is “an exercise of raw judicial activism,” and not the rule of law.

We normally should be able to feel secure that the Appeals Court, and eventually the Supreme Court, would reverse this ruling, but that is not assured when we have a flawed process that selects a Supreme Court justice that uses the statement, “I like beer,” to explain away his poor judgment in the past. It is likely the decision will be reversed, but not only should we be prepared in the event that it is not, we should also use this historical moment to advance the cause of health care justice for all.

Ezra Klein describes how a decade of Republican opposition to ACA has only shown that any effort to placate or compromise would be futile, and thus we should move forward with construction of Medicare for All. Medicare is the law of the land and the half century of its continued existence solidifies the constitutionality of the program.

Ironically, by relying on a pair of non sequiturs for his decision, Judge O’Connor is awakening us to the imperative of moving forward with much needed reform right now, but reform that works best for the people and not reform that tries to fulfill the fantasies of right-wing ideologues like him.

The greatest risk at the moment is that the passion for reversing Judge O’Connor’s decision may transfer into passion for support of lesser measures: 1) moderates supporting grossly inadequate policies such as a public option or Medicare buy-in, and value-based purchasing proposals such as accountable care organizations and other MACRA alternative payment models, and 2) conservatives supporting their pet policies of consumer-directed health care, including an expansion of health savings accounts, and expanding the insurance market with inexpensive, but nearly worthless bare bones coverage.

The reform we need to aim for should not be just any old thing labeled Medicare, but it should be true health care nirvana: Single Payer Medicare for All.

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