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Philip R. Lee’s 1986 Call for National Health Insurance

Philip R. Lee’s 1986 Call for National Health Insurance

A UCSF and US titan of health policy, Philip R. Lee, nearly 40 years ago described our health insurance options, and wisely preferred national health insurance. Our country chose differently, relying heavily on private insurers and incremental fixes that missed the opportunity for efficiency and heath justice. We must fight for Dr. Lee’s choice.

This Date in UCSF History: National Health Insurance Ahead?, Synapse, UCSF Student Voices, April 23, 2024

(Originally authored by Dr. Philip R. Lee — a UCSF professor of social medicine and director of the Institute for Health Policy Studies — and published in Synapse on April 24, 1986.)

Twenty years ago, states throughout the country began to implement federal legislation (Title XIX, Social Security Act) establishing a national program for medical care for the poor (Medicaid). In the same year, 1966, the federal Medicare program began providing hospital and medical insurance for the elderly.

With these two public programs, the public sector began to fill the major gap in private health insurance.

Private health insurance was largely provided on a group basis, through employment, with employers paying the bulk of premiums.

In the 1960s and early 1970s the idea that access to health care was a merit good or a right of citizenship was widespread.

It seemed only a matter of time before the remaining gaps would be filled by universal health insurance, albeit with a mixture of public and private payment mechanisms.

In the 1970s and early 1980s, as costs of health care rose rapidly and as efforts to contain costs seemed ineffective, the idea took hold that national health insurance was impossible and that health care was not a merit good.

Instead, many advocated that health care should be treated like other goods and services, and that price competition and the marketplace should be the primary approach to resolving the problems of cost, access and quality.

Policies established by Congress and the Reagan administration have strongly supported this approach.

Many states, including California, have adopted pro-competitive policies. The results of the recent policy changes have been mixed.

The rate of increase in health care costs has slowed, hospital admissions have declined, length of hospital stay has been shortened and hospital occupancy has been reduced. All this seems to be for the better, but patients have found themselves discharged from hospitals “sicker and quicker.”

Posthospital services, described as a “no-care zone” by UCSF Professor Carroll Estes, have been unable to cope adequately with the changes.

The number of people who are uninsured or underinsured has risen rapidly and local governments, such as San Francisco County, have found themselves obliged to care for increasing numbers of sick, disabled and poor.

Three future scenarios seem possible given the current environment:

  • Continued reliance on price competition and the marketplace with the evolution of a “three-tiered” system of care consisting of fee for service, HMOs and public sector.
  • A variety of incremental strategies to fill the gaps in coverage at the state level through mandated private insurance coverage, state funds to cover the uninsured and an expansion of Medicaid.
  • Publicly funded national health insurance, along the lines of the Canadian model.

Although the odds are against national health insurance, this proposal would provide the most equitable solution to health care access with effective means to control costs while assuring freedom of choice for consumers and providers.

Personally, I believe it is the preferred solution.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

Philip Lee was an icon of health care justice, perhaps most noted for his role in implementing Medicare. Particularly noble was his use of Medicare funding as a lever to eliminate segregation in the nation’s hospitals and, by extension, throughout the medical system. Over his career, he remained a champion of health equity and justice for all. Thus, his commentary authored 38 years ago comes as no surprise to us.

Let’s review the challenge he described from today’s perspective, nearly four decades later. Of the three scenarios Dr. Lee described, the US followed a mix of free market and incremental changes; not the national health insurance option he preferred. Dr. Lee was prescient. As a result, we accumulated decades of fraught experience – high costs, low health care access, and high mortality.

Dr. Lee’s “publicly funded national health insurance, along the lines of the Canadian model” has proven to be quite effective in other wealthy nations. We should have chosen the option that, as he describes, would combine equity, choice, and cost control. Health justice for all, efficiently.

Clearly the market approach and mandated private insurance succeeded in creating wealth for health care investors but was certainly ineffective in ensuring affordable, comprehensive care for everyone.

Philip Lee bestowed on us this powerful message of health justice. We should act on his advice. It’s not too late.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Cutting Back Medicare & Medicaid Would Kill Tens of Thousands

Analysis by a team based at Yale University finds that proposals to delay Medicare eligibility, undo COVID Medicaid growth, and impose work requirements on Medicaid would result in an estimated 25,000 – 33,000 additional deaths in coming years, as well as increasing morbidity for hundreds of thousands.

Study: Proposed changes to Medicare, Medicaid could cost thousands of lives, Yale News, April 22, 2024, by Mallory Locklear

Proposed changes to the United States’ Medicare and Medicaid programs could lead to thousands of additional deaths each year, a new Yale study reveals.

Recent proposals to reduce program costs include a recommendation to raise the eligibility age for Medicare from 65 to 67 – put forward by a 2022 report from the House of Representatives’ Republican Study Committee – and a proposed work requirement for Medicaid coverage – a recurring Congressional consideration during federal budget negotiations.

While neither of those have yet been adopted, one major change to Medicaid is already underway: A provision authorized at the start of the COVID-19 pandemic that required states to keep existing Medicaid recipients enrolled in the program expired last year. Since then, states have begun disenrolling Medicaid recipients who no longer qualify or are unable to complete the renewal process.

Such changes will drive up the number of uninsured people in the U.S., said Alison Galvani, the Burnett and Stender Families Professor of Epidemiology (Microbial Diseases) at Yale School of Public Health (YSPH) and senior author of the study. The study was published April 22 in the Proceedings of the National Academy of Sciences.

The Congressional Budget Office has assessed two strategies for raising the eligibility age over time – by two months or three months each year until the eligibility age reaches 67. According to the new study, the approaches would result in an additional 17,244 deaths or 25,847 deaths respectively during the transition.

A separate proposal to institute work requirements for Medicaid recipients, meanwhile, would lead to an additional 613 deaths per year among U.S. adults, the researchers report. Further, the ending of continuous Medicaid enrollment in 2023 could lead to 7,900 additional deaths each year.

They found 456,966 people with diabetes under the age of 65 could lose access to health care following the end of continuous Medicaid enrollment, and 325,613 seniors would lose care if the Medicare age were raised.

“Working in the field of public health, it can be frustrating to see policymakers propose strategies that ignore evidence-based solutions capable of saving lives, boosting prosperity, and reducing health care costs,” said Galvani.

In a previous study, Galvani and her colleagues found that a single-payer universal health care model would save more than 68,000 lives and $450 billion annually, while the current proposal to raise Medicare eligibility age would save a maximum of $25.5 billion across five years and cost thousands of lives.

“It’s disheartening to see people in positions of power who have access to all of this information argue that retractions in health care are for the benefit of the country,” she said. “If policymakers want to save lives and costs, our analyses have shown single-payer universal health care is the solution.”

Comment:

By Don McCanne, M.D.

No comment need be appended to these excerpts since Alison Galvani and her team have said it all. Ridiculous proposals that reduce health care and cost lives should be rejected, especially when we know that the single-payer universal health care model, structured properly, would save both lives and money. If only Congress and the President could get on our wavelength.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Medicare Advantage and Vertical Consolidation in Health Care

By Hayden Rooke-Ley
American Economic Liberties Project, April 30, 2024

A new wave of health care consolidation is underway. Health insurance and retail conglomerates are rapidly acquiring providers, from primary care practices and surgery centers to home-based and post-acute care. UnitedHealth Group (UnitedHealth), for example, is now the nation’s largest insurer and the largest employer of physicians. Humana is now the largest provider of “senior-based” primary care and in-home care. CVS Health, Walgreens, and Amazon, which have been aggressively consolidating the prescription drug supply chain, are now acquiring physician practices. And private equity investors—looking to consolidate industry segments and then sell to these conglomerates as an eventual exit—are accelerating these rollups.

With dominant market power, the new health care conglomerates can dictate which physicians patients can see, which medications are prescribed to them, and which insurance plans they enroll in. By acquiring medical practices, these corporate employers can shorten visit times, require more clinical coding and box-checking, and replace physicians with lower-cost clinicians. Meanwhile, by coordinating across lines of business, conglomerates like UnitedHealth can squeeze out independent practices and community pharmacies. They can also shuffle money between subsidiaries and use other financial tactics to skirt regulations and exploit payment loopholes, increasing health care costs.

This paper details the causes and costs of this new frontier of consolidation and offers a set of solutions to address it. In short, sweeping changes in health care financing policy are causing insurers and retailers to restructure as vertically integrated conglomerates. While technical, how the government pays providers and insurers fundamentally shapes the business strategies of health care companies. As the government continues to privatize Medicare and Medicaid, it is significantly overpaying insurance companies to administer benefits. With this excess capital, these insurers are acquiring providers, gaining control of key points in the delivery system that enable them to capture greater government payments and minimize spending on patient care. To take one prominent example, control over primary care clinicians allows these corporate owners to manipulate billing and coding practices to make patients appear sicker to the government, thereby increasing payments.

Part I of this paper explains how government policy over the last two decades has transformed health care financing. In an attempt to solve health care’s value problem— high spending and poor health outcomes—policymakers have steadily abandoned “fee- for-service” financing, in which medical providers are reimbursed for each service that a patient receives. Instead, public programs have increasingly adopted “capitation-based” financing. In this model, the government pays a fixed budget to a “risk-bearing entity”—an insurance company, hospital system, or group of physicians—to manage the total health care costs for a patient. The risk-bearing entity turns a profit if it keeps costs below the established budget, which is adjusted based on the perceived sickness of the population and metrics of care quality. In this paper, this policy agenda and its underlying ideological framework are referred to as health policy’s “Capitation Consensus.”

Medicare Advantage, the privatized version of Medicare that now covers more than half of Medicare beneficiaries, is the most prominent example of the Capitation Consensus. But this financing approach has spread across public health care programs: nearly all of Medicaid has moved to capitation-based financing, and Medicare’s prescription drug benefit, Part D, operates entirely on capitation. In the last decade, traditional Medicare— the historically fee-for-service model of Medicare—has been integrating versions of capitation through accountable care organizations and other value-based care models. Despite high hopes, the shift to capitation has yet to deliver on its primary objective of cost reduction. Most concerning is that Medicare Advantage now costs taxpayers anywhere from $75 billion to $140 billion annually in over-subsidization relative to traditional Medicare.

Part II of this paper explains how the Capitation Consensus is driving vertical consolidation. With excess capitation payments, Medicare Advantage insurance conglomerates are plunging capital into provider acquisitions, and retailers and private equity investors are following suit. As noted above, owning physician practices enables conglomerates to inflate the perceived disease burden of patients, thereby enhancing capitation-based payments from the government. Vertical consolidation also enables patient steering: conglomerates can push patients to receive care at their own provider subsidiaries. In doing so, these companies squeeze out local providers, such as independent physician practices and community pharmacies. Steering also generates “captive revenue,” which allows conglomerates to game federal regulations requiring that government payments are spent on patients, not profits. Further, these conglomerates use their insurance-side subsidiaries to pressure independent practices to sell to their provider-side subsidiaries, effectively “flipping” new patients to their own medical practices and insurance plans.

Turning to solutions, Part III of this paper argues for an alternative policy framework— aimed at a new “industrial policy” for health care—that would depart from the Capitation Consensus and center at least three principles. First, this approach would be suspicious of concentrated corporate power—whether horizontally or vertically combined—and would promote the autonomy and collective power of clinicians. Second, it would revive a legal and policy focus on the ownership structure and governance of health care providers, protecting the medical profession from corporate influence and minimizing financial strategies that increase prices and administrative costs. Third, a proactive health care industrial policy would emphasize the “supply side”: how policymakers, particularly in Medicare, can exercise greater control of public money and directly rationalize the production and allocation of health care capacity.

The paper offers two sets of policy recommendations. The first would directly combat the emerging forms of vertical consolidation that are fueled by the Capitation Consensus. The second set of policies offers alternatives to large-scale, investor-driven health care. These proposals are geared toward building robust health care infrastructure—owned by clinical providers and local communities—that meets growing care needs and is insulated from corporate consolidation.

full policy brief:
http://www.economicliberties.us…

A Doctor at Cigna Said Her Bosses Pressured Her to Review Patients’ Cases Too Quickly. Cigna Threatened to Fire Her.

Cigna tracks every minute that its staff doctors spend deciding whether to pay for health care. Dr. Debby Day said her bosses cared more about being fast than being right: “Deny, deny, deny. That’s how you hit your numbers,” Day said.

By Patrick Rucker and David Armstrong
ProPublica, co-published with The Capitol Forum, April 29, 2024

In late 2020, Dr. Debby Day said her bosses at Cigna gave her a stark warning. Work faster, or the company might fire her.

That was a problem for Day because she felt her work was too important to be rushed. She was a medical director for the health insurer, a physician with sweeping power to approve or reject requests to pay for critical care like life-saving drugs or complex surgeries.

She had been working at Cigna for nearly 15 years, reviewing cases that nurses had flagged for denial or were unsure about. At Cigna and other insurers, nurses can greenlight payments, but denials have such serious repercussions for patients that many states require that doctors make the final call. In more recent years, though, Day said that the Cigna nurses’ work was getting sloppy. Patient files that nurses working in the Philippines sent to her, she said, increasingly had errors that could lead to wrongful denials if they were not corrected.

Day was, in her own words, persnickety. If a nurse recommended denying coverage for a cancer patient or a sick baby, she wanted to be certain it was the right thing to do. So Day said she researched guidelines, read medical studies and scrutinized patient medical records to come to the best decision. This took time. She was clearing fewer cases than many of her peers.

Some of her colleagues quickly denied requests to keep pace, she said. All a Cigna doctor had to do was cut and paste the denial language that the nurse had prepared and quickly move on to the next case, Day said. This was so common, she and another former medical director said, that people inside Cigna had a term for these kinds of speedy decisions: “click and close.”

“Deny, deny, deny. That’s how you hit your numbers,” said Day, who worked for Cigna until the late spring of 2022. “If you take a breath or think about any of these cases, you’re going to fall behind.”

In a written response to questions, Cigna said its medical directors are not allowed to “rubber stamp” a nurse’s recommendation for denial. In all cases, the company wrote, it expects its doctors to “perform thorough, objective, independent and accurate reviews in accordance with our coverage policies.” The company said it was unaware of the use of the term “click and close” and that “such behavior would not be tolerated.”

During Day’s final years at Cigna, the company meticulously tracked the output of its medical directors on a monthly dashboard. Cigna shared this spreadsheet with more than 70 of its doctors, allowing them to compare their tally of cases with those of their peers. Day and two other former medical directors said the dashboard sent a message loud and clear: Cigna valued speed. (ProPublica and The Capitol Forum found these other former Cigna doctors independently; Day did not refer them.) One of Day’s managers in a written performance evaluation called the spreadsheet the “productivity dashboard.”

Measuring the speed and output of employees is common in many industries, from fast food to package delivery, but the use of these kinds of metrics in health care is controversial because the stakes are so high. It’s one thing if a rushed server forgets the fries with your burger. It’s another entirely if the pressure to act fast leads to wrongful denials of payment for vital care. Walgreens in 2022 dropped measurements of its pharmacists’ speed from their performance reviews after some alleged that practice could lead to dangerous mistakes.

ProPublica and The Capitol Forum examined Cigna’s productivity dashboards for medical directors from January and February 2022. These spreadsheets tallied the number of cases each medical director handled. Cigna gave each task a “handle time,” which the company said was the average amount of time it took its medical directors to issue a decision.

Day and others said the number was something different: the maximum amount of time they should spend on a case. Insurers often require approval in advance for expensive procedures or medicines, a process known as prior authorization. The early 2022 dashboards listed a handle time of four minutes for a prior authorization. The bulk of drug requests were to be decided in two to five minutes. Hospital discharge decisions were supposed to take four and a half minutes.

“Medical directors would message me and say, ‘We can’t do these cases in four minutes. Not if you want to do a good job,’” Day recalled.

As ProPublica and The Capitol Forum reported last year, Cigna built a computer program that allowed its medical directors to deny certain claims in bulk. The insurer’s doctors spent an average of just 1.2 seconds on each of those cases. Cigna at the time said the review system was created to speed up approval of claims for certain routine screenings; the company later posted a rebuttal to the story. A congressional committee and the Department of Labor launched inquiries into this Cigna program. A spokesperson for Rep. Cathy McMorris Rodgers, the chair of the congressional committee, said Rodgers continues to monitor the situation after Cigna shared some details about its process. The Labor Department is still examining such practices.

One figure on Cigna’s January and February 2022 dashboards was like a productivity score; the news organizations found that this number reflects the pace at which a medical director clears cases.

Cigna said it was incorrect to call that figure on its dashboard a productivity score and said its “view on productivity is defined by a range of factors beyond elements included in a single spreadsheet.” In addition, the company told the news organizations, “The copy of the dashboard that you have is inaccurate and secondary calculations made using its contents may also be inaccurate.” The news organizations asked what was inaccurate, but the company wouldn’t elaborate.

Nevertheless, Cigna said that because the dashboard created “inadvertent confusion” the company was “reassessing its use.”

Day was afraid to look at the dashboards. Anyone could see that by Cigna’s measures, she was a laggard. In January 2022, only a third of her peers had lower scores, and in February 2022, it was just a quarter.

In a recorded phone call and in emails with supervisors, Day complained that Cigna’s metrics failed to account for the quality of decisions. She said she and others asked higher-ups how often medical director decisions were overturned on appeal but nobody would say.

Day gave Cigna written permission to discuss her employment with ProPublica and The Capitol Forum.

The company described Day as a “disgruntled former employee” and said her “personal view is not an accurate representation of the work of the many medical directors and clinicians we employ.” Cigna added that prior authorization requests are often time-sensitive and the company’s “mission is to ensure our patients receive the right care as quickly as possible.”

Cigna rejected the assertions that denying cases was an effective way of working faster. “Even if medical directors were incentivized to review more claims — which they are not — it makes no sense to suggest that this incentivizes denials; it would be far quicker to approve all claims,” the company spokesperson wrote. The insurer said that denials take more time because they require a deeper review of clinical data, potentially requesting additional reviews by senior clinical directors, drafting denial letters and possibly phoning the treating physicians.

But another doctor who had worked at Cigna also said that denying a request for payment was far quicker than approving one since the nurses served up language that could be used to justify the denial. That former Cigna medical director said, “Sometimes you just have to accept the nurse and click and close if you had too much work.” (That doctor asked not to be named because they feared repercussions if they commented publicly.)

When Debby Day got her job at Cigna in November 2005, she thought it was a godsend.

She had been working for a health insurance startup in North Carolina. The charismatic founder of the company, Day said, had told her and a handful of principal executives to expect a windfall when the company went public. That never happened, and Day was eventually left with no job and no severance.

When a recruiter mentioned the medical director job at Cigna, it sounded like a perfect fit. The job was based in North Carolina, but Cigna didn’t mind that she was licensed in California, where she did her residency at Harbor-UCLA Medical Center. She was ready to leave the executive track, and the position allowed her to put her medical training to good use without the daily grind of working in a clinic.

The daughter of an ophthalmologist, Day had watched her father perform eye surgery when she was a child, and she found medicine fascinating. When Day started practicing, she learned quickly that while she enjoyed the intellectual challenges of medicine, the hands-on work of seeing patients drained her. As a medical director, she said, “I could really take care of patients without having to talk to them all day long.”

Cigna, like all health insurers, makes patients get approval in advance for certain treatments. Day became one of the people who reviewed these prior authorization requests, deciding what to cover and what to deny. Everyone Day worked with was under one roof in Raleigh, North Carolina. The office buzzed with conversations among colleagues, and she was able to consult with specialists on complex cases.

She never felt pressure to do anything but make the right decision for the patient. At the same time, she said, she didn’t hesitate to reject treatment she thought was improper.

A couple years into her time at Cigna, Day noticed some doctors prescribing a costly treatment called intravenous immunoglobulin, or IVIG, that helps patients with weakened immune systems fight off infections. Only she found they were prescribing it in cases where it didn’t make any medical sense. That wasn’t good for patients or for Cigna. “Some of these guys were pouring it into every patient they could get their hands on and then making hundreds of thousands of dollars billing for it,” she recalled.

At the time, Cigna didn’t have a policy for when IVIG should be used, so Day developed one based on the scientific evidence available at the time. Day said this saved millions of dollars and that Cigna rewarded her with bonuses and stock options.

“In my head I truly believed that you could marry good health care with business,” she said.

As Day neared the end of her first decade at Cigna, the company closed regional offices in favor of a nationwide review system, she said. With medical directors working from home, Day could no longer pop down the hallway to consult with doctors in other specialities.

Cigna had used a productivity dashboard for years, but by 2019, these metrics began playing a more prominent role in the company’s evaluations of medical directors, Day said. Now, making a fast decision seemed more important than making the right decision, she said. In February 2019 emails to her managers, Day openly questioned this system.

Her boss responded: “We all understand that many cases are involved and take more time,” he wrote. “We have tried to account for that additional time in the allotment allowed for certain cases.”

Still, he made it clear that transaction volume — the metric on the dashboard that was similar to a productivity score — was one of the factors “we use to determine merit raises, bonus” and stock awards. When asked about this, Cigna said that “any assertion that our Medical Directors’ compensation (cash or stock) is tied to denials or their handle time for cases is false.”

In that same 2019 email, Day’s boss added, “We want to assist every medical director who wishes to improve his or her efficiency.”

Day shot back, “Some of our newer MDs are quite terrified of the ‘counting,’” she wrote. “All ask — ‘how is quality measured?’”

Soon, Day realized that her boss wasn’t talking in the abstract about improving efficiency; he was talking about her. She learned that managers were going to help her pick up the pace of her reviews.

When bosses reached out, they didn’t discuss whether she was making the right call, only how long it took her to decide, she said.

By then, Day said, Cigna had shifted much of the nursing work to the Philippines. She found mistakes in the case files that these nurses sent. In an email to Day, a fellow medical director lamented the amount of time it took to untangle one case and said the reports by “the overseas nurses” were “messes.”

Some of the more astonishing problems that Day spotted have stayed with her. In a case involving a newborn who needed an epilepsy evaluation, Day noticed that a Cigna nurse had listed the mother’s name as the patient, rather than the baby’s. Day fixed that mistake, avoiding what certainly would have been a denial. In another case, a nurse recommended denying payment for an ultrasound of the neck because the treatment wasn’t medically necessary. But the nurse had gotten the body part wrong. It was a hip that was injured, and the imaging was needed. An appeal that landed on Day’s desk involved Cigna’s decision to reject payment for a test because it wasn’t medically necessary for a patient with a sexually transmitted disease. But Day figured out that the patient had toenail fungus, not an STD.

Day said her bosses didn’t want to hear that she was catching errors. By October 2020, Cigna had placed Day on a performance improvement plan that required her to raise her “productivity level” — referring to the score on the dashboard — to at least 70%, which would be a significant jump for her but was slightly below the median for medical directors. The company made the consequences crystal clear: If she failed to successfully complete the plan, she could be terminated.

ProPublica and The Capitol Forum asked Cigna how it calculated that score, but the company wouldn’t say. “Transaction volume helps gauge productivity and efficiency — the amount of work done, not the speed at which it is done,” a Cigna spokesperson wrote. The company said this metric measured the time a medical director spent on tasks involving medical judgment versus other work, such as internal meetings or training.

On the early 2022 productivity dashboard, though, a different calculation could explain Day’s score, and this math reflects how fast medical directors reviewed cases. ProPublica and The Capitol Forum multiplied the number of cases Day handled by the time Cigna allotted for each type of case, then divided that total by the hours she worked that month. The resulting percentage equaled her score. Medical directors who spent every available minute of their workdays clearing cases within the time constraints Cigna set would score at least 100%. Indeed, some medical directors had scores greater than 100%, meaning they cleared cases in even less than the allotted time. The newsrooms’ formula accurately reproduced the scores of 87% of the Cigna doctors listed; the scores of all but one of the rest fell within 1 to 2 percentage points of the number generated by this formula. When asked about this formula, Cigna said it may be inaccurate but didn’t elaborate.

Day said her bosses told her that the way to boost her score was to review more cases during her normal work hours.

Responding to questions, Cigna said the productivity dashboard was “primarily used to ensure that we have enough medical directors to perform the amount and type of work that needs to be done.” It is not used, the company said, to evaluate the performance of medical directors or track the speed at which individual doctors do their work.

Cigna, however, later said of the dashboard that “in the unusual situation that a medical director is a significant outlier to peers performing similar types of reviews, managers might use this metric as one data point to understand and discuss the variance with the medical director.” It also said Day was placed on a performance improvement plan “to help her meet the most basic standards to support patient care.”

During the time Day spent on the performance improvement plan, she refused to change her approach, which she felt was necessary to make the right call.

In December 2020, she appealed to the human resources department, figuring that colleagues there would see that it was wrong to fire a medical director for taking care to decide critical medical questions.

She was wrong.

“You feel that the time constraints/metrics, which are in place to review these cases are unreasonable, for some cases are very complex consisting of multiple pages to review,” a Cigna human resources employee wrote, summing up Day’s feelings as the matter escalated.

And while Day’s supervisor “appreciates your attention to detail,” the human resources employee wrote, he “also realizes that there are metrics in place that he must hold everyone to.”

When asked about this, Cigna said, “Dr. Day raised questions about her performance improvement plan through appropriate internal ethics channels available to all employees, and there was no wrongdoing found.”

Eventually, the daily stress of being pushed to work faster coupled with the threat of being fired took a toll on Day. Sleepless and fighting depression, Day was at the breaking point.

“I actually sort of had a mental breakdown,” she recalled.

On a recorded call with her boss about her lagging productivity score, Day brought the subject back to the quality of the decisions she was making. Her boss made it sound like Day was a broken record.

“We have the same discussion every time we talk,” he said. While saying “nobody’s asking you not to do quality work,” her boss said, “you must know I just have to redirect our discussion.”

But Day continued: “When there is no measurement of quality, then the discussion will continue to have that element to it.”

The supervisor said he heard Day’s concerns “loud and clear” but warned that “at the end of the day, we need to get your productivity up and we don’t have a lot of time to do that.”

The focus on metrics was proof Cigna was losing its way, Day told her boss. When she started working at Cigna 15 years earlier, there was a “commitment to quality and taking care of our customers.” Day said that it was still important to her and other medical directors that “we go home at the end of the day and think we’ve done a good job for Cigna.”

In a response to questions, Cigna said the supervisor, who works in California, was unaware that he was being recorded and that under that state’s laws, it is illegal to record a private phone call without all parties’ consent. Day said that she was in North Carolina during the call and that North Carolina law allows a person on a call to record without getting the consent of others.

Day took a monthslong leave from the job in mid-2021 that allowed her to work part time, and she found a therapist who helped her manage the depression. When she returned, Day said, it was more of the same.

In the late spring of 2022 she decided to retire from Cigna.

Maya Miller contributed reporting.

https://www.propublica.org…

Medicare for All Individual Cost Calculator

Medicare for All saves money overall … but what will it mean financially for specific individuals and families? That’s the question this new calculator answers for national M4A, in just a few minutes.

Congresswoman Pramila Jayapal, Email to supporters, April 25, 2024

Republicans HATE Medicare for All and they’re doing everything in their power to protect Big Pharma and our private, for-profit health care system.

This 100% free and accessible calculator compares the information you give for current spending on health care and your Medicare for All spending based on a progressive tax model proposed to fund the program. All you need to do is click here to get started ››

Use the Medicare for All Calculator ››

You may be asking yourself, what would Medicare For All accomplish?

The answer is: SO MUCH! Medicare for All will pay for all medically necessary care. Just look at everything it would cover:

  • Inpatient, outpatient, emergency, and preventive care
  • Dental, vision, and hearing care
  • Prescription drugs
  • Lab and diagnostic services
  • Medical devices
  • Reproductive health care such as abortion, prenatal care, infertility treatment and more
  • Gender affirming care
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  • Hospice care
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  • AND MORE!!!

Our calculator is an accessible tool for disassembling Republican disinformation and fear mongering about Medicare For All. Using this calculator is incredibly easy and FREE. So please, take a moment and use our new Medicare For All calculator! ››

Comment:

By Jim Kahn, M.D., M.P.H.

The many economic analyses which demonstrate that single payer would reduce US health care costs fall short in one crucial way: they don’t indicate how any particular person or family will fare financially. Understandably, people want to know – how will this kind of program affect my costs? Since there will be some new taxes, maybe I’m at risk of paying more.

That’s the question the on-line calculator is designed to answer. Full disclosure – I led the technical team that worked with Congresswoman Jayapal and her staff to implement this calculator.

The calculator uses estimates from the Congressional Budget Office of how much new revenue the federal government would need to fully fund Medicare for All as specified in Rep. Jayapal’s bill. We designed a tax strategy to generate that revenue. It includes a 1.65% payroll tax; a progressive income tax starting at 1% at $178,000 for joint filers and $89,000 for single filers, and rising to 11%; a 15% tax on corporate profits; and a 3% wealth tax on individuals with >$30 million in assets.

The calculator asks for the user’s prior year costs – premiums and out-of-pocket spending. And asks for income; this determines the new taxes. And then, simple math, the calculator compares the two, yielding net savings (or costs).

We did a California calculator in 2022. This national calculator is very similar, with a refined tax strategy and two additional questions. As we reported in HJM for California, “Four thousand individuals reporting current healthcare spending and income reveal that … nearly 9 in 10 will save money, more than $5000 per year on average, with single payer.”

We’re eager to see the results on the national level. So — visit and use the site!

Geek comment: we’ll be able to explore the impact of different tax strategies on the distribution of savings and costs.

We hope the calculator will be a valuable organizing tool – to inform, energize, and advocate for Medicare for All. Please share information about the calculator widely via email, social media, and other channels.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

The Tragicomedy of Medicaid

Millions have been disenrolled from Medicaid, nominally due to the “unwinding” of COVID eligibility rules … but also due to administrative glitches. Lots of other problems with Medicaid. It’s a crisis, worthy of the deep scrutiny and biting wit of John Oliver.

Medicaid: Last Week Tonight with John Oliver (HBO), (28 minute video), April 18, 2024

John Oliver discusses why millions of people have been kicked off of Medicaid, why Medicaid access was difficult even before the current “unwinding”, and what would happen if fruits and vegetables could talk.

[Alert: Oliver uses profanity for emphasis]

Comment:

By Jim Kahn, M.D., M.P.H.

It’s so tragic it’s comic. Medicaid – health insurance for 90 million US poor – is a vivid example of the chaos and inefficiency that result when a program is designated and designed for individuals who lack political power and social standing. The beneficiaries are disrespected and poorly served. As HJM discussed, in most states private “managed care” insurers exploit the massive Medicaid cash cow to extract profits via restricted services and higher government spending. This essential health insurance lifeline is frayed.

What we need is a public insurance system that serves everyone, and thus is subject to natural quality control. Everybody needs it, so it works. Think social security, fire departments, and highways. They function well, fulfilling important societal functions.

In the health insurance arena, that’s single payer / Medicare for All. Successfully implemented around the world. Generous, equitable, and efficient. Advocated by John Oliver.

Oliver’s plea in this video for better management of Medicaid unwinding is appropriate, but IMO doomed to succumb to the dysfunctional dynamics of the Medicaid system. Hence my – and Oliver’s – plea for real system reform.

Universal public insurance is a heavy political lift, due to all the private entities – most of all insurers – who will lose tens of billions in profits. So we need to keep up the fight. John Oliver is our best cheerleader.

https://healthjusticemonitor.org…

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Political Party Split vs. Concurrence on Government Guarantee of Health Care

The Dem and GOP party split is nearly equal. Yet, we largely concur on worries about health care availability and affordability, and on a government role to assure we all have health care. Medicare for All / single payer is the path.

Changing Partisan Coalitions in a Politically Divided Nation, Pew Research Center, April 9, 2024

The combined effects of change and continuity have left the country’s two major parties at virtual parity: About half of registered voters (49%) identify as Democrats or lean toward the Democratic Party, while 48% identify as Republicans or lean Republican.

The continuing close division in partisan identification among voters is consistent with the relatively narrow margins in the popular votes in most national elections over the past three decades.

American Anxieties, GALLUP, April 9, 2024

Tell me if you personally worry about this problem a great deal, a fair amount, only a little or not at all.

The availability and affordability of healthcare [fifth item on the list]

  • 51% – A great deal
  • 27% – A fair amount
  • 21% – Only a little/Not at all

Comment:

By Don McCanne, M.D.

Over three-fourths of our nation (78%) is concerned about the lack of availability and affordability of health care. And yet the political activity we see is some nominal support of private insurance patches on the part of Democrats, when private insurance is proving often to be a detrimental method of funding health care, and Republican proposals to pass more of the costs on to patients through high deductibles and schemes such as health savings accounts. These political “solutions” actually result in the perpetuation of problems with both the availability and affordability of health care.

With three-fourths of the nation quite concerned, that certainly includes both Republicans and Democrats. Surely most of them do not believe that health care reform calls for a mandate of a private sector solution because that is what is available to everyone right now through the private insurance market. Without insurance, most cannot afford to pay for a major medical event or at least do not want it to displace other expenditures such as a down payment on the home they wanted to buy, the kids’ college education expenses, or funding of their retirement programs. But today, the private insurance industry and other intermediaries have become additional major sources of increased expenses and barriers to health care since those entities are on a mission to prioritize increasing investor wealth over patient health.

The majority of Americans want the federal government to guarantee health care and don’t trust insurers. Almost everyone approves of the government making health care available and affordable for people over 65, in the form of Medicare. In recent years, efforts have been made to privatize Medicare and that needs to be reversed by eliminating private insurers in order to return to patient care as guiding priority. Also, the benefits need to be expanded (vision, hearing, long term care, etc.) and deductibles and copayments should be eliminated so that Medigap insurance would no longer be necessary. Then, with other improvements, this version of Medicare should be expanded to include absolutely everyone, and it would be made equitable by funding it with progressive taxes, recovering some of the excessive revenues that have been moving into the coffers of the billionaires and the mega trillion dollar corporations.

Surely the large majority of us who are concerned about the availability and affordability of care can see the fairness in the rewards of our productivity that have been siphoned off by the super-rich being returned to us in funding for health care for all. No more silly knee jerk reactions against the labels “single payer” or “Medicare for All.” They will be labels that we can all be proud of because we earned them.

https://healthjusticemonitor.org…

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Medicare for All Explained Podcast: Episode 110

We don’t Need Health Insurance Companies

April 15, 2024

Podcast host Joe Sparks relates a recent experience filling a prescription at Costco to remind us that corporate health insurers add nothing of value to U.S. health care.

When he asked his pharmacist how much his prescription would cost if he paid out of pocket, he was surprised to learn that, “I paid four times less when I did not use my insurance.”

Additional episodes will be uploaded monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Cross-National Insurance Contrasts in Amusing 1-minute Videos

Two entertaining YouTube shorts highlight how the US lags on health insurance. Unaffordable premiums if you lose your job, and outrageous cost-sharing to give birth.

POV Losing Your Job in the US vs France, YouTube Short, Roya @royaventurera, March 29, 2024

[American accent] “Does this mean I lose my health care too? … You’re lucky you’re insured, you can actually continue your coverage through a program called Cobra, on average it’s about $700 every month … That’s almost my entire unemployment benefit! …

[French accent] what happens to my health care? Don’t worry your health care is not tied to employment in France …

Cost of Giving Birth Around the World vs US, YouTube Short, Roya @royaventurera, March 30, 2024

France? gratuit [free], Spain … Mexico … Brazil … all free

US? about 2-3 thousand dollars … if you do have insurance, otherwise could be 10-30-100 thousand … highest maternal mortality of any developed nation …

Comment:

By Jim Kahn, M.D., M.P.H.

These little dialogues bring a smile to my face (if not raucous laughter). I appreciate that, despite our dire insurance situation and my determination to reform the system.

The videos also remind us that all we need to do is adopt proven approaches to health insurance from other low (and middle!) income countries.

  1. Look around, outside our borders.
  2. Imitate.

Such an easy recipe.

https://healthjusticemonitor.org…

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Latest Corporate Intermediary Scam, For Out-of-Network Charges

Here’s the latest corporate innovation to extract resources from health care, by creating yet another inefficient but highly profitable intermediary. This time it’s for out-of-network charges. Who pays more? Patients.

Insurers Reap Hidden Fees by Slashing Payments. You May Get the Bill, The New York Times, April 7, 2024, by Chris Hammy

MultiPlan is a little-known data analytics firm that works with UnitedHealthcare, Cigna, Aetna and other big insurers to decide how much so-called out-of-network medical providers should be paid. It promises to help contain medical costs using fair and independent analysis.

But a New York Times investigation, based on interviews and confidential documents, shows that MultiPlan and the insurance companies have a large and mostly hidden financial incentive to cut those reimbursements as much as possible, even if it means saddling patients with large bills. The formula for MultiPlan and the insurance companies is simple: The smaller the reimbursement, the larger their fee.

Here’s how it works: The most common way Americans get health coverage is through employers that “self-fund,” meaning they pay for their workers’ medical care with their own money. The employers contract with insurance companies to administer the plans and process claims. Most medical visits are with providers in a plan’s network, with rates set in advance.

But when when employees see a provider outside the network, many insurance companies consult with MultiPlan, which typically recommends that the employers pay less than the provider billed. The difference between the bill and the sum actually paid amounts to a saving for the employer. But, the Times found, it means big money for MultiPlan and the insurer, since both companies often charge the employer a percentage of the savings as a processing fee.

In recent years, the nation’s largest insurer by revenue, UnitedHealthcare, has reaped an annual windfall of about $1 billion in fees from out-of-network savings programs, according to testimony by two of its executives. Last year alone, MultiPlan told investors it identified nearly $23 billion in bills from various insurers that it recommended not be paid.

The little-understood financial incentive for insurers and MultiPlan has left patients across the country with unexpectedly large bills, as they are sometimes asked to pick up what their plans didn’t pay. In addition, providers have seen their pay slashed, and employers have been hit with high fees. In some instances, the fees paid to an insurance company and MultiPlan for processing a claim far exceeded the amount paid to providers who treated the patient.

After MultiPlan’s founder sold it to private equity investors in 2006, the company pursued a more aggressive approach. It embraced pricing tools that used algorithms to recommend lower payments, and no longer protected patients from having to pay the difference.

Once insurers were no longer obligated to use the nonprofit database, FAIR Health, they began looking for ways to combat billing and other charges they considered egregious. Insurers contended that overbilling would skew payments too high. Cigna: “We need someone external to Cigna to develop acceptable rates.” UnitedHealthcare emphasized companies still using FAIR Health, “understand they don’t want to be on that program anymore.”

UnitedHealthcare had a big incentive to encourage this change. When it processed claims from employer plans using FAIR Health, the insurer collected no additional fee. But when it used MultiPlan, it typically charged employers 30 to 35 percent of the difference between the billed amount and the portion paid.

MultiPlan, too, charged a percentage of the savings, meaning it could make more by recommending lower payments. (FAIR Health charged a flat fee.)

While UnitedHealthcare was MultiPlan’s largest customer, Cigna and Aetna also embraced its tools and fee model. Other insurers that work with MultiPlan include Kaiser Permanente, Humana and some Blue Cross Blue Shield plans. Employers with self-funded plans administered by insurers include large companies like Coca-Cola and AstraZeneca and smaller organizations like school districts and union locals.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

Theoretically, health insurance should allow us to equitably pool our funds in order to make health care both accessible and affordable for everyone participating. We have had a goal to expand that to include everyone. However, we have relied heavily on the private insurance industry which has engaged in business activities designed to increase profits for its shareholders and compensation for its executives. These activities have impaired access and resulted in an increase in medical debt for those for whom the system should be designed: the patients.

Not only are the insurers placing financial pressures on the physicians, hospitals, nursing homes and the many other providers of health care services, but they have also been attempting to further increase their incomes through increases in insurance premiums, deductibles, copayments, excessive prior authorization requirements, narrow provider networks, and limitations in coverage. Frequently these are applied in a manner that denies patients needed care, care that they can usually obtain if they are enrolled in a government program such as Medicare, Medicaid, VA Health if their particular program has not been overly privatized.

So what is the insurance industry offering us now? An example in the article: The physician provides medical services and bills $1000 for them. The self-insured employer pays the fee determined by MultiPlan which is only $200 of the $1000. The amount “saved” for the employer is $800 of which MultiPlan receives 7% or $56 and the insurer receives 35% or $280. A $800 balance remains which “the patient is potentially on the hook for.” Whether the patient or the physician is out the remaining $800 of the medical bill, clearly the insurers are no longer fulfilling what we consider the traditional function of insurers, yet they are leaching much of our health care dollars for worthless functions.

This is yet another intermediary strategy to extract profits. This time it focuses on out-of-network charges (those unregulated by the “No Surprises” Act). The “business model” is to add complexity via inserting extra corporate actors in a previously simpler arrangement. Just like Pharmacy Benefit Managers insert themselves between drug companies and pharmacies. They promise savings, but actually increase costs. This removes resources that should be spent on health care, and redirects them to shareholders of for-profit entities. Patients pick up the slack.

We’ve long said that it is time to get rid of the private insurers and their add-on leaches, and this development seems to make it even more of an imperative. It is high time to improve Medicare and to expand it to cover everyone as a single payer system that is equitably funded through progressive taxes.

Of the multitude of New York Times reader comments for this article the most popular was by a Canadian physician commenting on their single payer system who wrote,” The US needs to get their act together.

https://healthjusticemonitor.org…

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May Day 2028 National Strike: Focus on Medicare for All

Prominent labor leader Shawn Fain has proposed a national strike of unionized workers four years from now, to highlight and advance the needs of workers and their families. This riveting vision will be super-charged with a focus on unified public funding of health care.

The UAW’S 2028 National Strike Should Center Medicare for All, JACOBIN, March 31, 2024, by Jonathan Michels & Will Cox

United Auto Workers president Shawn Fain has called on unions to come together for a national strike on International Workers Day, May 1, 2028. This is a radical idea – and elevating Medicare for All as a central demand would give workers across sectors a reason to join in.

Shawn Fain’s call to utilize labor power – four hundred thousand working members and six hundred thousand retirees make up the UAW alone – for the “good of the entire working class” is a major departure from business-as-usual unionism and represents a potential game changer for social movements to secure public goods, including Medicare for All, that extend beyond the shop floor.

The struggle for single-payer health care is part of a larger conflict between the working class and the billionaire class. Incremental reforms have gotten the single-payer movement nowhere, while legislative lobbying has proved insufficient. Nothing short of a nationwide campaign of rank-and-file workers – union and nonunion alike – willing to confront capital will be strong enough to secure transformative health reform.

In order to win, single-payer activists must embrace this once-in-a-generation opportunity and join in solidarity with workers in ways many never have before.

A general strike as envisioned by the UAW will take cooperation from other unions willing to align their contract expiration dates with April 30, 2028.

Fain frames workers as warriors locked in a struggle against the billionaire class, with economic equality and security for the working class hanging in the balance. This kind of class rhetoric shows an understanding among UAW leadership that there are some issues, such as the financing of high-quality health care, that are too burdensome for any one union to reasonably carry alone. Though it is still too early to tell, we could be witnessing union officials taking the first steps away from maintaining private welfare states for members and toward securing social goods for the benefit of all.

Of all the social reforms before the American public today, single payer is not only the most popular – a 2020 Fox News exit poll showed a staggering 72 percent of Americans want publicly funded health care – it also has the potential to be the most transformative.

Meanwhile, the only effective path to winning a transformative national health program is through our collective labor power. Any movement of workers willing to connect their struggle to a larger class struggle, and especially the struggle for single payer, is imperative.

There doesn’t need to be a general strike in 2028 to build the kind of worker-led movements in the United States that shook the halls of power even before unions were officially made legal. It is the process of organizing and building solidarity that is much more important than the turn out for a single event, march, or rally.

In order to win public goods, the union movement will have to become a mass movement.

The Medicare for All movement will need union and nonunion workers to build class-conscious organizing committees that draw strength and inspiration from unions, and that carry their fight into the community.

The starting point is when workers become aware that their interests are opposed to their bosses’ interests – and this should also frame how people organize for a universal national health program. Likewise, single-payer activists need to frame their fight as a class-conscious struggle. It’s going to affect all of us, so it’s going to take workers from every sector – from the factory worker to the academic, from physicians to food service workers.

You need a broad social coalition and labor needs to be out front.

Solidarity is not reading the news and telling your friend, “I hope the workers win.” It’s putting yourself on the line. The defining feature of the working class is that they must sell their labor in order to survive. That describes almost all of us.

Whether on a picket line or at a rally, it is imperative that single-payer advocates plug into rank-and-file organizing campaigns and make themselves available. We should see clinicians in white coats and nurses and health care workers in scrubs standing shoulder-to-shoulder with sanitation workers, autoworkers, and teachers. Anywhere workers are standing up, single-payer supporters should be there, too.

Only then will it become clear that we are part of the same struggle.

Comment:

By Don McCanne, M.D.

How long have we been doing this? (a long time)

How close are we to our goal? (not very close at all)

Do we anticipate a legislative solution? (not soon, but we should forge ahead anyway)

Do people want something done with our health care system?

There does seem to be wide agreement that our system is not working as it should be. Medical debt is a major problem faced not only by the uninsured but also by the insured who have difficulty paying premiums, deductibles, copayments, and disallowed charges. People frequently find that they cannot afford the care or medications they need.

People do not oppose government participation in health care since many enroll in Medicare, Medicaid, VA health, and other government programs as appropriate. Polls indicate support for publicly funded programs. Politicians promote government programs. Biden is supporting the ACA plans, and Trump is supporting government plans “better than Obamacare” though he hasn’t stated what that would be.

The point is that when the public realizes that we can have a plan that will ensure access to health care for everyone while keeping it affordable for everyone, eradicating the problem of medical debt, maybe it is time for mass public action. The JACOBIN article suggests a date of May 1, 2028 (and it is well worth reading the fairly long article in its entirety), but actually the organizing can begin right now.

Yes, there is a political divide in our nation. But the divide here is not so much left and right as it is all of us workers on all levels and the billionaires. We want health care for all the people, and, yes, we’ll include the billionaires.

https://healthjusticemonitor.org…

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MAGA Mike Johnson Explores Medicare for All

GOP Representative Mike Johnson, aiming to gain Dem support for his threatened position as Speaker, told a reporter he is willing to consider Medicare for All. He said that universal public insurance works well in countries with robust market economies and even conservative governments.

Embattled House Speaker Reaches Across Aisle to Dems on Health Reform, USA Wire Service, April 1, 2024, by Bir Nisan

Mike Johnson (R, LA), Speaker of the US House of Representatives, is struggling with a razor thin GOP majority and a looming vote on his leadership position due to a petition from Marjorie Tayler Greene (R, CO). He is contemplating desperate measures to garner support.

In an interview, Mr. Johnson offered a surprising reply to the question, “Are you seeking Democratic votes for your Speaker position?”

“Public perceptions of my absolute partisanship are mistaken. Of course, I vigorously advance Republican values and policies. However, when opportunities arise, I’m open to building alliances across the aisle.

“Here’s one example. My staff recently reviewed international experience with health insurance. They found that having public agencies pay for all medical care works very well in numerous nations. It saves money and is popular. All of these countries have thriving free market economic systems, and many have conservative governments.”

Rep. Pramila Jayapal (D, WA), lead sponsor for H.R. 3421, the Medicare for All Act (113 co-sponsors), expressed enthusiasm for the Speaker’s sentiment. “I’m surprised, given his past positions on health reform, not to mention on many other priority progressive issues. But if the Speaker has seen the light on this issue, we’re more than willing to work together.”

Other GOP lawmakers declined comment.

Johnson added, “As a very religious person, I believe health care is a moral imperative. They say only Nixon could undertake rapprochement with China. Well, maybe only Mike Johnson can join a cross-party coalition for Medicare for All in the US.”

Comment:

By Jim Kahn, M.D., M.P.H.

Amidst the most severe and vitriolic political divisions in memory, and a historically intense presidential election campaign, this report is eye-catching, even shocking.

Could it be that the Speaker, to this point a stalwart opponent of Democratic (let alone progressive) legislation, is offering an olive branch on comprehensive insurance reform? Has his staff done their homework and convinced him of what we in the single payer movement have been saying for years? That is, that single payer allows us to achieve the moral goal of universal access to health insurance, within the context of (and strengthening) a robust market economy?

It feels like a dream.

Well, yes, it is a dream. An April Fool’s fantasy.

Sorry my friends. Maybe someday this story, or one like it, will come true.

Meantime, let’s focus on strengthening the role of Democrats, and progressives in particular, in Washington DC and across the nation. And continue our quest for generous, efficient, people-oriented health insurance – single payer.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.