PNHP

Single Payer 20/20 Vision: Advantages & Obstacles

Single Payer 20/20 Vision: Advantages & Obstacles

Summary: Today we summarize what single payer offers, and the challenges to achieving it, using the arbitrary framework of 20-item lists. (With President’s Day on Monday, perhaps Lincoln’s “Four score …” sent a subliminal message.) The incredible advantages justify continued struggle to overcome the daunting obstacles.

Comment:

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

Advantages:

  1. Everyone has high quality health insurance, with broad benefits. Forever.
  2. You never need to choose or change insurance.
  3. Health coverage is highly equitable: everyone has the same insurance.
  4. You can see any doctor or other licensed provider (eg therapist).
  5. Physical and mental health are equally well-covered.
  6. Dental, vision, and hearing are covered.
  7. Long-term care is covered.
  8. No more financial barriers to care: deductibles are gone, with no or minimal copays.
  9. No more out-of-network financial penalties for patients.
  10. No more bankruptcies due to medical bills.
  11. Wasteful insurance paperwork disappears, leaving more money for medical care.
  12. Insurer profits disappear, leaving more money for medical care.
  13. Sky-high drug prices disappear, leaving more money for medical care.
  14. The doctor-patient relationship is paramount.
  15. Your doctor has no financial incentives to minimize care.
  16. There are no health insurers to interfere with your care.
  17. The electronic health record is stripped of billing complexity, so it’s easy to use and focused on clinical care.
  18. The US treats healthcare as a public good, not a private commodity.
  19. People in the US are proud of our excellent insurance and healthcare.
  20. Full access to care reduces deaths by 100,000 per year.

Obstacles:

  1. Insurers will lose their healthcare business and profits.
  2. Many pharmaceutical companies will lose sky-high profits.
  3. Some large hospitals and provider systems will lose market power and profits.
  4. Doctors worry that they’ll lose income (they won’t, and most will make more).
  5. Some high-paid specialist physicians may earn less.
  6. Insurers make huge donations to politicians and lobby (including against single payer).
  7. Pharmaceutical companies make huge donations to politicians and lobby …
  8. The American Medical Association makes huge political donations and lobbies …
  9. Hospitals make huge political donations and lobby …
  10. The massive healthcare financing enterprise (which consumes 3% of our national income) will need to reorganize, shrink, and shift its resources to clinical care.
  11. The even more massive healthcare industry (nearly 1/5 of our economy) will need to transform its values system – from profit maximization to universal care access.
  12. People like their doctors, and don’t realize that under single payer they can keep that doctor.
  13. People worry about losing what they have with their current insurance.
  14. People don’t know how well health insurance works in other wealthy countries.
  15. Health insurers run a huge ongoing public relations campaign to extol the wonders of private insurance.
  16. Health insurers promote “choice” – but that means choice of insurance, not doctor.
  17. The health system is so complex it’s nearly impossible to understand and explain.
  18. Opponents of single payer spread misinformation about it.
  19. The myth of the healthcare market persists, despite being discredited repeatedly.
  20. People often have trouble remembering all the ways that our system fails us daily, and how single payer would fix those problems. When they do understand, they see huge barriers to change. They just hope that they’ll be ok. Single payer seems out of reach.

The advantages of single payer are formidable, and so are the obstacles. Working in our favor is majority popular support for the idea. Achieving single payer would be transformative, both in the health care it provides and the triumph of community and democracy over profit and rule by the wealthy few.

http://healthjusticemonitor.org…

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Hospital Price Skirmishes vs. Solidarity-Driven Transformation

Summary: In Connecticut, a large hospital system is being sued to stop anti-competitive practices that raise prices for insurers, employers, and patients. Good, as far as it goes. But it’s just minor tweaking of a profoundly dysfunctional market-based system. Where’s the needed transformation?

Patients are coming after hospital monopolies, AXIOS, Feb. 16, 2022, by Bob Herman

A group of citizens in Connecticut is suing Hartford HealthCare, alleging the large hospital system has amassed monopoly power “to extract higher prices from insurers, employers, and patients.”

Why it matters: This is another class-action lawsuit arguing hospital consolidation has crushed everyone’s bank accounts and has led to the rise of anti-competitive contracts that force insurers and employers to accept take-it-or-leave-it terms.

“Even if you don’t live in Connecticut, you should be worried about [these hospital behaviors], because you’re paying for this through your insurer,” said Ellen Andrews, head of the consumer advocacy group CT Health Policy Project.

Driving the news: People with commercial insurance in Connecticut allege Hartford HealthCare, a $5 billion hospital system, has scooped up hospitals throughout the state and rolled that leverage into insurance contracts, including:

“All-or-nothing” contracts. Insurers exclude hospitals from networks if hospitals have lower quality or higher prices, but Hartford allegedly required insurers to include all of its hospitals — including more expensive ones in more competitive areas — in networks.

“Anti-steering” contracts. Insurers may entice people to go to lower-cost or higher-quality hospitals by making out-of-pocket costs lower for those facilities, but Hartford allegedly mandated insurers not to make those kinds of “steering” provisions (or to make them weaker).

Comment:

By Don McCanne, M.D., M.P.H.

There is general agreement that we are in drastic need of health care reform that will benefit patients – all patients. So what “reform” activities are taking place? Those that will benefit one portion or another of the medical-industrial complex and their investors – overall to the detriment of the patients.

What is missing? Social solidarity on the community level…Give this some thought, and it won’t seem so cryptic.

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.

A Call for Antiracist Action

By David A. Ansell, M.D., M.P.H.; Brittani James, M.D.; and Fernando G. De Maio, Ph.D.
New England Journal of Medicine. February 16, 2022

On January 22, 2022, neo-Nazis marched on Boston’s Brigham and Women’s Hospital, with a banner claiming that the hospital “kills Whites” and flyers featuring photos of Drs. Michelle Morse, a Black woman, and Bram Wispelwey, a White man, who have led antiracism work at the hospital. The group denounced the physicians and the hospital for “creating preferential health care treatment policies for non-White patients.” This was not the first time that Morse and Wispelwey were attacked for their work.

On March 17, 2021, the two physicians published “An Antiracist Agenda for Medicine” in the Boston Review.1 The article described the historical failure of color-evasive (or what many term “colorblind”) solutions to racial inequity in health care and offered a race-conscious approach they named “The Healing ARC.” They called for a structural shift in racial equity work toward holding health care institutions accountable, contending that only race-explicit programs will directly address the underlying causes of racial health inequities and mitigate the current impact of racism in medicine.

With other colleagues, Wispelwey and Morse uncovered racial inequities in the treatment of patients with cardiac failure at the Brigham.1 They found that Black and Latinx patients were less likely than White patients to be admitted to the cardiology service, which was associated with better outcomes. Wispelwey and Morse implemented changes to rectify these practices. Their efforts to correct this disparity led them to rethink the approach to racial justice in medicine.

The Healing ARC has three components: acknowledgment, redress, and closure. Health care providers must acknowledge how racism has contributed to unequal health outcomes; redress the damage by providing restitution to the population that has been harmed, which involves offering pathways for access to services and care that have historically been denied; and facilitate closure, achieving reconciliation with the community that has been harmed by the health care system and reaching agreement that the harm has been redressed.

The framework applies the principles of applicative justice to racial health inequities at the level of the health system. It recognizes the need for race-conscious approaches in medicine. While it affirms that race is a sociopolitical construct with no biologic basis, a race-conscious approach allows the identification and rectification of long-standing racial health inequities. This effort is not about race-preferential treatment, as the neo-Nazis and others on the political right have claimed, but about eliminating obstacles to care that harm systematically excluded populations. The Healing ARC builds on the work of William Darity, Jr., and A. Kirsten Mullen calling for federal reparations for Black descendants of formerly enslaved people,2 acknowledging that race-conscious approaches are necessary in medicine because colorblind approaches have not closed racial gaps in health outcomes.

Predictably, there was backlash. Fox News was the first major U.S. news source to attack the article and the authors in 2021. Extremist social media figures including an editor and supporters of Quillette — a known source of White supremacist hatred and discredited, racist “science” — amplified the Fox attack. Morse has been subjected to repeated racial slurs, harmful rhetoric, and threats to her safety.

In 2020, as racial gaps in Covid-related mortality and murders of Black people touched the national conscience, more than 200 health care organizations, including the American Medical Association (AMA), declared racism a public health crisis. They pledged to take steps to eliminate racial health inequities by removing systemic barriers that block people of color from achieving better health outcomes. This is a critical moment for health care leaders to publicly reaffirm their support through organizational actions for antiracism in medicine. The AMA and the Massachusetts Medical Society have issued statements, and a group of physicians and health care workers have signed a petition of support, but we believe that more leaders of national health care organizations should publicly express their support for Drs. Morse and Wispelwey and their antiracism efforts — and then put their words into actions.

The neo-Nazi protest in Boston is a reflection of reactionary efforts in both medicine and broader society to deny that racism exists or invalidate antiracism efforts as “anti-White.” A 2021 Commonwealth Fund survey found that 53% of Americans do not believe racism is a problem in the United States.3 Yet one out of three Black or Latinx survey respondents reported experiencing discrimination in health care during the previous year.3

Efforts to embed racial justice in medicine and advance health equity have been launched — and critiqued. There have been concerted attacks on critical race theory, whose precepts are central to health equity work: critical race theory acknowledges that race is a social construct, identifies the mechanisms by which racism is embedded throughout society’s systems and policies, and opposes colorblind solutions to racial inequities. Most recently, the mainstream media has promulgated attacks on the language of health equity, contributing to an environment in which extremism can thrive. In the days leading up to the neo-Nazi protest, right-wing media mischaracterized tenets of race-conscious medicine, claiming that efforts to overcome inequities would result in White people being denied medical care.

Since the first scientific study of poor health outcomes among Black Americans was published by W.E.B. Du Bois in 1899 (The Philadelphia Negro: A Social Study),4 deep and persistent inequities in health outcomes between Black Americans and White Americans have been well documented. Today, the toll of structural racism on the life expectancy of Black Americans is revealed in devastating statistics, with large inequities in the leading causes of death, including heart disease and cancer. The racial and ethnic disproportionality in hospitalizations and deaths during the Covid pandemic has highlighted the long-standing structural and social fault lines that have always divided our nation.

The Commonwealth Fund recently reiterated the persistent reality that in most states where data are available, Black people, American Indians, and Alaska Natives are more likely than White people to die early in life from conditions that are treatable with timely access to high-quality health care (see graph).5 A large body of literature demonstrates that these gaps in health according to race and ethnicity reflect racism, rather than genetic or biologic differences. Even analyses that control for socioeconomic status confirm that Black people in the United States have worse health outcomes than their White counterparts. A race-conscious approach to eliminating health care inequities is thus required across all our health care institutions.

White supremacism has proved resistant to eradication over centuries. It appears in different forms — as denial of structural racism, in simplistic narratives of individualism and meritocracy, in stories that lay the blame for health inequities on the beliefs, behavior, or biology of historically marginalized people. And yes, White supremacism appears in the swastikas and uniforms of “freedom” protests against vaccination mandates and antiracist doctors.

Martin Luther King, Jr., noted that, “In the end, we will remember not the words of our enemies but the silence of our friends.” The neo-Nazi march on the Brigham and our physician colleagues and the attacks on health equity interventions are stark reminders of the obligation of physicians, particularly White physician leaders of our national health care organizations, to denounce White supremacism and reaffirm race-conscious antiracism efforts. We recommend three immediate actions: publicly defending Drs. Morse and Wispelwey and others who have become targets of hatred and rancor because of their antiracism work; implementing and evaluating race-conscious, intersectional interventions such as the Healing ARC, especially given that colorblind approaches have failed to achieve meaningful gains in health equity; and publicly reporting progress toward achieving racial equity in health outcomes. Inaction in the face of White supremacism must not be an option.

https://www.nejm.org…

References

  1. Wispelwey B, Morse M. An antiracist agenda for medicine. Boston Review. March 17, 2021
  2. Darity WA, Mullen AK. From here to equality: reparations for Black Americans in the 21st century. Chapel Hill: University of North Carolina Press, 2020.
  3. Commonwealth Fund. Confronting racism in health care delivery: an imperative to improve the public’s health. Boston: Harvard T.H. Chan School of Public Health September 28, 2021
  4. Du Bois WEB. The Philadelphia Negro: a social study. Philadelphia: University of Pennsylvania Press, 1995.
  5. Radley DC, Baumgartner JC, Collins SR, Zephyrin L, Schneider EC. Achieving racial and ethnic equity in U.S. health care: a scorecard of state performance. New York: Commonwealth Fund, November 18, 2021

Joe Biden Is Quietly Pursuing the Creeping Privatization of Medicare

The Biden administration has quietly decided to continue a Trump administration scheme whose ultimate goal is the privatization of Medicare. Americans would be outraged — if anyone knew about it.

By Branko Marcetic
Jacobin, February 16, 2022

Last November 30, a collection of physicians and activists were in Washington, DC, its federal buildings still largely closed for business thanks to the pandemic and fear of another Trumpist uprising. They were there to protest what they warned was an attempt to end Medicare as we know it.

Physicians for a National Health Program (PNHP), the leading group behind the effort, had been trying for some time to make its displeasure about the “direct contracting” program known. After collecting more than thirteen thousand signatures for a petition opposing the initiative, they’d asked repeatedly for a meeting with Health and Human Services (HHS) secretary Xavier Becerra to hand it to him. They called, emailed, left voice messages, all to no avail. The most they got was a single response from a staffer, sent the night before their DC visit, promising to set up a meeting sometime in the future.

The next day, the group marched into HHS headquarters, petition in hand, only to be stopped by security and told that was as far as they could go without an appointment. They’d have to ask someone to come downstairs and pick it up — only to learn there was no one available in the offices to do it. After close to an hour, the group left the petition with security and departed, having been blocked from carrying out one of the most basic and foremost rights enumerated in the constitution.

Locked doors, unreturned emails, a large crowd with no one around to hear it — nothing more perfectly captured the struggle of public health care advocates to raise the alarm about direct contracting, a pilot program begun under Donald Trump and continued under Joe Biden.

In the middle of a pandemic, and during what pundits describe as a fundamental shift in Americans’ views of the government’s role in their lives, an initiative to shoehorn for-profit companies between retirees and their Medicare coverage should in theory have prompted a public outcry. The only problem is, no one seemed to know it was happening.

“A Corporate Goldmine”

Over the past year, seniors around the country have been getting letters from the Centers for Medicare and Medicaid Services (CMS) informing them that they needn’t worry, but their doctor was now part of something called a direct contracting entity (DCE). “Your Medicare Benefits have not changed,” the letters stress no less than twice. “NO ACTION NEEDED,” they blare.

If you take it from CMS, DCEs are simply a collection of different health care providers “who agree to work together to keep you healthy” — an innovative new payment model to keep health care costs down and raise the quality of care up. For its critics, the initiative is something far less benign.

“What direct contracting does is turn the public side of Medicare into a corporate goldmine,” says Diane Archer, president of Just Care USA.

Under traditional Medicare, when a beneficiary gets care from a doctor, a hospital or any other health care provider, the program reimburses that provider directly at a set rate. Direct contracting adds a third party into the mix: Medicare makes a monthly payment to a DCE, which then decides what care a beneficiary will get, and uses that money to cover a specified part of their medical expenses — pocketing whatever they don’t spend as profit. While making cost-saving efficiencies usually means cutting out the middleman, direct contracting adds one in.

Critics like PNHP warn that the program comes with the same kinds of pitfalls as Medicare Advantage, the program that for the first time carved out a role of private insurers in the public Medicare system, when it was passed as part of a Reagan-era deficit reduction bill forty years ago. One is “upcoding,” the notorious practice where Medicare Advantage insurers make their patients appear less healthy than they really are, the better to drive up the payments they get from Medicare.

As a result, according to the very congressional agency set up to give policy advice on Medicare, the risk scores for patients under the semi-privatized system are 8 percent higher than for those on traditional Medicare, something one analysis determined cost taxpayers more than $106 billion in overpayments from 2010 to 2019.

After puffing up their profits at the taxpayer’s expense, Medicare Advantage insurers then tend work aggressively to minimize the costs on their end. A 2018 HHS inspector general report found inappropriate denial of care was rampant in the program, and a Kaiser Family Foundation analysis determined Medicare Advantage enrollees tended to pay more for longer hospital stays. It’s all well and good until you get seriously ill, at which point your out-of-pocket costs start soaring.

“The insurance companies are making twice as much money from Medicare Advantage than they do form employer-sponsored health insurance,” says Dr Ana Malinow, professor of pediatrics at the University of California San Francisco. “Workers have no more money, employers don’t, but who does? The government.”

Privatized by 2030

Malinow and others say that despite the similarities, direct contracting is even more pernicious than Medicare Advantage. That’s because direct contracting specifically targets those who have rejected this semi-privatized model, and chosen to stay in traditional Medicare. Those beneficiaries get a letter in the mail, open it up, and learn their doctor, and by extension, they, are now in a DCE. They’re assured all the while that everything is fine — that they’ll soon be getting “better quality care,” even — and never told if they can opt out, or how.

When DCE opponents won a Zoom meeting with Center for Medicare and Medicaid Innovation (CMMI) director Liz Fowler last December, she assured them it was possible to opt out — as long as you switched primary care providers. The attendees were shocked. Finding a new doctor is disruptive for anyone, let alone seniors who may have spent years with one they trusted, and it was deeply unpopular. Just think back to Barack Obama’s insistence that “you can keep your own doctor” under Obamacare, one of the most potent attacks on that health care reform effort. Besides that, it’s something easier said than done in rural areas short on health care choices.

But the 54 percent of the nearly $900 billion Medicare budget that’s still devoted to the program’s traditional version is too tempting to simply leave untouched by the for-profit health care industry. “The largest national insurers are positioning to become DCEs,” former CMS administrators Richard Gilfillan and Donald M. Berwick wrote last year.

That includes companies like Aetna, Alignment Health, Humana, and Clover Health, backed by Google parent company Alphabet. This isn’t the half of it, according to PNHP, which charges that virtually any company, even a venture capital firm, can apply to be a DCE and doesn’t need Congress to be approved. All are eager to take advantage of the looser rules around DCEs: while Medicare spending on administrative costs is in the single-digit percentages, and Medicare Advantage plans are forbidden by law from putting more than 15 percent of their premium revenue toward paying them, direct contracting has no such limit.

Critics also see something even more nefarious behind the initiative.

“The goal is to privatize all of Medicare through this program,” says PNHP president Susan Rogers.

It echoes the warnings of Gilfillan, Berwick, and virtually every other critic of direct contracting. Though a pilot program for now, CMS has made clear it wants to eventually move all enrollees of traditional Medicare into “a care relationship with accountability for quality and total cost of care by 2030” — vague jargon that nevertheless echoes the language direct contracting proponents use to talk about the program.

In other words, if the government has its way, by the end of the decade, every beneficiary of the traditional, entirely public Medicare will have a private, for-profit entity jammed between them and their health care. The largest remaining segment of the US health care system not dominated by corporate hands will becoming something else.

Paved With Corporate Greed

The road to this point has been paved by multiple administrations from both parties. CMMI, the CMS “innovation center” that came up with direct contracting, was created by the Affordable Care Act (ACA), the Obama administration’s corporate-shaped, flagship health care reform effort. Originally meant to devise new health care payment models that would fix the spiraling costs and quality of care issues endemic to US health care, its mission was ripe for hijacking by the corporate interests that find a way to infiltrate every well-meaning government agency.

That moment came in 2018, when Trump’s HHS secretary appointed health care executive Adam Boehler to head CMMI, where he soon set the plans for direct contracting into motion. According to the Intercept, Boehler designed direct contracting with specific companies in mind, including Oxeon, the venture capital firm that had backed a number of DCEs-to-be, including the very start-up Boehler had left to join CMMI — and which he contracted with to staff the agency as it developed the initiative.

One would have thought the Trump program would have been nixed by the Biden administration, particularly with talk of the new president’s Rooseveltian ambitions and a coming revival of activist government. Instead, the administration simply canceled one iteration of direct contracting, and went ahead with a different one in April 2021, with more set to roll out this year.

The administration remains financially in thrall to the for-profit health sector. Biden’s campaign had been backed from the very start by the for-profit health care industry, and by the end of the general election, Biden had out-raised Trump among health care executives, insurance companies, and pharmaceuticals.

That includes the very officials responsible for direct contracting’s continuation. Fowler, the head of Biden’s CMMI, played a key role in drafting the insurer-friendly ACA, and had gone to work for pharmaceutical giant Johnson & Johnson prior to this current stint in Washington. Before all that, she’d served for two years as vice president of public policy for health insurer WellPoint. In 2014, WellPoint changed its name to Anthem — one of the big insurers involved in the direct contracting pilot through its subsidiary, CareMore.

Yet even Fowler appears to privately understand the folly of deepening the for-profit sector’s involvement in Medicare. Judy Albert, an ob-gyn and a clinical assistant professor at the University of Pittsburgh, recalls Fowler telling her and other DCE critics in December that a single-payer system would be the best solution — if they were starting from scratch.

“I think part of that is they were playing to the audience,” she says. “But why don’t they try that for a model?”

Action Needed

For a long time, hardly anyone even knew about direct contracting, whether the public, the press — or even members of Congress. Members of PNHP recalled briefing eight lawmakers and their staffers about DCEs late last year, who were shocked to learn the program existed, let alone that the Biden administration had chosen to keep it going.

Since then, momentum for pushing back has gradually built. Archer says she and other DCE opponents began educating members of Congress about it early last year, and she credits Representatives Mark Pocan (D-WI), Katie Porter (D-CA), Lloyd Doggett (D-TX), and Bill Pascrell, Jr (D-NJ) with acting “swiftly and effectively,” writing a letter to HHS secretary Becerra in the middle of the year, to which he replied in August.

After the anti-DCE coalition’s briefing, Congressional Progressive Caucus cochair Pramila Jayapal (D-WA) gathered more than fifty signatures for another letter to Becerra this January, this one demanding an end to direct contracting and returning things to the status quo by the first of July this year. To kick off February, Senator Elizabeth Warren (D-MA) used her position as chair of the Senate finance subcommittee on fiscal responsibility and economic growth to denounce the program, warning of the “fiscal disaster” of inviting the “corporate vultures … already scamming Medicare” to skim more from the program, and calling on Biden to stop it.

But as welcome as they are, these are still relatively isolated actions, considering the stakes.

“What should be happening right now in Congress is not happening,” says Archer.

Meanwhile, with the issue gaining prominence, the health care industry is mounting its own pushback, reaching out to lawmakers to correct what they say is misinformation about the program, which they claim is simply focused on bringing “the virtues of organized groups into what is really a fragmented and dysfunctional model.”

On February 14, the National Association of ACOs (Accountable Care Organizations), an industry trade group representing DCEs, delivered to Becerra its own letter, calling on CMMI to “fix, don’t end, the direct contracting model.” Its suggestions include limiting the kinds of DCEs that can take part in the program, and a “rebranding and name change.” In turn, PNHP countered with its own letter arguing the opposite, one signed by twenty-four thousand health professionals.

It is still an uphill battle for the opponents of DCEs. Money talks in Washington, and past, current, and prospective DCEs have spent $2 million in 2021 alone lobbying Congress, CMS, HHS, and other bodies on issues that include direct contracting. That includes names like Oak Street Health, Clover Health, agilon health, and America’s Physician Groups, the DCE trade group that has been reaching out to lawmakers. Tenet Healthcare, a massive hospital operator, spent more than $4 million alone lobbying on a variety of issues this year, including direct contracting.

To beat back such well-funded efforts, opponents need to muster public outrage. But DCE opponents say it’s been slow going trying to get the national press to cover the issue, and even now, it continues to fly largely under the radar, with only a handful of mainstream outlets covering it. Should the issue pick up more champions in Congress, and inspire more coverage in the press, Americans learning about the risks of direct contracting may be inspired to pick up the phone and demand to their local representatives that CMS gets its government hands off their Medicare.

Joe Biden was elected on the promise of building on the progress of the Great Society. We may have to settle for simply preventing him from gutting one of its greatest legacies.

https://jacobinmag.com…

Physicians Slam Industry Push to ‘Fix’—Not End—Medicare Privatization Scheme

“The industry thinks they can save it with minor tweaks and cosmetic fixes. But we won't back down until Direct Contracting is shut down, for good,” one doctor said of the Trump-era program.

By Jake Johnson
Common Dreams, February 16, 2022

Physicians and progressive advocates on Tuesday urged the Department of Health and Human Services to reject an industry appeal to tweak and rebrand—not end altogether—a Medicare privatization scheme known as Direct Contracting, which the Trump administration launched in 2020.

Members of Physicians for a National Health Program (PNHP), which represents 24,000 doctors and other health professionals, has been working for months to bring lawmakers’ attention to the DC program and pressure the Biden administration to terminate it while it’s still in an experimental phase.

As a result of PNHP’s efforts, dozens of Democrats—including Rep. Pramila Jayapal (D-Wash.) and Sen. Elizabeth Warren (D-Mass.)—have spoken out against the DC pilot, opposition that appears to have caught the notice of healthcare industry groups that stand to benefit from the program.

In a letter sent earlier this week, more than 220 healthcare organizations—including active participants in the DC program known as Direct Contracting Entities (DCEs)—implored HHS Secretary Xavier Becerra “to not cancel” the privatization scheme and dismissed recent criticism of the experiment as “misleading and flat out false.”

“Fix, don’t end, the Direct Contracting Model,” reads the letter. “For example, you can limit participation to certain types of DCEs, such as provider-led DCEs, and place additional guardrails and add more beneficiary protections. A rebranding and name change would also help communicate how this model is part of the evolution to accountable care.”

But PNHP countered in a letter of its own on Tuesday that such “superficial tweaks and cosmetic changes will not alter DC’s fundamental flaws.”

The industry coalition’s proposal to increase provider control over DCEs—the majority of which are currently controlled by investors—would do little to alter the DC program’s core imperatives, PHNP president Dr. Susan Rogers argued in the new letter to Becerra.

“Even with more provider governance, DCEs are ultimately accountable to investors, which include private equity firms and commercial insurers active in [Medicare Advantage],” Rogers wrote. “Investors want a return on their investment, creating a dangerous incentive for DCEs to both maximize revenues through upcoding, and minimize medical expenditures by restricting patient care.”

As for the industry recommendation of additional “guardrails” for the DC program, Rogers wrote, “Our experience from Medicare’s other managed care experiment, Medicare Advantage, shows that when regulators install new guardrails that threaten profits, the industry will simply build a bigger truck to run them over.”

“The DCE industry represents its own interests and that of its investors, and does not speak for physicians,” Rogers continued. “As physicians, we urge you to end the dangerous DC program and work tirelessly to strengthen and protect Traditional Medicare, both for today and for generations to come.”

The Trump administration quietly announced the DC pilot in April 2019 despite internal legal concerns about the program, under which the federal government pays DCEs to cover a specified portion of a patient’s medical care.

DCEs are allowed to keep as profit the funding they don’t spend on care, a set-up that critics say incentivizes DCEs to skimp on patients.

“Direct contracting is nothing more than privatizing Medicare,” Alex Lawson, executive director of the progressive advocacy group Social Security Works, said in a statement Tuesday. “It inserts a corporate bureaucrat between a patient and their doctor in order to deny care and make Wall Street money. The Biden administration must completely eliminate Direct Contracting—nothing less than that is acceptable.”

The DC experiment, which the Biden administration has thus far refused to cancel, was developed by Adam Boehler, who served as director of the Center for Medicare and Medicaid Innovation (CMMI) during Donald Trump’s presidency.

Prior to his tenure at CMMI, Boehler was the CEO of Landmark Health, a venture capital-backed startup that was selected in late 2020 to participate in the DC pilot.

CMMI is currently headed by Elizabeth Fowler, the former vice president of public policy and external affairs for WellPoint, Inc.—a firm that later became Anthem, one of the largest for-profit insurance companies in the U.S. and a major player in the Medicare Advantage industry.

“We can’t afford even more for-profit middlemen getting between America’s seniors and the care they need, especially seniors that chose to avoid Medicare Advantage for a variety of reasons,” argued Eagan Kemp, a health policy advocate for Public Citizen. “HHS should be working to strengthen Medicare, not pushing seniors into an untested program where for-profit companies can benefit by denying care. There are much more savings to be had by cracking down on Medicare Advantage than through pushing seniors into Direct Contracting.”

Advocates and healthcare professionals fear that if the DC program is allowed to run its course, traditional Medicare could be fully privatized by the end of the decade—without the consent of patients or a vote in Congress.

“Direct Contracting Entities and their Wall Street investors hoped they could fly under the radar of seniors, healthcare advocates, and members of Congress,” Rogers said in a statement Tuesday. “Now that HHS is feeling pressure to end this backdoor privatization of Medicare, the industry thinks they can save it with minor tweaks and cosmetic fixes. But we won’t back down until Direct Contracting is shut down, for good.”

https://www.commondreams.org…

Doctors and Health Advocates to HHS Sec. Becerra: End Medicare Direct Contracting, Don’t Tweak It

Physicians, seniors, and health advocates reject industry-proposed fixes to the Trump-era pilot program and demand an immediate end to the privatization of Traditional Medicare

FOR IMMEDIATE RELEASE: Feb. 15, 2022

Media Contact: Clare Fauke, Physicians for a National Health Program communications specialist, clare@pnhp.org

Today, a group of 25,000 physicians and health professionals sent a LETTER to Health and Human Services (HHS) Secretary Xavier Becerra, demanding that he reject proposed changes to the controversial Direct Contracting (DC) pilot program and instead end it immediately.

The doctors, members of Physicians for a National Health Program (PNHP), were joined by leaders from Pubic Citizen, Social Security Works, and Just Care USA in calling on Sec. Becerra to end the program.

“Direct Contracting Entities (DCEs) and their Wall Street investors hoped they could fly under the radar of seniors, health care advocates, and members of Congress,” said Dr. Susan Rogers, president of PNHP, an organization of 25,000 physicians who support Medicare for All and oppose Direct Contracting. “Now that HHS is feeling pressure to end this backdoor privatization of Medicare, the industry thinks they can save it with minor tweaks and cosmetic fixes. But we won’t back down until Direct Contracting is shut down, for good.”

On Monday night, members of the DCE industry sent a letter to Sec. Becerra, asking him not to cancel the DC program but to “improve” it by, among other things, implementing unspecified “guardrails.”

In response to the industry’s letter, PNHP reminded Sec. Becerra that DC has tarnished the reputation of HHS, and ending the program would demonstrate a commitment to improved integrity and the best interests of beneficiaries. The letter points to the conflicts of interest present at the program’s inception: DC was developed in 2019 by Adam Boehler, who, prior to leading the CMS Innovation Center (the agency responsible for the DC program), was founder and CEO of Landmark Health, which later won a DC contract. After leaving the administration, Boehler was co-founder of Rubicon Partners, which is now partnering with physician practices to join DC or Medicare Advantage (MA) programs.

PNHP also explained that as long as the program provides a profit motive for DCE middlemen, they will find a way around proposed “guardrails” on abuse. “Our experience from Medicare Advantage (MA) shows that when regulators install new guardrails that threaten profits, the industry will simply build a bigger truck to run them over,” the letter said, noting that despite government efforts to rein in fraud, it overpaid MA insurers by more than $106 billion from 2010 through 2019.

Several other advocacy groups called on Sec. Becerra to end, not tweak, the DC program.

“Direct contracting is nothing more than privatizing Medicare,” said Alex Lawson, Executive Director of Social Security Works. “It inserts a corporate bureaucrat between a patient and their doctor in order to deny care and make Wall Street money. The Biden administration must completely eliminate Direct Contracting — nothing less than that is acceptable.”

“We can’t afford even more for-profit middlemen getting between America’s seniors and the care they need, especially seniors that chose to avoid Medicare Advantage for a variety of reasons,” added Eagan Kemp, the Health Policy Advocate for Public Citizen. “HHS should be working to strengthen Medicare, not pushing seniors into an untested program where for-profit companies can benefit by denying care. There are much more savings to be had by cracking down on Medicare Advantage than through pushing seniors into Direct Contracting.”

Diane Archer, President of Just Care USA, which advocates for seniors and caregivers, said, “Medicare Advantage data show that putting insurers between patients and their doctors threatens patients’ health and drives up costs,”  “Direct Contracting is another version of Medicare Advantage, but worse, because it overrides people’s choice of Traditional Medicare. We need to end it now, before it destroys Medicare.”

PNHP’s letter to Sec. Becerra is available HERE. 

Physicians for a National Health Program (pnhp.org) is a nonprofit research and education organization whose more than 25,000 members support single-payer Medicare for All reform.

Medicare for All Explained Podcast: Episode 71

Medicare for All Changes That Will Make Your Life Better

February 15, 2021

Podcast host Joe Sparks describes the practical ways in which single payer would make life better for the average American, including guaranteed coverage, free choice of doctor, and no more medical debt. “There are other proposals to change our health care system,” he says, “but only Medicare for All provides all of the benefits that I have discussed.”

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

https://medicareforallexplained.podbean.com

Single Payer is Free Love

Comment:

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

Let me explain today’s title. It’s not what some of you Boomers who remember the 1960s and 1970s might think.

Providing access to health care with no financial barriers is love—of fellow human beings.

Single payer saves money by eliminating profits and administrative waste. Thus, it’s free, even with added services like long-term care.

Ergo, single payer is free love.

Happy Valentine’s Day!

http://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.

Cost Sharing for Health Insurance: Too Big a Price to Pay by the Insured?

By John P. Geyman, M.D.
Counter Punch, February 14, 2022

Most health care economists in the U. S. have accepted a conventional theory of health insurance for more than 40 years that assumes that insured people will overuse health care because they have insurance. Based on that assumption, higher cost sharing will save money for the insurance companies. We now have enough experience with it, however, to know that it also fails to contain increasing costs of health care, and instead erects barriers to access. At the same time, it remains a bonanza for insurers while avoiding serious concerns within the health policy community.

This commentary briefly reviews the experience with cost sharing in the U. S., summarizes its adverse impacts, discusses winners and losers from this approach to health care financing, and lists advantages of its being replaced by single-payer financing.

The conventional theory of health insurance has been built on the concept of “moral hazard,” whereby those with insurance are expected to overuse health care services and lead to uncontrolled increases in health care costs. As health care inflation has continued as a major problem in recent decades, however, it is remarkable that this theory has not been seriously challenged in most circles. Some economists have even suggested that high health care prices can be good since they reduce moral hazard.1

An early exception to acceptance of a moral hazard-based view of health insurance, however, was advanced in 2003 by John Nyman, health economist and Professor of Public Health at the University of Minnesota. With The Theory of Demand for Health Insurance, he called for replacing the previously unexamined axiom of risk avoidance with the axiom of welfare maximization. He further proposed that insurance-induced utilization of health care should be viewed as an increase in social welfare.2 In a rare article ten years later supporting Nyman’s re-formulation of moral hazard related to health insurance, economists Sander Kelman and Albert Woodward noted that “Despite its evident validity and enormous implications, Nyman’s work has received very little attention or recognition in the health economics literature.”3

Despite those rare exceptions to the common “wisdom” of health insurance, however, cost-sharing has continued to the present day in most insurance offerings, especially in the form of higher deductibles and copayments, negatively impacting both private insurance as well as privatized public programs. The continuing mantra underlying this approach is that patients will be more judicious in their use of health care if they have “more skin in the game” through cost-sharing at the point of service.

The Case Against Cost-Sharing in Health Care

This approach can be disproven by experience over past years for these kinds of reasons:

1) It has failed to contain the prices and costs of health care. Uncontrolled prices remain the single biggest cause of run-away health care inflation ranging across our medical-industrial complex from pharmaceuticals to medical devices and high administrative costs. Figure 1 shows how health care costs in the U. S. have relentlessly grown over the last 40 years as compared with the consumer-price index.

2) It stands as a barrier to access, results in underuse of needed care, and still leaves many patients with high medical bill and debt problems.4 Medical bankruptcy now accounts for two-thirds of personal bankruptcies, involving 530,000 families each year.5

3) Insurance premiums and deductibles have increased faster over the last 10 years than workers’ wages. (Figure 2) The average deductible for a single worker with employer-sponsored health insurance grew from $379 in 2006 to $1,350 in 2018.6

4) Many insurers offer plans through deceptive marketing practices with attractively low premiums, high deductibles, but restricted benefits in the fine print.

  • Insurers restrict choice of hospital and physician through narrowing networks,7 and even have an average denial rate for in-network claims of 18 percent.8
  • A 2019 study found that four in ten people with job-based insurance don’t have enough savings to cover the deductible.9
  • Many people with high deductibles and less coverage are forced to forego or delay essential care, leaving them with worse outcomes later. Figure 3 shows how high deductibles reduce access to care across the board.10

Dr. Veena Shankaran of the Hutchinson Cancer Research Center in Seattle sums up the financial barriers to access to care in these words:

“High-deductible plans are really the epitome of the access to care problem. People don’t have the liquid cash to meet the deductible, so you see delays in care or even avoiding treatment altogether.”11

5) While over-utilization of health care services by people with insurance is not driving inflation of health care costs, over-utilization for other reasons is indeed so related. It has been well known for years that up to one-third of all health care services in this country are either unnecessary or inappropriate.12 Three of four physicians surveyed by the American Board of Internal Medicine in 2016 believed that unnecessary tests and procedures are a continuing problem.13

Winners and Losers with Cost Sharing

Winners: As private health insurers consolidate and gain market share without significant oversight or regulation by government, the insurance industry continues to prosper by avoiding higher risk enrollees, increasing premiums without restraint, narrowing their networks, denying services, and exiting markets when not sufficiently profitable.

Overpayments are widespread and increasing in both privatized Medicare and Medicaid plans, more than doubling from $92 billion in 2010 to $360 billion in 2016.14 Insurers typically increase their revenues from Medicare Advantage by up-coding diagnoses, thereby exaggerating how sick their enrollees are, then claiming payment for conditions for which no care was provided.15 Overpayments to private Medicaid managed care plans are common in more than 30 states, often involving unnecessary and duplicative payments to providers.16

Losers: Patients, families and taxpayers are the big losers in our present financing system for health care. In the most expensive health care system in the world, the U. S. rations care based on ability to pay. The fact that so many Americans cannot afford care is a principal reason that we compare so poorly with other advanced nations in terms of access, quality and outcomes of care, as documented by the periodic studies by the Commonwealth Fund of health care in 11 advanced countries.17 A recent national study by Gallup and West Health, a non-profit organization, found that 58 million adults reported their inability to pay for needed drugs or medicine prescribed by their physicians. It also found that 34 million adults know someone who has died after not getting necessary care because of its unaffordability.18

A 2020 study of unmet needs for U. S. adults ages 18-64 years between 1998 and 2018 drew these conclusions:

  • “most measures of unmet need for physicians’ services have shown no improvement, and financial access to physicians’ services has decreased;
  • the rise of narrow networks, high-deductible plans, and higher co-pays has contributed to the growth of unmet medical needs in the U. S. since the 1990s; and
  • our findings call into question the value of private insurance today, when it fails to ensure that health care is affordable when needed.”19

Taxpayers lose because of the expensive and wasteful bureaucracies established by insurers to deny care, in both private and privatized public plans, that we get to pay for. It is not well known that the private health insurance industry has received continuous federal subsidies for many years averaging $685 billion a year.20

How Single-Payer Medicare for All Can Reform Health Care Financing

As other advanced nations found many years ago, a national system of health insurance will redress the problems listed above while providing universal coverage for all Americans without rationing by inability to pay for care. These advantages can be obtained by replacing our current, multi-payer financing system with a not-for-profit single-payer system:

  • Comprehensive benefits based on medical need, not ability to pay, with full choice of physicians, other health professionals, and hospitals anywhere in the country.
  • Financial barriers to care removed, with no cost sharing at the point of service and no need for pre-authorizations of services.
  • Access, equity, quality, and outcomes of care improved.
  • Cost containment achieved through large-scale cost controls, including (a) negotiated fee schedules for physicians and other health professionals; (b) global annual budgets for hospitals and other facilities; and (c) bulk purchasing of drugs and medical devices.
  • Administration simplified at much lower cost, with an overhead estimated by the Congressional Budget Office as low as 1.5 percent compared to the administrative overhead of privatized Medicare Advantage of 13.7 percent.21
  • Sharing of risk for the costs of illnesses and accidents across all 330 million Americans.

Conclusion

Given the above evidence and experience-based facts with the results from a for-profit, corporatized multi-payer financing system feeding at the trough of federal funding while compromising the health of our population, isn’t it time to adopt a not-for-profit single-payer system directed to the common good?

https://www.counterpunch.org…

Dr. John Geyman is professor emeritus of Family Medicine at the University of Washington School of Medicine in Seattle, where he served as Chairman of the Department of Family Medicine from 1976 to 1990. His most recent publications are Struggling and Dying under TrumpCare: How We Can Fix this Fiasco (2019) and a pamphlet, Common Sense: The Case For and Against Medicare for All, Leading Issue in the 2020 Elections (2019).

References

  1. Pauly, MV. When does curbing health care costs really help the economy? Health Affairs (Millwood) 14 (2): 68-82, 1993.
  2. Nyman, JA. Is “moral hazard” inefficient? The policy implications of a new theory. Health Affairs (Millwood) 23 (5): 194-199, 2004.
  3. Kelman, S, Woodward, A. John Nyman and the economics of health care moral hazard. ISRN Economics, January, 2013.
  4. Davis, K. Half of insured patients with high-deductible plans experience medical bill or debt problems. New York. The Commonwealth Fund, January 27, 2005.
  5. Himmelstein, DU, Lawless. RM, Thorne, D et al. Medical bankruptcy: Still common despite the Affordable Care Act. Am J Public Health, March 2019.
  6. Mathews, AW. Cost of employer health plans jumps. Wall Street Journal, September 26, 2019.
  7. Rosenthal, E. An American Sickness: How Healthcare Became Big Business and How You Can Take It Back. New York. Penguin Press, 2017, pp. 235-236.
  8. Silvers, JB. This is the most realistic path for Medicare for All. New York Times, October 16, 2019.
  9. Levey, NN. Health insurance deductibles soar, leaving Americans with unaffordable bills. Los Angeles Times, May 2, 2019.
  10. Brot-Goldberg, ZC, Chandra, A, Handel, BR, Kolstad, JT. What does a deductible do? The impact of cost sharing on health care prices, quantities, and spending dynamics. National Bureau of Economic Research, October, 2015.
  11. Shankaran, V. As quoted by Stallings, E. High-deductible health policies linked to delayed diagnosis and treatment. NPR, April 18, 2019.
  12. Wenner, JB, Fisher, ES, Skinner, JS. Geography and the debate over Medicare reform. Health Affairs Web Exclusive W-103, February 13, 2002.
  13. Hancock, J. How tiny are benefits from many tests and pills? Researchers paint a picture. Kaiser Health News, October 12, 2016.
  14. Schoen, C, Collins, SR. The Big Five health insurers’ membership and revenue trends: Implications for public policy. Health Affairs 36 (2), December, 2017.
  15. Livingston, S. Insurers profit from Medicare Advantage’s incentive to add coding that boosts reimbursement. Modern Healthcare, September 4, 2018.
  16. Herman, B. Medicaid’s unmanaged managed care. Modern Healthcare, April 30, 2016.
  17. Doty, MM, Tikkanen, R, Fitzgerald, M, et al. Income-related inequalities in affordability and access to primary care in eleven high-income countries. The Commonwealth Fund, December 9, 2020.
  18. Curtin, A. New study shows staggering consequences of for-profit healthcare system and Americans’ inability to pay for it. Nation of Change, November 16, 2019.
  19. Hawks, L, Himmelstein, DU, Woolhandler, S. Trends in unmet needs for physician and preventive services in the United States, 1998-2017. JAMA Intern Med, January 13, 2020.
  20. Bruenig, M. A new Congressional Budget Office study shows that Medicare for All would save hundreds of billions of dollars annually. Jacobin Magazine, December 19, 2020.
  21. Ockerman, E. It costs $685 billion a year to subsidize U. S. health insurance. Bloomberg News, May 23, 2018.

Advocacy is an Essential Skill in Health Justice

Summary: Advocacy is a skill set usually overlooked in public health training. A new blog makes the compelling case that advocacy courses should be mandatory, if we want to achieve health equity and justice.

Public Health Advocacy Must be Taught, Health Affairs Forefront, February 7, 2022, by Alexandra Carter, Lori Dorfman, Tony Iton, and Harry Snyder

The COVID-19 pandemic gave contemporary meaning to 19th-century physician Rudolf Virchow’s famous observation that medicine is bound by politics. We have long understood that the solutions to public health problems lie not only with the best available science but also in bold policies for social reform. Indeed, the field’s greatest achievements—from sanitation infrastructure and workplace safety to seat belt laws and tobacco control—are all products of policy change, informed by public health research and catalyzed by the concerted efforts of advocates. Yet, in the decades preceding the pandemic, public health and our academic institutions have increasingly distanced themselves from their roots in political activism and accepted a more neutral, scientific identity.

As our society struggles through the evolution of COVID-19, the crucial question is: Are we preparing the next generation of public health practitioners to not only investigate what harms health but also to advocate affirmatively for what is needed to advance health, particularly for groups plagued by structural inequities?

Policy development and the ability to “create, champion, and implement policies, plans, and laws that impact health” are among the 10 Essential Public Health Services (EPHS) that outlines the activities necessary to protect and promote public health. … Schools and programs of public health in the US are accredited based on criteria [which include] students’ ability to “advocate for political, social, or economic policies and programs that will improve health in diverse populations.”

The EPHS represents an important guiding vision, but there is a clear disconnect between what public health professionals should be able to perform to be effective and what is currently being taught and fostered in our schools of public health. … [R]equired courses in policy and media advocacy are markedly absent from most graduate-level curricula. Schools … of public health in the US excel in teaching rigorous research methods … [They] routinely map [required advocacy] competencies to general courses on community health, public health leadership, and health administration, which may or may not include discrete advocacy skill building. This is a mistake. …

Success for most public health academics is defined not by their demonstrable contributions to improving public health but by their numbers of peer-reviewed publications in high-impact journals.

[T]he [2020 EPHS] revision centers health equity where it once revolved around research. … The positioning of equity as a core value explicitly calls on the field to “actively promote policies, systems, and overall community conditions that enable optimal health for all.”

If we want health equity to be more than an aspiration on a teaching diagram, advocacy must be taught and required as a core skillset for graduation from accredited schools of public health.

It’s imperative that our academic public health institutions be held accountable to their accreditation standards and equip the next generation of practitioners with the skills to … address the root causes of inequity through policy change.

We can start by designing and requiring policy and media advocacy breadth courses, distinct from health care administration, to train students to bring public health science to bear on public policy. We should require our faculty to demonstrate how their research has contributed to improving health and health inequities.

Comment:

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

This superb blog drives home a crucial point: achieving health justice is a multi-faceted endeavor. Of course good analysis is essential (that’s my main gig), as is strong program management. But another critical part of the toolbox is advocacy – how to fight for what is right. It’s a skill that can and must be learned. And therefore must be taught in schools of public health. Required, per accreditation standards.

I can’t make the pitch better than this elegant commentary, so I won’t try.

But two comments:

1) Normally HJM shows only the first author, but this time I listed all four because of the astounding breadth they represent. The first is an advocate, the second a media expert, the third a health foundation leader, and the fourth a longstanding advocacy leader. I don’t mean to omit their other terrific roles and credentials, just to highlight their impressive expertise and perspective.

2) Lest you think “public health” is only about community health promotion and disease control programs, please reconsider. Achieving universal high quality health insurance – single payer – is a huge part of the US public health mission. As the blog urges, let’s improve our advocacy for this noble goal!

http://healthjusticemonitor.org…

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How Medicare is quietly being privatized

By Abdul El-Sayed, M.D.
Detroit Metro Times, February 9, 2022

Healthcare is big business — literally one of the most lucrative corporate endeavors in the country, accounting for one-fifth of our total economy. And the way that the business of healthcare interferes with actually providing Americans with appropriate, accessible, and affordable healthcare has been a frequent subject of my writing in these pages. From hospital consolidation to drug pricing, rising premiums to healthcare inequities, the fact that our healthcare system is designed to maximize profit for a few large corporations is the root, if not all, of the problem.

The fattest slice of that very, very large pie is healthcare for seniors — the Americans who most often need care. American seniors are insured through Medicare, a government health insurance program that’s supposed to offer them affordable, comprehensive healthcare. But as this is the American healthcare system we’re talking about, the knives are constantly out for Medicare — looking for just another bite.

Late last year, I wrote about the Medicare (dis)Advantage program, a frontal assault on Medicare, which cajoles beneficiaries into selecting privately managed Medicare plans. The private health insurance corporations that administer these plans get to keep the money they don’t spend on healthcare as profit, putting $27 billion of taxpayer money into the pockets of health insurance corporations in 2018 alone.

As bad as Medicare Advantage is, a new plan hatched under the Trump administration — and being allowed to proceed under the Biden administration — is even worse. But unlike Medicare Advantage, most seniors haven’t even heard about it.

It’s called Direct Contracting. Designed by the Trump administration, it’s a sop to the health insurance corporations and private equity firms that have been such a persistent force in Republican healthcare circles. They agree on a simple goal: privatize everything.

To understand Direct Contracting, it’s worth reviewing how traditional Medicare works. Like any private insurance program with which most of us are familiar, Medicare beneficiaries pay a certain premium depending on their income to have access to the service. When they see a doctor or go to the hospital, Medicare kicks in to pay for their care. In Medicare’s case, the bulk of their healthcare costs are subsidized by taxpayer dollars.

But that’s changing as corporations champ at the bit to get as much taxpayer money as they can. Medicare Advantage does this by coaxing seniors to enroll in privately operated versions of Medicare for a few added perks. Direct Contracting does it behind seniors’ backs and offers nothing in return. Instead of cajoling seniors to hand over their Medicare dollars, large corporations, called Direct Contracting Entities, target doctors. When a doctor signs up, all of the Medicare beneficiaries they see are signed up too — without their knowledge or consent. The Direct Contracting Entity acts as a middleman between the physician and Medicare — and like Medicare Advantage, they profit off of the Medicare dollars that aren’t spent on beneficiaries. In exchange for signing up, the doctors earn a kickback from the Direct Contracting Entity.

This isn’t even the worst version of Direct Contracting. Right now, Direct Contracting Entities have to recruit physicians to join willingly. In the iteration the Trump administration had previously developed, Medicare would just hand a defined geographic area over to a specific entity into which any physician practice seeing Medicare patients would automatically be enrolled.

Nevertheless, Direct Contracting will cheat seniors and taxpayers. To understand how, you have to understand the incentives of a profiteering Direct Contracting Entity. On the one hand, they want to get as much money per beneficiary as possible — and because Medicare gives the Direct Contracting Entity more money to care for sicker patients, they have an incentive to upcode (or exaggerate) patient diagnoses by leaning on enrolled physicians to upcode their patients in turn for a cut of the income. But while they have an incentive to exaggerate patient diagnoses, they also have an incentive to spend as little money as possible for their care so as to keep as much of the money that Medicare gives them in profits. Code high, treat low. That’s how Direct Contracting Entities maximize profits.

Imagine the experience for seniors: without telling you, your physician enrolls you in a scheme to make money off your Medicare dollars by partnering with an unnamed, unseen corporation that then presses on them to over-diagnose you while skimping on your care. You’re told you’re sicker, but receive less care for it.

Everyone from traditional health insurers to private equity firms are lining up to cash in. But Direct Contracting isn’t a matter of law; Congress never voted on this. It’s just a pilot program designed by the Trump administration … that the Biden administration is now carrying forward. They could kill Direct Contracting in its tracks if they wanted to! The fact that it’s not should be extremely worrying to seniors, consumer rights advocates, and anyone who pays taxes to the U.S. government.

The irony here is that President Biden ran on a public option — which doesn’t look to be coming anytime soon. Instead of that promise, his administration is allowing a backdoor private buyout of Medicare.

Originally published Jan. 25 on The Incision. Get more at abdulelsayed.substack.com.

https://www.metrotimes.com…

Lessons from the Demise of AB 1400

Summary: The recent non-vote defeat of California’s single payer bill, AB 1400, generated much scrutiny, soul-searching, and opining. We offer a survey. Prescriptions range widely: better explain single payer to political actors and business, accept a lesser version of “universal” care, throw in the towel on progressivism, double down on progressivism. Multi-pronged efforts seeking a true single payer solution seem inevitable and essential.

Single-payer health care is dead in California until these things change, San Francisco Chronicle, Feb. 2, 2022, by Josie Lepe

Single-payer isn’t just dead for this year, it is dead for the foreseeable future unless its supporters can explain it better — starting with winning over people who, in theory, should be with them, like organized labor, Gov. Gavin Newsom and Kalra’s fellow Democrats. Supporters would have to elect at least 10 more progressive legislators this year to replace the current batch. …

Polls have consistently shown that a majority of California voters support single-payer. But advocates still have trouble convincing people — from employers to state legislators — that while they will pay more in taxes under a single-payer system, they will ultimately save money.

“A single-payer plan is kind of nirvana for patients: Go to any doctor, any hospital, no premiums, no deductibles, no co-pays. That sounds like exactly the kind of system many patients would want,” Levitt told me. “The problem is that that system doesn’t exist now. So you’re asking people to take on faith.”

Employer-based health insurance was a failure during the pandemic. Here’s how single-payer healthcare could do better. Business Insider, Feb. 5, 2022, by Paul Constant

When ordinary Americans understand that a wealthy handful of people are making billions in profits off of their misery, the rules of the game tend to change very quickly. If we reach that tipping point, a plan like Kalra’s will be necessary to actually meet the healthcare needs of all Americans, not just fluff up the corporate balance sheets of a few big insurance companies.

Single-payer healthcare in California is out of reach. Universal healthcare is a better bet, Los Angeles Times, Feb. 3, 2022, by George Skelton

It’s virtually impossible to pass legislation this revolutionary without hefty promotion and pushing from the governor. Newsom sat out this failed fight, although he ran for governor as a strong backer of single-payer. Since then, he has apparently been indoctrinated in political realism.

Gov. Newsom created a commission to develop a broad plan for universal healthcare. The panel hopes to report in April.

Single-payer seems out of reach. But universal coverage is close.

California liberals seethe after Democratic legislature kills single-payer, Politico, Feb. 5, 2022, by Jeremy B. White and Victoria Colliver

The unceremonious collapse of California’s single-payer health care legislation — without so much as a vote — has the left desperate for answers.

The bill’s failure “illustrates what an uphill battle we have ahead of us,” said David Campos, a California Democratic Party official and single-payer advocate who is running for state Assembly. “I think we need to figure out where we go from here as a progressive movement,” he added.

Email, Feb. 7, 2022, from Paul Song, M.D., Past President, PNHP California

Of 80 Assembly members and 40 Senators in California, 56 and 31 are Democrats. Despite this overwhelming Democratic majority, there were only 20 co-authors on AB1400, some of whom may have signed on only to avoid a primary from the left in very progressive home districts.

The Governor, who ran as a candidate strongly supporting single payer, claimed he never read AB1400. And it was very clear that there was little to no true support among the legislature. On top of this, Blue Shield, the California Hospital Association, and CMA all donated significant money to the Governor for his recall fight and the CA Democratic Party has continuously received tremendous financial support from the same groups.

I was pleasantly surprised to see AB1400 get as far as it did, and believe this was largely due to the relentless grassroots and social media campaign waged by dedicated single payer activists who organized like never before. But, in the end, it was a bought and bossed Sacramento that continually caves to its corporate donors that failed us once again.

To my fellow activists, I urge you not to give up, but to remember the words of Dr. Martin Luther King, Jr. “Human progress is neither automatic nor inevitable. Every step toward the goal of justice requires sacrifice, suffering, and struggle; the tireless exertions and passionate concern of dedicated individuals.”

All options are on the table, including a “Dem Exit” strategy in which Democrats not beholden to corporate interests coalesce in a truly progressive third political party.

We must continue to educate and organize.

Comment:

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

What lessons should we take from the fizzling of AB 1400 in the California Assembly, with no vote?

To me, Assembly Member Kalra’s decision not to call a vote should be treated with deference. Clearly the vote numbers were lacking. The tactical decision to withdraw the bill, rather than force on-the-record votes, is beyond my expertise.

Why were the votes lacking? Corporate control of the Democratic party (along with the GOP of course). That is, a general bias toward business interests, profoundly exacerbated by generous political donations from the major beneficiaries of current health care financing. We see the same phenomenon in Washington, as in the piecemeal health provisions in Build Back Better and CMS support for Direct Contracting Entities, which privatize traditional Medicare.

How to respond? I’m not a political strategist, so I consulted the views of those who know more about the most viable paths to pursue single payer. As you see above, proposed solutions vary widely. I’m unwilling to accept a shabby alternative to single payer, e.g., a cobbled together “universal” strategy that leaves massive inefficiencies (including extracted profits) and huge coverage gaps that results in tens of thousands of excess deaths per year.

Which leaves two broad alternatives:

Continue efforts to convince the Democratic party to respect popular support for single payer. Elect more progressive Dems, and expand and empower public voice. Pursue initiatives in multiple settings. As Michael Lighty proposes in a January 27th op-ed, States Now Hold the Key to Making Medicare for All a Reality – “the terrain for winning universal, publicly-financed comprehensive healthcare looks increasingly favorable.” I hope he’s right, and that when a state does pass single payer, the federal government provides the needed cooperation.

More radically, contemplate a “Dem Exit” strategy, as Paul Song described to me. Build a truly effective non-corporate third party. The US has a history of party shifts; perhaps it’s time to revive that playbook.

Here in California, the next step is the Spring 2022 report of the Healthy California for All Commission, which may include a significant single payer voice.

Again, I’m not a strategist, and have no political crystal ball. So I endorse pursuing multiple potential paths to what is the clearly optimal solution – single payer.

My contribution? I’ll keep reading, analyzing, and writing … being, as always, a health policy analyst desperate to see health care justice achieved, and ready to support any promising political action toward that end.

http://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.