PNHP

“National Health Spending Estimates Under Medicare for All”

“National Health Spending Estimates Under Medicare for All”

RAND 2019

Title: National Health Spending Estimates Under Medicare for All
Year: 2019
Authors: Jodi L. Liu and Christine Eibner
Institution: RAND
Funding Source: Modeled after H.R. 1384
Plan Analyzed: S. 1782 / H.R. 1200
Percent Change in National Health Expenditure under M4A (1-year): +1.75% (2019)
Percent Change in National Health Expenditure under M4A (10-year): NS
Increases in federal health expenditures: $2.4 trillion (2019)

Read Study:

National Health Spending Estimates Under Medicare for All

Study Abstract:

We estimate that total health expenditures under a Medicare-for-All plan that provides comprehensive coverage and long-term care benefits would be $3.89 trillion in 2019 (assuming such a plan was in place for all of the year), or a 1.8 percent increase relative to expenditures under current law. This estimate accounts for a variety of factors including increased demand for health services, changes in payment and prices, and lower administrative costs. We also include a supply constraint that results in unmet demand equal to 50 percent of the new demand. If there were no supply constraint, we estimate that total health expenditures would increase by 9.8 percent to $4.20 trillion.

While the 1.8 percent increase is a relatively small change in national spending, the federal government’s health care spending would increase substantially, rising from $1.09 trillion to $3.50 trillion, an increase of 221 percent.

Overview:

  • An update done by extrapolating projections from the microsimulation modelling in the 2016 RAND study. No new modelling was undertaken for this analysis.
  • This study considers:
    • Increased demand for medical services and long-term care services and supports (LTSS)
    • Savings from all-payer rates for services, prices for drugs and devices, administrative costs
    • Supply-side constraints for services
    • Level of financing needed for Medicare For All

PNHP Response:

Regarding increased utilization, we would highlight three studies from 2019 that found large-scale coverage expansions in the United States (Medicare/Medicaid in the late 1960s and the ACA in the early 2010s) did not lead to a society-wide increase in hospitalizations or doctor visits, and that large-scale expansions in other nations also did not cause a spike in utilization. (See “Utilization of health care services after large coverage expansions.”)

“Yes, We Can Have Improved Medicare for All”

Hopbrook Institute 2019

Title: Yes, We Can Have Improved Medicare for All
Year: 2019
Author: Gerald Friedman
Institution: University of Massachusetts at Amherst
Funding Source: Hopbrook Institute
Plan Analyzed: H.R. 676
Percent Change in National Health Expenditure under M4A (1-year): -20.0% (2019)
Percent Change in National Health Expenditure under M4A (10-year): -20.6% (2019-28)

Read Study:

Yes, We Can Have Improved Medicare for All

Abstract:

Growing public support for universal health coverage through a public program has provoked increasing attention to the question of how to finance such a program. There should not be any controversy about our ability to pay for universal health care. Given the nearly universal agreement that the current health-care system involves administrative waste and monopoly pricing, a system that would be more efficient and would reduce both should certainly be affordable. Studies finding higher costs for universal coverage programs have reached their conclusions by acknowledging efficiency savings but dismissing them by emphasizing, even exaggerating, the higher costs of providing better access to health care.  Such studies provide a poor guide to the possibilities for an overhaul of our health-care finance system. In this paper, I discuss the financing of a universal health-care program, beginning with a discussion of current projected spending and the savings to be achieved through administrative efficiency and reducing monopoly pricing. Next, I outline increased spending associated with universal coverage through covering the uninsured and reducing barriers to access. I consider the net cost of universal coverage, after taking account of savings and the cost of extending and improving coverage, under various scenarios with alternative immediate savings and savings over time. Finally, I discuss sources of funding for such a program, beginning with public funds already committed and including possible additional sources of revenue. I develop funding plans under a variety of assumptions regarding the course of the single-payer system, and under alternative assumptions regarding revenue sources. This work shows that compared with the current system of health-care finance, a program of Improved Medicare for All could save Americans over $1 trillion in the first year, and savings could increase over time. Because some of the savings would be returned to health care through programs of universal coverage and improved access, net savings could be over $700 billion in the first year, rising over the next decade. Depending on the assumptions made and the program details, total financial savings, after taking account of program improvements, would come to $10 trillion or more over the next decade, on top of gains in quality of life and reduced mortality through universal access. A variety of models are compared, with varying assumptions of the magnitude of administrative savings and savings through reduced monopoly rents, as well as savings from bending the cost curve and maintaining some cost-sharing. Overall, the ten-year national savings on health-care expenditures range from a low of over $6 trillion to a high of over $13 trillion.  In every model tested, Improved Medicare for All is cheaper than the current system even while providing improved health care.

Overview:

Comprehensive cost analysis conducted by Gerald Friedman updating his previous work on the subject with similar considerations for financing options.

  • Section 1: Current spending and waste
    • Administrative savings in provider offices
    • Savings from pricing at Medicare negotiated rates
      • Drugs and medical devices
      • Hospital and physician practices
  • Section 2: Additional spending with universal coverage
    • Medicare premiums
    • Cost of universal coverage
    • Cost of eliminating barriers to access
  • Section 3: Total Spending with Medicare for All
  • Section 4: Paying for Medicare for All
    • Available revenues
    • New revenues
  • Conclusion: We can afford Improved Medicare for All

“Improving the Prognosis of Health Care in the USA”

Yale School of Public Health 2020

Title: Improving the prognosis of health care in the USA
Year: 2020
Authors: Alison P. Galvani, Alyssa S. Parpia, Eric M. Foster, Burton H. Singer, Meagan C. Fitzpatrick
Institution: Yale School of Public Health
Funding Source: N/A
Plan Analyzed: S. 1804 Medicare for All Act of 2017
Percent Change in National Health Expenditure under M4A (1-year): -13.1% (2017)
Percent Change in National Health Expenditure under M4A (10-year): NS
Increase in Federal health expenditures: $773 billion (2017)

Read Study:

Improving the prognosis of health care in the USA

Study Abstract:

Although health care expenditure per capita is higher in the USA than in any other country, more than 37 million Americans do not have health insurance, and 41 million more have inadequate access to care. Efforts are ongoing to repeal the Affordable Care Act which would exacerbate health care inequities. By contrast, a universal system, such as that proposed in the Medicare for All Act, has the potential to transform the availability and efficiency of American health care services. Taking into account both the costs of coverage expansion, and the savings that would be achieved through the Medicare for All Act, we calculate that a single-payer, universal health care system is likely to lead to a 13% savings in national health-care expenditure, equivalent to more than US$450 billion annually (based on the value of the US$ in 2017). The entire system could be funded with less financial outlay than is incurred by employers and households paying for health care premiums combined with existing government allocations. This shift to single-payer health care would provide the greatest relief to lower-income households. Furthermore, we estimate that ensuring health care access for all Americans would save more than 68,000 lives and 1.73 million life-years every year compared with the status quo.

Overview:

  • In early 2020, Alison Galvani published a cost-analysis of the Senate Medicare for All bill, S. 1804. Of note, Galvani served as an “informal unpaid adviser” to the writers of this particular bill.
  • The Yale study focuses on:
    • Savings from reduced fees for hospital and clinical services, unified system for billing and administration, pharmaceutical price negotiation
    • The cost of expansion of coverage and services
    • Financing plan effects on employers and households
    • Public health approach to estimate “life-years” saved by Medicare for All
    • Positive spillovers from emphasizing preventive services
    • Creation of a Tool that can model costs/savings as well as revenue generation

Further Reading:

SHIFT Tool allowing users to modify inputs and assumptions

United States once again in 11th place out of 11

Income-Related Inequalities in Affordability and Access to Primary Care in Eleven High-Income Countries

By Michelle M. Doty, Roosa Tikkanen, Molly FitzGerald, Katharine Fields, and Reginald D. Williams II
The Commonwealth Fund, December 9, 2020

The Issue

As COVID-19 continues to ravage the globe, the United States faces renewed scrutiny for the stark disparities in health and economic impacts experienced by people with lower incomes and by Black and Latino communities. In other countries, the crisis has highlighted the need for greater resiliency of national health systems to ensure access to care.

To compare the health experiences of adults with lower income during the pandemic and the effect of income-related disparities, the Commonwealth Fund surveyed adults across 11 high-income countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the U.S. The results of the survey, conducted during the early part of the pandemic between February and May 2020, were published in the December 2020 issue of Health Affairs (Abstract below).

What the Study Found

  • In nearly all countries, adults with lower income were significantly more likely than those with higher income to have multiple chronic health conditions. However, on nearly every measure the study used, income-related disparities were greatest in the U.S.:
    • More than one-third (36%) of U.S. adults with lower income have two or more chronic conditions — significantly more than in other countries.
    • Approximately one-third of adults with lower income in the U.S. (36%), Australia (36%), and Canada (34%) reported having anxiety or depression, the highest rates in the survey. Their counterparts in Germany (14%) and Switzerland (15%) were the least likely to report anxiety or depression.
    • More than one-quarter (28%) of U.S. adults with lower income said that, in the past year, they worried about being able to afford basic necessities such as food or housing, a significantly greater proportion than seen in other countries, where 6 percent to 22 percent reported this.
  • Half of U.S. adults with lower income don’t get needed care because it’s too costly. In the survey, 50 percent reported skipping doctor visits, recommended tests, treatments or follow-up care, or prescription medications in the past year because of the cost. In contrast, just 12 percent to 15 percent of adults with lower income in Germany, the U.K., Norway, and France reported doing the same.
  • Difficulty in paying medical bills is mostly a U.S. phenomenon, with 36 percent of U.S. adults with lower income reporting this problem, compared to 7 percent to 16 percent in the other countries.
  • In most countries, virtually all adults with lower incomes reported having a regular doctor or place of care. Rates in the U.S., Canada, and Sweden, meanwhile, ranged from 85 percent to 89 percent.
    • Same-day and next-day appointments: About four in 10 adults with lower income in the U.S., Canada, New Zealand, and Norway were able to get a same- or next-day appointment to see a doctor or nurse when they were sick. In contrast, 74 percent of those in Germany and 63 percent those in the Netherlands were able to get this care.
    • After-hours care: The Netherlands stands out, with only 35 percent reporting difficulty getting after-hours care without going to the emergency department (ED). In all other countries, between 43 percent and 64 percent of lower-income adults reported this problem (58% in the U.S.).
    • Emergency care: Forty-five percent of U.S. adults with lower income reported using the emergency department in the past two years to get care that could have been delivered by their regular doctor had it been available. That is a significantly higher rate than in Australia, France, Sweden, and the U.K.

The Big Picture

Achieving greater health equity in the U.S. will likely require policies that extend insurance coverage, make health care easier to afford, and strengthen primary care. The study authors also say that greater investments are needed to address the social determinants of health — factors beyond traditional health care, such as housing, education, and nutrition, that also affect people’s health. The U.S. in particular, they say, has much to gain from examining the experience of countries where universal health coverage ensures people have access to affordable health care.

The Bottom Line

Income-related health disparities exist in all high-income countries but are far worse in the United States. And they may be undermining U.S. efforts to respond to the pandemic, including prospects for effective vaccination of the U.S. population.

https://www.commonwealthfund.org…

Income-Related Inequality In Affordability And Access To Primary Care In Eleven High-Income Countries

By Michelle M. Doty, Roosa S. Tikkanen, Molly FitzGerald, Katharine Fields, and Reginald D. Williams
Health Affairs, December 9, 2020

Abstract

A high-performing health care system strives to achieve universal access, affordability, high-quality care, and equity, aiming to reduce inequality in outcomes and access. Using data from the 2020 Commonwealth Fund International Health Policy Survey, we report on health status, socioeconomic risk factors, affordability, and access to primary care among US adults compared with ten other high-income countries. We highlight health experiences among lower-income adults and compare income-related disparities between lower- and higher-income adults across countries. Results indicate that among adults with lower incomes, those in the US fare relatively worse on affordability and access to primary care than those in other countries, and income-related disparities across domains are relatively greater throughout. The presence of these disparities should strengthen the resolve to find solutions to eliminate income-related inequality in affordability and primary care access.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

The results of another in the series of studies by The Commonwealth Fund on the health care systems of eleven wealthy nations should surprise no one who has followed the prior studies. The United States is last again, this time in income-related inequality in affordability and access to primary care.

The Health Affairs study: “Results indicate that among adults with lower incomes, those in the US fare relatively worse on affordability and access to primary care than those in other countries, and income-related disparities across domains are relatively greater throughout.”

The Commonwealth Fund report (same authors): “Achieving greater health equity in the U.S. will likely require policies that extend insurance coverage, make health care easier to afford, and strengthen primary care. The study authors also say that greater investments are needed to address the social determinants of health — factors beyond traditional health care, such as housing, education, and nutrition, that also affect people’s health. The U.S. in particular, they say, has much to gain from examining the experience of countries where universal health coverage ensures people have access to affordable health care.”

When we are already spending more than enough to fix our health care system, far more than any other nation, how much longer are we going to stand in shame and embarrassment before other wealthy nations that obtain much better results with far less per capita spending than we have in the U.S.?

For starters, we should enact and implement single payer Medicare for All. That will take care of health care for everyone without costing us any more than we are already spending. Then tending to other socioeconomic needs should move us up to first place, or close to it.

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

Been there. PNHP’s Dr. Susan Rogers on racism in U.S. medicine.

By Brenda Gazzar
Code Wack Podcast, December 14, 2020

Featuring Dr. Susan Rogers, new president of Physicians for a National Health Program. Dr. Rogers is recently retired from Stroger Hospital of Cook County, Illinois, but continues as a volunteer attending hospitalist and internist there. She is an Assistant Professor of Medicine at Rush University, where she is an active member of the Committee of Admissions. She is a Fellow of the American College of Physicians and a member of the National Medical Association.

What was it like growing up Black in America during the Civil Rights struggles of the 1960’s? What was the experience of systemic racism faced by students of color – especially Black women – in medical school during that era? With host Brenda Gazzar, Dr. Susan Rogers, new president of Physicians for a National Health Program, describes the life experiences that helped shape her commitment to social justice and healthcare equity.

Transcript

(10-second Talk back music)

Welcome to Code WACK!, your podcast on America’s broken healthcare system and how Medicare for All could help. I’m your host, Brenda Gazzar. 

Dr. Susan Rogers is at the forefront of the fight for single-payer health care — and healthcare equity — in America. She’s the new president of Physicians for a National Health Program. She was a young Black student in Chicago during the Civil Rights Movement and the Vietnam War protests. Those historic events helped shape her into the physician and patient advocate that she is today.

(5-second stinger music)

Dr. Susan Rogers grew up in Chicago’s Hyde Park community in the 1950s and 60s. It was near the University of Chicago and one of the only truly integrated neighborhoods in the city back then.

Rogers: I grew up with white friends, Asian friends, everybody. You know, there weren’t that many Latinos in the area, but it was totally integrated. And even though I would hear about things in the news, that was normal for me to grow up with people like that and I’m still friends with many of those that I grew up with from different races and so my perspective of the world was a little bit different in the sense that this was my normal.

When she was in the 7th or 8th grade, her mother took her and her siblings downtown to march with Dr. Martin Luther King, Jr.  The civil rights icon had come to Chicago to fight neighborhood segregation. He found it to be just as segregated, she said, as the South.

(Backdrop of protests sounds)

Rogers: And so we went down to that march, and I was just amazed. It was you know, at this time, there were boycotts at the school. The superintendent of schools at that time did not want to integrate the schools. So even though our school was integrated, he put up what they called these mobile classrooms. So, even though there were schools that were overcrowded,  he didn’t want Black students to go elsewhere or white students to go. So he put these mobile classrooms in the parking lots of these schools so that he could maintain segregated education and his last name was Willis, Ben Willis, and we all called them the Willis Wagons.

Sen. Bernie Sanders was once arrested after protesting the installation of these classroom trailers as a University of Chicago student.

Rogers: My mother was very active in a lot of the social justice issues of the neighborhood. And so I grew up thinking, this is the norm. This is what you do.

Dr. Rogers went to Kenwood High School in Hyde Park, where her class of 1971 was also very politically active.

Rogers: We walked out against the gang problem. We walked out against the Vietnam War. So it was a socially active group, even at that time, in terms of being involved in civil unrest and against the police.

After high school, Dr. Rogers went to a small liberal arts college in Colorado, which she had heard about from a friend back home. But she wasn’t prepared for that experience.

Rogers: It was like going to a foreign country. I had never met white people who had never physically seen a Black person. There was so much wealth at that school. I mean their idea of a summer job was taking care of their neighbor’s horse.

The school’s Black students congregated at a home that became the center of their social life. But they didn’t feel welcomed at the school.

Rogers: And I remember at the time, my second year, we rallied to get Black faculty because there really wasn’t any Black faculty on the campus. And so who they came up with, was a tennis coach.

(Sound of tennis ball volleying)

That was how they were going to integrate the faculty. It was a reflection really of how this country was. It was very separate, there wasn’t much interaction.

It was interesting because there was a white guy there, who I had grown up with, he was the one who told me about the school. He was a year ahead of me. And we never really talked while we were there. The separateness, even though we both grew up in a very integrated neighborhood, we both became separate because that was the culture at the school.

Dr. Rogers was also the only Black biology major at the school. That left her feeling somewhat isolated.

Rogers: The whole idea that I even mentioned being a doctor was “are you sure you want…?” I mean, I wasn’t encouraged. It was different…I’m glad I left, because I don’t think I would have gone to medical school, if I had stayed there.

I did have support at home but at the time, I was very angry. The Black Panthers were very active. The whole Vietnam War and all the subtle racism there at the school, that you become angry, and you lose sight of what you should do or what’s the right thing to do because … this anger. And so that’s why I’m glad I left, because then I could focus on what it was that I  wanted to do and what was the right thing to do, the good thing to do, what I was able to do versus being, you know, consumed by this anger.

So after two years, Dr. Rogers left Colorado College and went to a historically Black college, Hampton Institute, in Virginia. She ultimately graduated from Roosevelt University in downtown Chicago in order to be at home with her ill mother. 

Dr. Rogers says she was fortunate that her father was a dentist and the family was well off at the time. That enabled her to have choices.

And I realized that a lot of people have no choices. And as I’ve gotten older and read more about the history of this country and how atrocious it is, and all of that, most people don’t have choices in their lives.

It’s like, if you look at what’s happening today. Look at essential workers. They don’t have a choice. What is their choice? They can either go to work and risk COVID, and bring it home, or they cannot go to work and risk being homeless and hungry. Those aren’t choices. You end up doing what you need to do to survive to the next day.

When she went to the University of Illinois Medical school in 1975, U.S. hospitals had been integrated for less than a decade. She said the older white attending physicians who were training her didn’t believe she should be there.

Rogers: They had grown up in this totally segregated healthcare community and it was a struggle to prove that you were smart enough to do that. And I look back at some of the evaluations and they were totally unfair, totally unfair.

Her first medical school rotation was OB GYN.

(Sound of baby crying) 

It was eight weeks on rotation, three weeks off and then they had to take a big board exam.

And I read and read and I knew that I knew what I was talking about. I learned so much. but my evaluation says, although I wasn’t smart, I worked hard, so he passed me. And I knew that that was totally wrong…I felt awful. I cried. I mean how could this be?  And I was not a student who struggled.

I went to the dean, and the dean took me up there, and it was an older white guy, who was known for his racism. He said, “well, if you don’t believe me, you can talk to the residents” and I wish I had called his bluff but even then, I don’t know if the residents would have supported me versus supporting him, you know.

I look at where I am now and the fact that I was personally able to see that that wasn’t fair and that I didn’t let it convince me that I shouldn’t be there. And it’s still a struggle today. I mean that hasn’t changed — just being professionals, you know. The sense of entitlement in this country, regardless of what anyone else has done. Why should I have to continue to prove myself?

Dr. Rogers trained at a county hospital in Chicago because that was close to her heart.

I went into medical school telling myself, “I’m going to medical school to take care of Black people.” That was my goal and that was why I trained at Cook County and that’s why I retired from Cook County.

I did leave and did some other things in public health institutions, with the (Department of Veteran’s Affairs)  with community health centers and all. So I still stayed taking care of that population but I ended up coming back to (Cook) County Hospital.

And I did what I wanted to do. I took care of the people who I wanted to take care of.

Next time on Code WACK!, we’ll hear about Dr. Susan Roger’s experience treating patients at Cook County Hospital — now Stroger Hospital of Cook County —  in Chicago.

Find more Code WACK! episodes on ProgressiveVoices.com and on the PV app. You can also subscribe to Code WACK! wherever you find your podcasts. This podcast is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country.

https://heal-ca.org…

If you chose your health plan, you may well have the wrong one

It’s Not Just You: Picking a Health Insurance Plan Is Really Hard

Most Americans make poor choices. So do most professional insurance brokers, a new study finds.

By Margot Sanger-Katz
The New York Times, December 11, 2020

When Paul Krugman, the Nobel-winning economist and a New York Times columnist, started a teaching job at the City University of New York, he had a choice between one union health plan at The Times and an array of university options, “which I found incomprehensible,” he said in an email.

“I asked H.R. at CUNY if they could explain the differences; they said no. So I went with The Times, precisely because it didn’t require that I make a choice!”

For most Americans, with or without a Ph.D in economics, right now is the time to pick your health insurance. Medicare beneficiaries can choose a Medicare Advantage plan or a Part D prescription drug plan. People with coverage at work can choose from the options their employers offer. People who buy their own insurance can make a choice on the Obamacare marketplace in their state.

The range of choice is generally heralded as a good thing: Not everyone wants the same plan, the thinking goes, so offering multiple options helps people shop for the one that is best for them. That logic drove the creation of Medicare Advantage, with legislation passed by Republicans, and drove the design of Obamacare, with legislation passed by Democrats.

But it turns out in real life most people are terrible at picking the health plan that is right for them. Health insurance is a complicated financial product, and study after study has shown that people routinely pick bad plans, even choosing options that leave them worse off financially in every possible scenario. And, because people are so bad at choosing good plans, the market often sends weird signals to insurance companies, encouraging them to offer more of the wrong plans instead of the right ones.

People struggle to make good choices when it comes to all kinds of financial products, but health insurance is especially confusing, with its mix of technical benefits and fees. Many Americans don’t understand terms like “deductible” or “coinsurance” very well. And few are good at predicting what sort of health care needs they will have in the coming year. Picking an ideal health plan requires combining all of these features — knowing what you might use, what it might cost you, and how those expenses combine with the plan’s monthly premium.

The people most likely to make bad choices appear to be those least able to afford it. A recent study in the Netherlands, which offers insurance to everyone through an Obamacare-like marketplace, found that only 5 percent of Dutch customers did a better job at choosing an ideal plan than they would have by choosing a plan at random.

But even highly educated Dutch professionals struggled. People who worked in the insurance industry and had advanced degrees made a good choice about 30 percent of the time. And only about 40 percent of trained statisticians — the group with the best performance — chose good plans for their needs.

In the United States, a working paper has found that many professionals who help people select health insurance are also bad at picking plans, performing substantially worse than a computer algorithm.

Brigitte Madrian, the dean of the Marriott School of Business at Brigham Young University, has also studied health insurance, but said picking a plan for her family when she arrived in Utah was a heavy lift. She set aside an entire Saturday for the task, scouring websites and constructing spreadsheets. Ultimately, she asked her fellow health economists what they had chosen.

“If I’m having a hard time, what is the rest of the population doing?” she said she wondered. “They must be throwing darts.”

Reader response:

By Don McCanne, M.D., San Juan Capistrano, CA

The traditional Medicare program gives patients almost unlimited choices in their health care professionals and hospitals which are the choices they really want, not choices of confusing health plans.

But deductibles, coinsurance and potential catastrophic losses in Medicare may be a problem for some. If we were to fold Medigap-type benefits into Medicare then it becomes the one size that really does fit all that we truly want – a comprehensive program that works for everyone (i.e., an improved Medicare for All). There would be no need to have to choose between plans that limit your choices to provider networks, with a high risk of turning out to have been the wrong plan choice, as Margot Sanger-Katz’s article shows us.

The administrative efficiency would save hundreds of billions of dollars which would be more than enough to pay for the improved benefits of Medicare for All.

By Charles Pack, Redbank

Why do we do this to people, especially old folks like me? Insurance should be pooling everyone into one pool and sharing the “risk”. Asking everyone to choose a plan (and pay for it) assigns the risk to each individual. This is wrong and unnecessary. Single payer systems like Medicare for All is the only way to go.

https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

Americans make poor choices when offered a variety of plans through their employer, through an insurance broker, through the ACA exchanges, through Medicare Advantage, through Medicare Part D, or whatever. If you want more proof then you might check the three reports available through the “study after study” links in the article by Margot Sanger-Katz. Or do your own Internet search.

Suppose the government took away your choice of these confusing plans that often provide unpleasant surprises when you need to use them, like your own doctor isn’t covered, or your community hospital isn’t covered, or the deductibles and the surprise bills are unaffordable, or the insurer refuses to authorize the care your doctor recommended, or, well, the list goes on. Not such great choices.

Suppose instead the government limited you to only one plan – one that covered you from conception to death, one that provided you the freedom to choose your health care professionals and institutions, one that provided all essential health care benefits, one that made health care affordable based on your ability to pay regardless of the extent of your health care needs, one that covered you wherever you happen to be, one that eliminated the expensive and burdensome administrative excesses generated by the private insurance industry, and one that could do this in an efficient system that included your family, friends, associates and everyone else in the country. Would you really object to the fact that this means that you would bow out of a system in which the odds are you would make a poor choice in selecting a health plan – a plan that didn’t serve you very well?

Many of the reader responses to the New York Times article expressed a sentiment like that of Charles Pack of Redbank (above). Single payer Medicare for All is the one choice that most people really want. Many have had it with private health plans; President Biden doesn’t need to guarantee us any more of that!

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

Medicare for All Explained Podcast: Episode 47

Interview with Dr. James G. Kahn

December 14, 2020

Public health expert Dr. James G. Kahn notes that “COVID-19 revealed a lot of vulnerabilities in our health care financing system. These are not new revelations, but [the pandemic] really exposed them in stark contrast.” He also reminds us that, while U.S. patients have suffered terribly, commercial health insurers have seen their profits double (or more).

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

https://medicareforallexplained.podbean.com

Market-driven health care at odds with an effective pandemic response

By Robert Devereaux, M.D.
The Roanoke (Va.) Times, December 13, 2020

The failings of an American health care system that is based on free-market principles have been laid bare by the worst pandemic the country has faced in 100 years. Most of us are familiar with the statistics that demonstrate that the U.S. has lagged far behind other industrialized countries in our ability to mount a coordinated response to the virus. We are near the top of the list for number of cases and deaths as a share of the population when compared to most developed countries. Compared to Canada we have had twice the death rate and a seven-day average of new cases that is nearly four times higher according to data from Johns Hopkins.

The reasons for our failed response are myriad but the shortcomings of a health care system that is based more on generating a profit than on improving the health of our citizens bears much of the blame. Undoubtedly lack of access to timely testing and care by the 30 million Americans who are still uninsured, and the 40 million more who are covered but still have trouble affording care due to prohibitively high co-pays and deductibles, has contributed to the nation’s poor response to the pandemic. Many of the millions who have lost their jobs have been unable to obtain affordable coverage. Undocumented immigrants have barriers to accessing health care, resulting in delays in testing and treatment for COVID, contributing to our poor performance.

Some private health insurance companies have profited mightily during the pandemic. According to an analysis published in the Journal of the American Medical Association, the profits made by United Health Care and Anthem doubled in the second quarter of 2020 as compared to the same period last year. This is due to decreased utilization of elective and preventive health care as our hospitals and clinics are dealing with the pandemic. Insurance companies are making record profits during a time when these resources should be going to fighting the virus or refunding premiums to patients who have taken economic hits during this difficult time.

Even with these large profits, I can attest as a physician practicing earlier this year in rural Southwest Virginia where high-speed internet is lacking, many insurance companies would reimburse telephone visits at only a small fraction of what they would pay for an in-office visit. On the other hand, Medicare and Medicaid, the “government-run” plans plans, would reimburse fully for the phone visits, as has also been the practice in Canada where physician practices and hospitals have fared fairly well due to the difference in how that country funds its health care system.

The only way our country will ever be able to address future pandemics — in addition to the chronic problems of limited access to health care by many, health care outcomes that are among the worst in the developed world, high costs, and iniquities in delivery of care to persons of color — is to revamp the way we finance health care. Single-payer health care or “Medicare for all” as proposed in legislation sponsored by Democrats in both the House and the Senate would provide care without out-of-pocket costs to all Americans. Savings from reduced administrative costs and profits estimated to consume over 30% of the current health care dollar would help extend coverage to all.

A single source of funding would also allow our country to devote more resources to public health and other preventative health strategies to improve the health of our population. It is time to separate health care financing from employment and remove the profit motive that is often at odds with providing the care that people really need.

Dr. Robert Devereaux is a member of Physicians for a National Health Program. He lives in Pembroke.

https://roanoke.com…

CBO: Medicare for All Reduces Health Spending

By Matt Bruenig
People’s Policy Project, December 11, 2020

Yesterday, the Congressional Budget Office (CBO) released an estimate of the cost of implementing a single-payer health insurance program in the United States. The CBO’s report is more exhaustive than any other recent study on the subject and concludes that replacing our current system with a single-payer system would insure every American while reducing overall health spending in the country.

Modeling the cost of a single-payer program is relatively straightforward. You begin with the status quo health care system and then make educated guesses about the following questions:

  1. How many more units of health care services will be demanded and supplied when price barriers are removed?
  2. How much more efficient will health insurance administration be after the enrollment and payment systems are radically simplified?
  3. How much money will be saved by reducing the payments rates for health care providers and drug companies?

The CBO answered these questions for four different single-payer designs and found that a single-payer system would save $42 billion to $743 billion in 2030 alone.

Separately, the CBO took its most costly single-payer option — a program with high payment rates to providers and drug companies and low cost-sharing for individuals — and added long-term support and services (LTSS) to it to produce a fifth cost estimate. In that estimate, total spending rises by $290 billion.

The CBO option that most closely approximates current Medicare for All proposals is Option 3, which features low payment rates and low cost sharing. That option produces $650 billion of savings in 2030. Adding LTSS to that option, which also approximates what many current Medicare for All proposals does, looks like it would bring the savings down to around $300 billion.

More interesting than the CBO’s headline finding is the extremely detailed inquiry they do into each specific variable and the comparison of the results of their inquiry to the results of other similar studies.

The CBO option that most closely approximates current Medicare for All proposals is Option 3, which features low payment rates and low cost sharing. That option produces $650 billion of savings in 2030. Adding LTSS to that option, which also approximates what many current Medicare for All proposals does, looks like it would bring the savings down to around $300 billion.

More interesting than the CBO’s headline finding is the extremely detailed inquiry they do into each specific variable and the comparison of the results of their inquiry to the results of other similar studies.

The thing that stands out the most to me in this comparison is CBO’s deep dive into administrative costs. Medicare for All advocates have historically pointed towards the 2 percent administrative costs of traditional Medicare as what we should expect in a Medicare for All system. Critics of this view have typically argued, among other things, that Medicare’s low administrative costs are a mirage driven by the fact that their per-enrollee administrative costs are being divided by disproportionately large per-enrollee health care utilization.

This rebuttal never really made any sense. Private Medicare Advantage plans have a similarly sick and elderly enrollment population, but manage to spend a whopping 13.7 percent of their revenue on administrative expenses. The CBO’s analysis, which starts with the current Medicare administrative costs and then determines how each element of those costs would go up or down in a single-payer system, seems to put this claim to bed once and for all.

Indeed, the CBO finds that the current Medicare administrative costs that are often touted by advocates are actually higher than the administrative costs you would expect in a single-payer system because a large share of those costs are tied up in tasks like eligibility determination and collection of Medicare Part B premiums that would no longer exist in a Medicare for All system.

Thus, the payer administrative costs we could expect under single-payer are not the 6 percent touted by Urban and Mercatus. They are not even the 2 percent of the traditional Medicare program. Rather, they are more like 1.5 to 1.8 percent. These other estimates are therefore missing hundreds of billions of dollars of savings per year on this item alone.

Overall, the study confirms what serious Medicare for All analysts have known for some time now. It is possible to provide high-quality public health insurance to every person in the country while also saving money overall on health spending. The barriers to the policy are not technical deficiencies or costs, but rather political opposition from Republicans and conservative Democrats who would rather spend more money to provide less health care.

https://www.peoplespolicyproject.org…

CBO’s methods of analyzing single payer Medicare for All

How CBO Analyzes the Costs of Proposals for Single-Payer Health Care Systems That Are Based on Medicare’s Fee-for-Service Program

By CBO’s Single-Payer Health Care Systems Team
Congressional Budget Office, December 2020

Abstract

In this paper, CBO describes the methods it has developed to analyze the federal budgetary costs of proposals for single-payer health care systems that are based on the Medicare fee-for-service program. Five illustrative options show how differences in payment rates, cost sharing, and coverage of long-term services and supports under a single-payer system would affect the federal budget in 2030 and other outcomes. CBO’s projections of national health expenditures under current law are a key basis for the estimates.

CBO projects that federal subsidies for health care in 2030 would increase by amounts ranging from $1.5 trillion to $3.0 trillion under the illustrative single-payer options—compared with federal subsidies in 2030 projected under current law—raising the share of spending on health care financed by the federal government. National health expenditures in 2030 would change by amounts ranging from a decrease of $0.7 trillion to an increase of $0.3 trillion. Lower payment rates for providers and reductions in payers’ administrative spending are the largest factors contributing to the decrease. Increased use of care is the largest factor contributing to the increase.

Health insurance coverage would be nearly universal and out-of-pocket spending on health care would be lower—resulting in increased demand for health care—under the design specifications that CBO analyzed. The supply of health care would increase because of fewer restrictions on patients’ use of health care and on billing, less money and time spent by providers on administrative activities, and providers’ responses to increased demand. The amount of care used would rise, and in that sense, overall access to care would be greater. The increase in demand would exceed the increase in supply, resulting in greater unmet demand than the amount under current law, CBO projects. Those effects on overall access to care and unmet demand would occur simultaneously because people would use more care and would have used even more if it were supplied. The increase in unmet demand would correspond to increased congestion in the health care system—including delays and forgone care—particularly under scenarios with lower cost sharing and lower payment rates.

Working Paper 2020-08 (208 pages):
https://www.cbo.gov…

Blog by CBO Director Phillip Swagel:
https://www.cbo.gov…

Comment:

By Don McCanne, M.D.

As stated in the Abstract, “In this paper, CBO describes the methods it has developed to analyze the federal budgetary costs of proposals for single-payer health care systems that are based on the Medicare fee-for-service program.” Since their reports are provided for Congress, the emphasis is on federal spending rather than on our total national health expenditures. There should be no surprise that they do predict an increase in federal spending since the design of a single payer system does precisely that; it shifts health care spending to the federal government since financing is primarily through the tax system.

They do indicate that total national health expenditures would not change much when compared to our current spending, estimating somewhere between a decrease of $0.7 trillion to an increase of $0.3 trillion. They may have underestimated the savings in that, though they do credit the savings from the reduction of the administrative waste of the private insurers, they do not seem to quantify the very large savings from the reduction of the administrative burden placed on the health care delivery system, though they do acknowledge it as being a source of improved efficiency in the system. A recent systemic review by Christopher Cai, James Kahn and colleagues of twenty economic analyses of single payer indicate that they would all result in long-term net savings.

In indicating that increased demand would produce “increased congestion” in the health care system, they seem to underestimate the ability of the system to self-correct by giving a lower priority to services that are not of much benefit, though queue management is still important in any system.

Some of the experts consulted previously have been criticized for some of their assumptions in their single payer work, and others are experts in the aged and long term care and are not noted for their single payer work. There is also a notable absence of other academics who have long-standing reputations for their credible contributions to the single payer literature. In spite of that, this CBO report is still very useful in that it does what it says it does; it provides a description of CBO’s methods of analyzing single payer and thus would be helpful in understanding future single payer reports from them.

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

Insurers take advantage of Medicare funds

By Michael C. Huntington, M.D.
Albany (Ore.) Democrat-Herald, December 11, 2020

Have your mailbox and TV been inundated lately with Medicare Advantage offers? The healthy and happy-looking actors might make you think the “advantage” will be yours.

What is Medicare Advantage? Traditional Medicare as created in 1965 was a simple and effective system. Millions of seniors no longer had to use up their life’s savings to pay for health care. Traditional Medicare helped them ascend out of poverty and avoid the “poor house” that my grandparents used to talk about.

Then, in 2003, insurance companies came up with a way to siphon money from the Medicare stream. Setting loose multiple lobbyists per member of Congress, they created Medicare Advantage, a privatized form of Medicare. You turn over your Medicare money and coverage to an insurance company and you get a few perks in return. What could possibly go wrong?

Lots, as it happens. Advantage plans, by necessity and like all commercial health insurance plans, put company profits above your health. Companies garner unjustifiably high per-member payments from Medicare funds and keep more than they should. They exaggerate and upcode clients’ illnesses to charge more. They cherry-pick the healthy and lemon-drop the unhealthy clients. They restrict access to care by setting up narrow provider networks and pre-authorization hurdles. They squeeze clients out of Advantage plans as networks and formularies end up being too narrow to meet client needs for extended or specialized care. They generate a 10% administrative overhead compared to 2-3% for traditional Medicare. Lastly, companies abandon unprofitable geographic regions at will, leaving clients to scramble for new doctors and other caregivers.

Because Medicare Advantage is so lucrative, it can sometimes reimburse providers more than traditional Medicare can. Ironically, the lucre is in effect stolen from traditional Medicare funds.

You may like your Advantage plan now, but for reasons mentioned above, you may not like its long-term effects for Medicare or yourself. Ask your broker, “Is Medicare Advantage right for me?”

Instead of Medicare Advantage, I depend on traditional Medicare. Traditional lets me choose the provider I want instead of being confined to a narrow network of providers or other restrictions that might effectively exclude me. I recommend preserving traditional Medicare, improving it, and extending it to all, as prescribed in H.R. 1384, the Medicare for All Act of 2019.

H.R. 1384 is endorsed by Sen. Merkley and Reps. DeFazio, Blumenauer and Bonamici. Please thank them and urge Sen. Wyden and Rep. Schrader likewise to endorse this bill.

H.R. 6906, the Emergency Benefits Act of 2020, also deserves our support. It would require the Department of Health and Human Services to pay the out-of-pocket expenses of persons receiving medically necessary care during the COVID-19 pandemic. It guarantees care for those who were uninsured before the pandemic or have lost insurance because of job loss during the pandemic. Both senators and the three representatives above endorse H.R. 6906.

In Oregon, the ORS Chapter 629 Universal Health Care Task Force (SB 770 Task Force) is designing a state-based universal health care system. Please follow its work on the Oregon Health Authority Office of Health Policy website and let the task force hear your opinions. Bruce Goldberg, MD, former director of the Oregon Health Authority, chairs the task force. Ed Junkins, MD, of Corvallis is vice chair.

The task force is designed and committed to achieve a true advantage for Oregonians, not an advantage for insurance companies.

To learn more about the task force, please attend a virtual town hall 7 p.m. on January 6. For details and registration, go to the mvhca.org website.

Dr. Michael C. Huntington is a retired radiation oncologist and longtime member of Mid-Valley Health Care Advocates.

https://democratherald.com…

Northern New England PNHP Summer Internship 2025

The Vermont, Granite State (New Hampshire), and Maine chapters of Physicians for a National Health Program are once again offering five-week, full-time internships for at least six students during the summer of 2025. Accepted medical students and students of other health professions will each receive a stipend of $1,500. With the video-conference format we seek a seminar atmosphere, encouraging interns to interact with eminent guest speakers and discussion leaders from medicine, industry, and government. We make an effort to include viewpoints from all sides of a given issue.

The primary goal of the internship is to cultivate leaders who will fuse a solid understanding of health policy with the basic values of kindness and human decency so that they can transform the U.S. health care system to better serve the needs of all.

The dates of the internship will depend on the dates that applicants are available, since medical school academic calendars vary. Typically the internship starts sometime between June 1 and the day after Father’s Day, with some orientation time before the first day and a holiday on the Fourth of July or on the day Independence Day is observed.

If you are passionate about achieving health care for all in a fiscally-responsible way, but the size of the stipend prohibits you from applying, please contact internship program preceptor Dr. Betty Keller.

There are three components to the internship:

1. READINGS/DIDACTIC AND DISCUSSION SESSIONS ON HEALTH POLICY

Our prime aim is to give the student a solid foundation in current health policy. This comes from reading, lectures, and discussions on the following topics:

  • Health care systems: How all other developed countries provide coverage to all their citizens throughout the life cycle at far lower cost compared to the U.S.
  • The hodge-podge tactics for delivering and financing health care in the United States; our reliance on federal funding; and the obstacles to state-based reform.
  • The history of the U.S. multi-payer system, including reform efforts at both the national and state levels.
  • The effectiveness of both demand-side reforms (Medicaid, Medicare, Obamacare) and supply-side reforms (community health centers, Veterans Administration, Indian Health Service, etc.).
  • “Market failures” encountered when attempting to apply market forces to the health sector. 
  • Disparities in the delivery of medical services and in outcomes in different U.S. communities and populations.
  • Advantages and shortcomings of various reform models:
    • Voucher-based reforms
    • Categorical reforms (income-based, disease-based, etc.)
    • Universal reforms, including single-payer reform
  • Cost-control strategies, including:
    • ACO/HMO structures 
    • Bundled payments
    • Global budgeting for hospitals
    • Centralized vs. free-market approaches to distribution of health resources
    • Approaches toward reducing the cost of pharmaceuticals, medical supplies, and equipment
    • Current sources of waste in the U.S. health care system
  • The relationship between reform and planning of health information systems and health coverage.
  • The business model of the pharmaceutical industry, including research priorities, marketing strategies, and factors that lead to extravagant drug prices.

This educational component will include a substantial reading and audio-visual media curriculum.

2. VIDEO CONFERENCE MEETINGS WITH THOUGHT LEADERS FROM GOVERNMENT; THE PRIVATE SECTOR; AND SAFETY NET AND OTHER HEALTH INSTITUTIONS, AS WELL AS DISCUSSIONS WITH ACTIVISTS

Interns will interview physicians and other professionals working in community health centers, free clinics, a community outreach team, a concierge practice, and a Veterans Administration facility. They will interview hospital and private insurance administrators, as well as other private sector leaders. Interns will also meet with advocates on various sides of the health reform effort and with health sector leaders within state government.

3. LEADERSHIP DEVELOPMENT, ORGANIZING SKILLS & STRATEGIES TO FOSTER PUBLIC EDUCATION: PUBLIC SPEAKING, WORKING WITH MEDIA, OUTREACH TO PEERS

  • Didactic sessions are organized around strategies for working with traditional and social media; using local cable access TV or radio for education and advocacy; and organizing peers/developing SNaHP chapters.
  • Interns are encouraged to develop an outreach/education plan directed at fellow medical students and other health professions students.
  • Interns are responsible for completing two projects during the internship. Preceptors must approve the project choice, and must approve whether they work with partners or a small group, if requested.
    • The first is a presentation on the health care system of another country. If there are more than 6 interns, other options for a topic may be offered. Each intern will present their work to preceptors and other interns around the third week of the internship. We anticipate that interns will want to give their presentations to peers or the public in the fall.
    • The second project is a “Single Payer 101” presentation intended for an audience of the intern’s choice (e.g. peers, religious congregations, business associations, the general public, etc.). Each intern will give their presentation to preceptors and other interns in the fourth or last week of the internship, and again to their preferred audience in the fall. Alternative projects may be considered, especially if a PNHP member already gives a SP 101 talk at the intern’s school, or another intern from the same school is giving that SP 101 talk.

REQUIREMENTS

Electronics: All interns will need their own computer and access to a broadband internet connection permitting participation by both video and audio. Some preceptors and guest speakers are discouraged by a computer screen half-filled with black boxes, so plan to have your video on.

This is a full-time program, with interns accountable to the program Monday through Friday from 9:00 a.m. ET to 5:00 p.m. ET, but scheduled videoconference time is generally 4 to 6 hours per workday. Occasionally, a speaker may only be available at 7:30 a.m. ET, or may not be able to meet until after 5:00 p.m. ET. 

Interns should think of the program as being as rigorous as a graduate program, with reading and projects that may require working evenings or weekends, but any weekend events would be optional. As with a graduate-level seminar, attendance includes active participation in discussions.

The skills listed in the application are not prerequisites for this internship. They are asked merely to have an idea of where our interns are starting from, which interns might be of help to each other, and which skill instruction may be desired in our curriculum.

ELIGIBILITY

Students from any medical school or other health professions school are eligible to apply. Students accepted to medical school, to start in the fall of 2025, are especially encouraged to apply.

APPLICATIONS

If you have a resume, please review the application, fill out the first section, then be sure to also include other sections that are not in your resume.

Please submit the application via this Google form and send a cover letter, and your resume if you have one, to 

On the application, for education and work experience that is on your resume, you may simply state “see resume.”

We typically don’t start interviewing until after December 28. You can send your application without naming your references to expedite, and send that information by email as soon after as you can.

We will interview by telephone or video conference. Ideally, each intern is interviewed by two preceptors. We plan to accept four interns in January or February and additional interns in March or April.

We look forward to meeting and working with students from the classes of 2028 and 2029!

PRECEPTORS, NORTHERN NEW ENGLAND INTERNSHIP PROGRAM

Betty Keller, M.D., President, Vermont PNHP
bjkellermd@gmail.com

Marvin Malek, M.D., M.P.H., Past President, Vermont PNHP
mmalek66@gmail.com

Ken Dolkart, M.D., Granite State PNHP
kenneth.dolkart@gmail.com

Henk Goorhuis, M.D., Maine AllCare
henkmaine@gmail.com

Ted Cody, M.D., Sc.D., Secretary, Vermont PNHP
tscody@vermontel.net

STUDENT TESTIMONIAL

Medical student India Claflin describes her experience as an intern with the PNHP Northern New England 2021 summer internship program.