University of Chicago Press Journals, American Association for the Advancement of Science EurekAlert!, July 31, 2020

According to recent Gallup polls, socialism is now more popular than capitalism among Democrats and young people, and support for “some form of socialism” among all Americans is at 43% (compared to 25% in 1942). Policies that went unmentioned or were declared out-of-bounds in elections four years ago–a federal jobs guarantee, single-payer health care, free college, massive tax hikes on the rich, and the Green New Deal–are commonplace in Democrats’ 2020 campaigns.

However, in “Freedom Now,” a new paper published by Alex Gourevitch and Corey Robin in Polity’s May Symposium on the Challenges Facing Democrats, there is still no clear, unifying idea behind this political shift. “One has not heard anything on the order of Franklin Roosevelt’s Commonwealth Club speech or Reagan’s story of the free market,” the authors write. If these policies are to have a chance of breaking through, they will need a grounding principle, or ideology name the enemy, organize the policies, orient the actions, state the destination, and provide the fuel for the movement.

Gourevitch and Robin propose that that idea is freedom. “While the left once understood freedom as emancipation from the economy, the right spent the twentieth century neutralizing and appropriating the idea of freedom by reinventing the economy as the true site of freedom.”

To reclaim freedom as a value of the left, the authors believe the first place to start is the unfreedom of the workplace. “In nearly every capitalist country, one of the leading elements of the legal definition of employment is subordination to the will of a superior.” That can mean that employees must urinate–or are forbidden to urinate. It can mean that they should be sexually appealing–or must not be sexually appealing. They may be told how to speak, what to say, whom to say it to, where to be, where to go, how to dress, when to eat, and what to read–all in the name of the job. “But isn’t the worker free to leave a bad boss? Formally speaking, yes,” the authors write. “But even if they are free to exit this workplace, they are not free to exit the workplace.”

Reclaiming “freedom” names the problem that an increasing number of people face today: systemic unfreedom in the neoliberal economy. By confronting that unfreedom, the left can do more than identify, in a coherent and cohesive way, the myriad problems that individuals are currently facing. The authors find the seeds of that idea in Bernie Sanders’s rhetoric about being “organizer in chief,” and in proposals from the Warren and Sanders camps that would strengthen workers’ right to strike and organize.

However, they note, “A real politics of freedom posits a belief in the capacity of people to revise the terms of their existence and a commitment to the institutions that make these collective revisions possible.” In other words, freedom is best realized not through tending our own gardens but through disciplined commitment and collective struggle, in activities like mass strikes and party politics. “These democratic struggles are not simply expressions and experiences of freedom, though they are that. They are also the means to the freedoms people deserve.”

https://www.eurekalert.org…

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Symposium on the Challenges Facing Democrats: Freedom Now

By Alex Gourevitch, Brown University and Corey Robin, Brooklyn College and the Graduate Center, City University of New York
University of Chicago Press Journals, Polity, July 2020

Abstract

Left-wing politics is resurgent. Self-proclaimed socialists are unexpectedly popular. Proposals like universal health care are a commonplace of Democratic campaigns. But there is not yet a clear, unifying idea behind this political shift. We propose that that idea is freedom. While the left once understood freedom as emancipation from the economy, the right spent the twentieth century neutralizing and appropriating the idea of freedom by reinventing the economy as the true site of freedom. To reclaim freedom as a value of the left, we have to begin with the daily experience of most people: the unfreedom of the workplace. The authoritarian organization of work is not just an offense against freedom; it also helps us understand how freedom requires emancipation both from the economy and within the economy, and why that emancipation requires mass struggle.

https://www.journals.uchicago.edu…

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Comment:

By Don McCanne, M.D.

In simplified terms, “Freedom Now,” by Alex Gourevitch and Corey Robin, discusses how the political right captured the rhetorical concept of freedom, but that it can be reclaimed by the left by escaping the unfreedom of the workplace. To try to understand what this means, both the press release and the abstract of the article are reproduced above, since rephrasing helps. Actually, I found that I had to read the full article (available for free at the journals.uchicago.edu link above) – twice.

In my years of advocating for a single payer national health program, I’ve found that it is often difficult to find a common ground of communication with conservatives, libertarians, and even neoliberals. When I extol the virtues of Medicare for All, one common response from the right is that having the government involved takes away your freedom. That response, of course, has become a meme.

But Gourevitch and Robin show us that it is the unfreedom of the workplace from which we need relief. They conclude, “A real politics of freedom posits a belief in the capacity of people to revise the terms of their existence and a commitment to the institutions that make these collective revisions possible. In this instance, that translates into the belief that freedom is best realized not through tending our own gardens but through disciplined commitment and collective struggle, in activities like mass strikes and party politics. These democratic struggles are not simply expressions and experiences of freedom, though they are that. They are also the means to the freedoms people deserve.”

Social programs provided by the government but not dependent on the workplace, such as single payer Medicare for All, Social Security retirement, unemployment insurance, disability insurance, long term care, public education including that beyond the primary and secondary levels that eliminates the bondage of student loans, federal jobs guarantee, food security programs, guaranteed housing, progressive tax policies, and the like – dare we use the term “socialism” – provide freedom by freeing us up from the unfreedom of the workplace advocated by those on the right who support the capitalistic neoliberalism of the marketplace workplace. With appropriate social programs, capitalism, markets and the workplace still work for us, but they don’t take away our freedom.

Read the full article. Twice. Or three times. Freedom belongs to all of us. When we see that this disciplined commitment and collective struggle when acted out are the means to the freedoms people deserve, we will be able to shout out the words promulgated by Martin Luther King, Jr.:

Free at last! Free at last! Thank God Almighty, we are free at last!

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By Stuart M. Butler, Ph.D.
JAMA Health Forum, July 30, 2020

The coronavirus disease 2019 (COVID-19) pandemic is forcing a much-needed questioning of the US health system. What is the right balance of authority between the federal government and the states? How should the profound inequities and gaps in the system be better addressed? Should emergency regulations, like those allowing more telemedicine and flexible funding, become permanent features of the system?

Hopefully, this reassessment will encompass a constructive conversation about the basic structure of the US health system and how it can be based on a more robust chassis. What should that guiding framework be? Although I view the system though a center-right lens, I believe a variant of the Medicare-for-all idea could prove to be a new chassis that can attract broad support.

In practice, unlike most high-income countries, the US has several different health systems for different segments of the population—each with distinctive rules, subsidy arrangements, and eligibility criteria. There is 1 system for poor individuals; an employment-based system for most working individuals and their families; and yet another for elderly individuals. Transitioning between these systems, as almost all US residents must do at some point, often means disruptions in coverage and care. Millions also continue to fall through gaps between these systems. Moreover, the amount of assistance available to individuals seeking coverage differs greatly depending on such circumstances as geography and work status.

Many progressives have responded to this patchwork by calling for Medicare to become the chassis for the whole system. However, the Medicare-for-all proposals advanced by such politicians as Sen Bernie Sanders (I, Vermont) and Sen Elizabeth Warren (D, Massachusetts) have encountered skepticism from many liberals, as well as heavy criticism from conservatives.

Concerns About Medicare for All

One objection is the enormous increase in federal expenditure that would be involved in such a switch, and although supporters point to the large savings in private expenditures, the net costs depend on many considerations and design features.

Another concern, applying to some versions of Medicare for all, is that although the Medicare benefit package is comprehensive, traditional Medicare has significant out-of-pocket costs for all but the lowest income beneficiaries (who qualify as “duals” for overlapping Medicaid coverage). This feature effectively requires seniors to purchase private “Medigap” coverage as a supplement.

A third concern is disruption. This is the other side of the coin associated with having multiple health systems in the US; Medicare for all would mean big changes for most individuals with existing coverage.

However, it is important to remember that even Medicare is really 2 distinct systems. The focus of Medicare-for-all proposals is traditional Medicare, which is a fee-for-service program with a detailed payment schedule administered by the government. But in parallel with this is Medicare Advantage, which operates differently from traditional Medicare with private plans receiving a single capitated payment for each beneficiary enrolled in their plan, adjusted according to the beneficiary’s general health condition.

Medicare Advantage as the Framework

Medicare Advantage for all could be a good starting point for a bipartisan discussion on creating a new framework for the US health system. Unlike the higher-profile Medicare-for-all approach, a Medicare Advantage–for-all approach would have several advantages. For instance:

Medicare Advantage has wide popular support as well as broad political support. Medicare Advantage enrollment has been growing rapidly, doubling in the last decade, with the proportion of Medicare beneficiaries in such plans now exceeding 34% and rising. Moreover, Republicans as well as Democrats have supported and expanded Medicare Advantage, and the idea of making Medicare Advantage plans available to younger US residents has begun to intrigue some reformers on the right.

The capitation system permits competing Medicare Advantage plans to offer a variety of benefits beyond a required core of basic benefits. Moreover, in contrast to traditional Medicare’s rigid and detailed payments system, it allows plans to explore different payments as a means of achieving greater efficiency and beneficiary satisfaction.

In contrast with the design of traditional Medicare, Medicare Advantage plans are generally consistent with the growing managed care pattern in nonelderly coverage, including within the employer-based system. Today, about 90% of Medicaid beneficiaries are enrolled in some form of managed care. Meanwhile, about two-thirds of workers with employment-based plans are enrolled in health maintenance organizations or other network coverage that is similar to most Medicare Advantage plans. Medicare’s income-adjusted premiums are also broadly compatible with the structure of income-based subsidies available for plans in state health insurance exchanges, and many insurers offer Medicare Advantage and health insurance exchange plans that have similar designs. Thus, for a large proportion of households, transitioning from their existing coverage to coverage more like Medicare Advantage plans would not involve a big adjustment.

Recent changes in laws and regulations allow Medicare Advantage plans to include more nonclinical services that can influence health, such as nonurgent transportation, nutritional services, and even some simple home modifications to reduce the risk of injuries. This reflects the growing interest in addressing so-called social determinants of health.

Gradual, Not Radical

Choosing Medicare Advantage as the organizing theme for reforming the whole US system does not necessarily imply there must be radical legislation that literally replaces all existing coverage with the current Medicare Advantage program. That would be unnecessarily disruptive and regimented. Rather, it should mean gradually adapting existing forms of coverage so that over time they become very similar to Medicare Advantage, and there would essentially be no change in coverage as individuals change jobs, lose their jobs, or retire.

One step toward that outcome would be to merge state exchange plans with Medicare Advantage plans in the state. Another would be to slowly reconcile the subsidy system available for exchange plans with the tax benefits for employer-sponsored insurance, such that a similar structure of income-related subsidies would apply to everyone enrolling in insurance. Seniors would continue to receive assistance toward the cost of coverage that is reflective of the payroll taxes they paid and the national commitment to their health care, at least until there was agreement on a more comprehensive revenue and financing system, and the state-federal share of support would continue for lower-income households. A third step would be to move further toward the place of work being just a convenient location to facilitate plan selection, with employers handling the mechanics of government subsidies and payments by workers, and to move away from employers as plan sponsors.

None of these steps are small details, of course. They are major issues and would involve contentious debate. But to reach eventual agreement on big changes in society, it is necessary to have a framework in mind that is likely to command broad support and that the current system could evolve toward with minimum disruption. Medicare Advantage for all is such a framework. Medicare for all is not.

https://jamanetwork.com…

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Medicare Advantage is a Shell Game

By Stephen Kemble, M.D., Physicians for a National Health Program
JAMA Published Comment, July 31, 2020

A fundamental problem with competing private plans in health care is that too much of the per-beneficiary financial risk is predictable due to pre-existing conditions and social determinants of health, so that the primary driver of competition is to avoid risk. This means “cherry picking” the healthy and “lemon dropping” sicker and costlier patients from Medicare Advantage (MA) plans. Risk adjustment is far too crude to prevent this, and efforts to make it more accurate encounter prohibitive complexity and administrative cost. There is pervasive evidence that MA plans do selectively enroll healthier-than-average Medicare beneficiaries, and sicker, more complex patients selectively disenroll from MA plans. There is also extensive evidence of increased coding intensity in MA plans to beat risk adjustment formulas, and MA plans carry much higher administrative cost than traditional Medicare. The outcome is that the MA program has never saved money for the Medicare program as a whole, and MA claims of more cost-effective care are much better explained by the favorable risk pool the MA plans have been able to secure.

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Comment:

By Don McCanne, M.D.

In response to the strong support of single payer Medicare for All there have been several sources recommending instead Medicare Advantage for All – using private insurance instead of a public insurance program based on an improved version of the traditional Medicare program. This particular article is important because of its author, Stuart Butler.

Stuart Butler was the primary architect of the Heritage reform proposal that led to the Patient Protection and Affordable Care Act (ACA), aka Obamacare. Butler’s views are more moderate than those of the conservative Heritage Foundation and thus he transferred to the centrist Brookings Institution. In this JAMA article, he labels himself as viewing the system through “a center-right lens.” As his article indicates, he rejects a publicly-administered Medicare for All program but rather supports a market of competing private plans. His primary innovation for ACA was the exchanges (marketplace) for the private plans that would receive government subsidies to make them more affordable. The market of private Medicare Advantage plans have far more similarities with the ACA exchanges than there are differences.

There are a great multitude of reasons why the private Medicare Advantage plans are vastly inferior to a well designed improvement in the traditional Medicare program. The JAMA comment provided by Stephen Kemble explains probably the most fundamental flaw, and it’s a matter of ethics. Medicare Advantage plans have profited by enrolling healthier, less expensive patients, and by gaming risk adjustment to qualify them for higher payments. The U.S. is noted for the profound administrative waste in its financing system, and Medicare Advantage plans add significantly to that waste, not only for their own excessive costs but also for the heavy financial burden they place on the health care delivery system.

Amongst other reasons that Medicare Advantage plans are inferior include: their restricted provider networks frequently do not allow access to the care that you need; coverage may be unstable as plans enter and leave markets at their will; rules may prohibit enrolling in supplemental Medigap plans if returning to traditional Medicare; plans may profit by withholding beneficial care that you did not know was available and appropriate for your circumstances; plans may not have contracts with centers of excellence; etc., etc.

Responding to a few additional points made by Stuart Butler:

• Butler says that Medicare for All has encountered skepticism from many liberals, but it is really some of the neoliberals and not the progressives who prefer market solutions who have been less supportive; the majority of Americans support Medicare for All
• Butler cites the objection to the increase in federal expenditures, but he concedes the offset of the large savings in private expenditures
• He notes that traditional Medicare has significant out-of-pocket costs requiring the purchase of Medigap plans, but a well designed Medicare for All program folds in the benefits of Medigap plans plus adds other important benefits, eliminating most out-of-pocket costs (except for the equitable taxes used to fund the system)
• He states that Medicare for All is disruptive, but, like John Lewis has said, this is good trouble – patients have their full choice of providers while eliminating financial barriers to care; that’s disruption we would all like to have
• He states that Medicare Advantage has popular support, but that is primarily because Congress provided an unfair competitive edge to private plans by enabling them to offer their plans at low premiums – virtually all enrollees would prefer traditional Medicare free at the time of service with a full choice of providers, if it were available, as it would be with Medicare for All
• He notes that Medicare Advantage can offer additional benefits beyond the core benefits, but if they are benefits that should be covered with taxpayer funds, then, in fairness, Congress should offer the same benefits through the traditional Medicare program
• He describes Medicare Advantage managed care as being advantageous, not acknowledging the managed care backlash of the 1990s
• He suggests merging ACA exchange plans with Medicare Advantage plans – of course he would

In conclusion, we tried Stuart Butler’s previous proposal, and we have a very expensive mess on our hands. Let’s not do that again. Let’s go straight to single payer improved Medicare for All. We need some good trouble.

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By Toren L. Fronsdal, Jay Bhattacharya, Suzanne Tamang
National Bureau of Economic Research, July 2020

Abstract

We study a unique all-payer data set spanning 38 states to examine the differences in inpatient reimbursement rates paid by traditional Medicare (TM), Medicare Advantage (MA), Medicaid, and private (under-65) insurers, and the differences in negotiated rates across the 60 largest private insurers. After controlling for enrollee and hospital mix, we find that private insurers pay 37 percent more than TM, and MA pays 10 percent more than TM for the five most common inpatient diagnoses. The correlation in risk-adjusted payments by private insurers and by TM at the same hospital for the same diagnosis is only 0.10. There is significant variation in negotiated prices within and across private payers. Among the five largest US insurers, the most expensive insurer negotiates prices that are 5-26 percent higher than the mean price for the 20 most common inpatient diagnoses. Additionally, we find a 10 percent increase in insurer market share corresponds to a 7 percent decrease in inpatient negotiated prices and a 10 percent decrease in the standard deviation of prices. This finding suggests that increased insurer market power allows payers to negotiate prospective payment contracts – rather than the more common fee-for-service payments – thereby offloading financial risk to providers.

From the Conclusion

We find an inverse relationship between insurer market share and negotiated prices. A 10 percent increase in insurer market share is associated with a 7 percent decrease in negotiated prices. Additionally, a 10 percent increase in insurer market share is associated with a 10 percent decrease in the standard deviation of negotiated prices at a provider. This suggests that insurers with greater market share are able to negotiate favorable payment structures that offload financial risk to the providers.

https://www.nber.org…

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Comment:

By Don McCanne, M.D.

Health care providers are paid to provide health care. Insurers are paid to accept and manage risk of health care costs. This study indicates that insurers with greater market share are able to offload financial risk to the providers. Then why do we need private insurers? About $600 billion of administrative costs could be recovered if we got rid of the private insurers – funds which could be used to expand comprehensive health care to everyone. The government should be the logical agent to accept and manage risk and would be under single payer Medicare for All.

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The Value in Health Care Act aims to increase APM participation by extending incentives and correcting arbitrary qualification standards under MACRA and the Medicare Shared Savings Program.

By Jacqueline LaPointe
REVCYCLE INTELLIGENCE, July 28, 2020

A bipartisan bill introduced late last week aims to increase alternative payment model (APM) participation by making “commonsense changes” to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.

Specifically, the Value in Health Care Act seeks amendments to many program parameters of Medicare’s APMs, including MACRA’s Advanced APM pathway and the Medicare Shared Savings Program (MSSP). Among the changes would be a six-year extension of the 5 percent incentive payment for Advanced APM participants and lower thresholds for Advanced APM participation from 75 percent to 50 percent of Medicare patients in performance year 2021.

HHS would also be able to increase the threshold by no more than 5 percent each performance year under the bill.

The bill also intends to increase accountable care organization (ACO) participation in the MSSP by increasing shared savings rates for shared savings-only ACOs. The levels would be at least 50 percent for ACOs in Levels A and B of the BASIC track and 55 percent for those in Levels C and D.

The shared savings rate would be at least 60 percent for ACOs in Level E.

Also, the bill would modify risk adjustment to allow for a greater score increase and adjust benchmarking to remove ACO beneficiaries from the regional reference population under regional benchmarking.

Additionally, the bill would eliminate the high-low revenue distinction implemented during an overhaul of the MSSP in 2018. If passed, all ACOs in the program would be subject to low revenue policies, according to the legislation.

The changes would incent participation in the models, while accelerating the transition to value-based care, Representatives Suzan DelBene (D-WA), Peter Welch (D-VT), and Darin LaHood (R-IL) said.

Signed into law in 2015, MACRA established a value-based reimbursement system for Medicare providers. The law created the Quality Payment Program, which includes the Merit-Based Incentive Payment System (MIPS) and the Advanced APM pathway.

While most Medicare providers participate in the Quality Payment Program via MIPS, policymakers intend for the program to ramp up participation in APMs through the Advanced APM pathway.

https://revcycleintelligence.com…

“Value in Health Care Act of 2020”:
https://delbene.house.gov…

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Association between specialist compensation and Accountable Care Organization performance

By Ishani Ganguli, MD, MPH; Claire Lupo, BBA; et al
HSR Health Services Research, July 27, 2020

Objective

To determine if Medicare Shared Savings Program Accountable Care Organizations (ACOs) using cost reduction measures in specialist compensation demonstrated better performance.

Conclusion

Incentivizing specialists on cost reduction was not associated with ACO savings in the short term. Further work is needed to determine the most effective approach to engage specialists in ACO efforts.

https://onlinelibrary.wiley.com…

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Comment:

By Don McCanne, M.D.

The policy community, with the support of the politicians, has been fixated on MACRA, ACO, MSSP, MIPS, APM, P4P, etc., etc. as a means of achieving value-based health care. So far the results have been very unimpressive, though some reports claim that the approach is about to show some benefit, so they wish.

As an example of how inadequate this approach is, the HSR study shows that incentivizing specialists has not been associated with ACO savings. If it is not working for specialized services, then it is not working, period.

Now the “Value in Health Care Act of 2020” is being introduced to provide some tweaks to the system in an effort to increase participation in these payment models. If you read the proposed legislation you will see that it will likely have very little net impact, but it will have been effective in further delaying truly beneficial reform such as the single payer model of Medicare for All. Sometimes it seems as if that is their primary goal after all.

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At least 360 Democratic delegates, mostly his supporters, have signed a pledge to oppose the Democratic platform unless it endorses single-payer.

By Holly Otterbein
POLITICO, July 27, 2020

More than 360 delegates, most of whom back Sanders, have signed on to a pledge to vote against the Democratic Party’s platform if it does not include support for “Medicare for All,” the petition’s organizers told POLITICO. They argue that single-payer health care is an urgent priority amid a worldwide pandemic and the biggest unemployment crisis since the Great Depression.

The warning is all but certain to set up a clash between Sanders’ most dedicated supporters and presumptive Democratic nominee Joe Biden, who opposes Medicare for All, at a time when the party is seeking to demonstrate unity ahead of its August convention. Though the petition signers have little chance of revising the platform to include Medicare for All support, they do have the numbers to draw attention to their protest and cause.

The left-wing groups Progressive Democrats of America and RootsAction.org are announcing Monday that they support the vow to vote against the platform if it doesn’t include Medicare for All. The Bernie Delegates Network, a coalition made up of hundreds of Sanders delegates, said it will also publicize the petition. Organizers expect those efforts will net hundreds more signatures, including from Biden delegates.

“The sea change that’s underway could swell as a result of this initiative,” said Norman Solomon, national director of RootsAction.org and a Sanders delegate. “It’s a reasonable hope that historians will look back at the next couple of weeks as a time when hundreds of delegates stepped forward and said, ‘This is a red line for a humane society and we’re not going to stop saying so.’”

Despite their frustration with Biden, progressive leaders behind the pledge all said they are voting for Biden and working to elect him.

https://www.politico.com…

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Comment:

By Don McCanne, M.D.

The majority of Democrats support Medicare for All, but the presumed candidate, Joe Biden, is opposed. The task force that was to bring the moderates and progressives together was deliberately weighted in favor of the Biden supporters, and thus they rejected a recommendation to include single payer Medicare for All in the party platform.

The progressives and many of the moderates have not given up. They are organizing to have Medicare for All included in the platform. At the same time, they agree to support Joe Biden regardless of the outcome. That should allay the fears of the moderates who are concerned that the progressives would split off, allowing Donald Trump to be reelected.

Joe Biden has made his position clear, so it really doesn’t matter whether or not single payer is included in the platform; Biden will oppose it. If the delegates do vote to include it in the platform, more progressives will stay on board. Although the progressive leadership will continue to support Biden, even without a single payer plank, the rank and file progressives may fail to vote or may cast a protest vote for a third party candidate.

Between the pandemic and the recession, Democrats really don’t need the additional hit of being told by their leadership that Medicare for All is off the agenda for the foreseeable future. We don’t need a superimposed second pandemic of clinical depression.

PNHP does not endorse any political party or candidate.

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