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Are members of the policy community driven by beneficial policies or by ideology?

Are members of the policy community driven by beneficial policies or by ideology?

What Values and Priorities Mean for Health Reform

By Katherine Baicker, Ph.D., and Amitabh Chandra, Ph.D.
The New England Journal of Medicine, September 16, 2020

Political slogans paint stark choices for health care reform: “Medicare for All” or “Free-Market Competition.” These slogans are designed to be simple and appealing — but vague enough to obscure the trade-offs involved, allowing listeners to fill in their own notions and masking varying beliefs. “Medicare for All” appeals to preferences for universal coverage, but sidesteps necessary trade-offs over which Americans may disagree. “Repeal and Replace” may appeal to skepticism about government’s role in health care, but leaves voters to imagine what the “replacement” might be.

The direction each of us would choose for our health care system depends on our answers to some fundamental questions: How much do we want to spend to expand coverage for low-income Americans? What health insurance features are most important to us? And what should the roles of government and the private sector be in making those decisions? Answering these questions involves wrestling with unavoidable trade-offs. Expanding insurance to cover more Americans will require deciding how generous that coverage should be, given competing priorities for public resources. Implementation of a single-payer plan as envisioned in some proposals would involve trade-offs between coverage features and costs. Similarly, free-market competition could drive down prices for some Americans, but leave care unaffordable for others. There is no single right answer to these questions, and slogans can’t tell us how to prioritize.

These slogans often paint a picture of a deeply divided America, while obscuring both shared priorities and disparate preferences. Enduring reform must be built on clear goals that guide the way we deploy inherently limited resources. Expanding public insurance means either spending less on other public programs or raising taxes. Having insurance with more generous coverage and lower copayments means paying higher premiums. Though there is ample room to compromise over policies that are designed to achieve shared goals, there is little prospect for consensus on reforms without agreement on what we want from our health system.

Several surveys track Americans’ views about the health care system, but they don’t generally capture the extent of agreement about these fundamental trade-offs. To help illuminate where Americans might agree or diverge on fundamental reform issues, in terms of both means and ends, we worked with the University of Chicago Harris School of Public Policy and the Associated Press–NORC Center for Public Affairs Research to assess these views (see the Supplementary Appendix for survey details). We fielded surveys of a nationally representative sample of more than 2000 Americans, with two waves in February 2020 and May 2020 spanning the explosion of the Covid pandemic, though there are of course limits to the generalizability of any two snapshots. To elucidate some central trade-offs involved in redistribution and plan design, we focused on three aspects of preferences and priorities: how altruistic Americans are, the importance they place on various features of insurance plans, and their beliefs about government’s effectiveness in improving the health care system.

Some observers argue that expanding insurance pays for itself, but there is little evidence to support this claim: expanding public insurance primarily benefits the people who gain coverage, and it requires additional spending. Support for expanding insurance must therefore be built on substantial altruistic concern about other people’s coverage. Perhaps surprisingly, our respondents were much more concerned about others’ access to affordable health care than about their own. Some 54% of participants who were asked how concerned they were about Americans without health insurance reported being very concerned, whereas only 24% of those asked how concerned they were about (potentially) being uninsured themselves reported being very concerned. Although participants who identified as Republicans were substantially less concerned overall about insurance coverage than those who identified as Democrats, both groups expressed greater concern for uninsured Americans broadly than for themselves.

But though there may be broad support for expanding coverage (albeit by varied mechanisms), the viability of a policy that would enroll the population in a single plan hinges on the alignment of people’s coverage preferences. As our results suggest, we all want different things from our health insurance plans — and our preferences vary in ways that don’t line up with our party affiliations. We asked participants which aspects of insurance plans were more important to them, focusing on the inherent trade-offs between costs and coverage (e.g., higher premiums for broader coverage versus lower premiums but restricted networks). There was no dominant view, with preferences almost evenly divided on multiple trade-offs (see table). For example, 47% of Democrats and 46% of Republicans said they would prefer to have an insurance plan with lower costs but more restrictions on covered care (vs. higher premiums but fewer restrictions).

Different reform proposals involve different mechanisms for making decisions about the trade-offs in resource use and plan features. The single-payer approach, for example, relies on government to have primacy in the health care system and to assume many of the functions of private insurers. When we asked participants whether they had greater faith in government or in the private sector to address health system problems, we found big differences in views about the government’s role in financing health care: 79% of Democrats thought the government was not spending enough on improving the nation’s health, while only 31% of Republicans concurred. Relatedly, 78% of Democrats thought that Americans should spend less on health care themselves but pay more in taxes, whereas only 37% of Republicans held this view.

We also saw a sharp partisan divide in faith in government as compared with the private sector to expand access, improve quality, and control spending: 72% of Democrats but only 33% of Republicans said they trusted the government more than the private sector to reduce costs. The pattern was similar for guaranteeing insurance coverage. But the majority of both Democrats and Republicans said they trusted the private sector more than the government to drive innovation, with only 35% of Democrats and 18% of Republicans saying the opposite.

If we want to improve our health care system, we must confront the difficult trade-offs inherent in the allocation of limited resources for potentially lifesaving care. If we want to expand coverage to people who can’t afford it, we have to prioritize making the resources available to do so. And if we want to have more expansive plan features and more generous coverage, we have to be willing to pay higher premiums.

Expanding insurance coverage is a priority that many of us share, but a one-size-fits-all single-payer plan is unlikely to meet everyone’s needs. Americans vary in their level of concern about coverage, cost, and quality, but most are more concerned about those features for others than for themselves. People’s divergent preferences regarding features of their own insurance highlight the value of having varied options to choose from — and the challenge of designing one insurance plan that would satisfy everyone.

Views regarding the government’s role in improving the system are sharply divided along partisan lines, in keeping with evidence from many polls about political divisions in support for particular health policy provisions. Such divisions suggest that the prospects for large-scale reforms remain limited by the political landscape. A successful approach might be to extend insurance coverage protections while maintaining a range of insurance plan designs and private-sector incentives to drive innovation. This approach differs from those taken by many other countries (and touted in many reform proposals), but is in fact the core approach in Medicare Advantage, Medicare Part D, and the Affordable Care Act — and it seems to match Americans’ priorities.

A natural question is whether these views have been substantially affected by Covid. In fact, our survey results from February and May were quite similar, which suggests that we may be capturing durable, fundamental preferences about health care and its delivery.

Political slogans simply don’t capture the types of reforms that are likely to achieve a nuanced set of objectives. Like the health care system itself, Americans’ priorities for it are complicated. Successful reforms must be informed by those priorities, but the trade-offs involved mean that they’re unlikely to take “simple,” polarized forms. The good news is that there are policy options available that preserve choice and promote innovation while honoring our shared commitment to making lifesaving care available to all.

https://www.nejm.org…

Supplemental Appendix: Survey Instrument:
https://www.nejm.org…

Comment:

By Don McCanne, M.D.

What do the American people really want out of their health care system? The authors of this NEJM article suggest that the prevailing rhetoric – such as “Medicare for All” and “Repeal and Replace” – may be simple and appealing, but that it is vague enough that it obscures the various health policy trade-offs involved. Of course, since they are simply labels, they communicate very little, but that does not mean that people do not have general concepts in mind when they use these terms. One term refers to a government-run health insurance program in which everyone is included, and the other refers to a program relying primarily on the private market for the financing of health care in which coverage is not guaranteed but is based on the ability to pay. These two approaches are driven more by ideology rather than by the specifics of beneficial health policy.

Policy considerations are fairly obvious. Should a health care financing system be designed to include everyone? Make it affordable for each of us? Provide us with choices of our hospitals and health care professionals? And so forth. Most people would agree that we should have a better health care system that’s affordable for all of us. But some people are hung up on the ideology. Should the system be based on social solidarity or based on free market competition?

Using an AP/NORC survey, people were asked about concerns about their own insurance coverage and concerns about Americans who did not have insurance coverage. Both Democrats and Republicans showed some concern about both, but they were more concerned about others having coverage than having their own. On this policy issue, individuals from both major parties seemed to be altruistic, though the Democrats were more so. When asked about plan variation in costs and coverage, there was no dominant view and no partisan preference. Yet Democrats greatly preferred to have the government spend more on health care, paid through taxes, whereas only about one-third of Republicans agreed. Also, Democrats had more faith in the government to expand access, improve quality and reduce costs than did the Republicans. Obviously, ideology does influence policy.

Since the authors are noted, influential authorities in the policy community, it is helpful to try to extract from this article what their approach would be. Policies may be beneficial or detrimental, which explains why there is little agreement when individuals are required to choose from various trade-offs (e.g., exposed to financial hardship or being denied benefits). On the other hand, political ideology is more fixed and thus drives greater divides.

In this case, the authors reject one-size-fits-all single-payer, presumably because people should have choices between the policy trade-offs, so theoretically we can ignore the ideological preference for a program that is taxpayer financed and publicly administered. Then the authors mention private insurance programs that are at least partially publicly financed to demonstrate their preference: Medicare Advantage, Medicare Part D, and the private plans of the Affordable Care Act, claiming that these seem to match Americans’ priorities. Is introducing into a public program the use of private insurance a beneficial policy preference or an ideological preference? Beneficial for whom? Not the patients.

What they miss is that policy trade-offs do not necessarily require giving away beneficial features. As an example, you do not have to reduce benefits to eliminate excessive cost sharing. You can trade off the profound administrative waste created by our private insurance industry in order to have a full benefit package without the necessity of including the financial barriers of cost sharing. And ideology? Why would we want to screw up beneficial health care policies with nutty right-wing innovations?

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Ask Trump and Biden how they’d fix gross inadequacies of US health care: Medical students

We hope Trump and Biden discuss health care in the first presidential debate. We're medical students who already see it's chaotic, costly and unequal.

By Rohit Anand, Dhiksha Balaji, Aparna Narendrula and Jasmine Serpen
USA Today, September 21, 2020

In medical school, we rely on acronyms to summarize critical aspects of complicated topics. We have one such acronym to describe key aspects that we hope our health care system will one day embody: USA — universal, simple, affordable. Today, health care in America meets none of these criteria. Our country is the only industrialized nation that has yet to commit to providing all of its residents access to affordable, quality care.

As medical students in Cleveland and leaders of our school’s health justice organizations, we find it fitting that the first 2020 presidential debate will be hosted on Sept. 29 on the Health Education Campus, an education hub we share with other health professional students.

Our half-billion dollar HEC stands in stark contrast to Hough, the neighborhood where our school is located. Despite being surrounded by multiple prominent hospital systems, Hough, a predominantly Black neighborhood, suffers from an infant mortality rate nearly four times higher than the national average, and at least 15% of its residents are uninsured. Health inequities continue to be overlooked and perpetuated by our system in Hough and the many other communities like it across the nation. They deserve better.

Red tape, chaos in US health care 

Given the debate location on a health care campus in a socioeconomically deprived neighborhood, amid a global pandemic, we sincerely hope that health care reform will be a key focus of the debate between President Donald Trump and former Vice President Joe Biden.

The pandemic highlights the gross inadequacies of our health care infrastructure to meet the most fundamental health needs of Americans, and the urgency with which our system requires reform. Unlike most other nations, American health care is fragmented and disorganized, with quality care buried in layers of bureaucracy.

Clinicians and patients are plagued by the red tape and regulations from the insurance industry and lack of price transparency. The organizational structure of our health care system is designed to incentivize drug companies, insurance companies, hospitals and physicians to maximize their own profits. The complex interplay between stakeholders and regulations makes health care unaffordable, both to patients stressed by high deductibles and copays as well as to taxpayers and governments, which finance a majority of health care. Even though we are at the beginning of our training, we have already experienced the toll that administrative burdens place on clinicians and patients alike.

An American health care system rooted in universality, simplicity and affordability would alleviate many of these issues.

Patients skip treatment due to costs

Universality would allow us to treat everyone in our communities without concern for each individual’s insurance status or ability to pay. Simplicity would improve patient access to timely care and reduce physician burnout rates, which exceed 50%, allowing us to spend far less time on administrative hassles compared with our mentors and to redirect that time toward caring for our patients. Affordability is essential and will improve health outcomes and overall public health. Even this early in our medical training, we are already exhausted by seeing patients forgo treatment due to the financial jeopardy they could be placed in.

With over 40,000 lives lost each year due to lack of health care access, incrementalism and discussing the nuances of laws is not sufficient. Americans need and deserve a more comprehensive discussion on health care reform, and the Sept. 29 debate presents that opportunity. We believe that health care questions in this upcoming debate should focus on principles, and not get caught up in technical jargon and a maze of policy particulars.

Every year, graduating medical students across the country recite the Hippocratic oath. They promise to uphold ethical principles sacred to the practice of medicine, including perhaps the most widely known, “do no harm.” We believe the infrastructure of health care in America is an injustice to our patients and a barrier to carrying out those principles. As part of the emerging generation of health professionals, we are personally committed to advocating for a system built on principles that strive to provide equitable care to all and to promote health through addressing the structural and social causes of illness.

Rohit Anand (@ro_anand), Dhiksha Balaji (@DhikshaBalaji), Aparna Narendrula (@a_narendrula) and Jasmine Serpen (@jasmine_serpen) are medical students at Case Western Reserve University School of Medicine in Cleveland. The views expressed here are solely their own and do not reflect those of their institution.

https://www.usatoday.com…

Venture capitalists are moving into mental health

The Rise of Venture Capital Investing in Mental Health

By Ravi N. Shah, M.D., M.B.A.; Obianuju O. Berry, M.D., M.P.H.
JAMA Psychiatry, September 16, 2020 (Online first)

Mental health care is ripe for innovation. Less than a third of people with mental health disorders receive treatment, and even a smaller proportion receive adequate care. The private sector has taken notice of this economic mismatch (high demand with inadequate supply) and is aggressively pursuing mental health and wellness as an investment opportunity. In 2019 alone, venture capital (VC) companies invested a record-breaking $637 million in more than 60 different mental health–oriented companies, which is more than 22.8 times the investment in 2013. This rapid rise in investment in the mental health and wellness space brings new challenges related to defining, quantifying, and assessing products and services that had previously resided within traditional health care.

Although self-guided smartphone applications and digital products have received a great deal of public attention, the financial market is dominated by companies that provide direct clinician-patient services. Most of these companies focus on anxiety, depression, and insomnia with little emphasis on severe mental illness.

Concerns Related to Private Investment in Mental Health

Physicians, caregivers, payers, and patients should have real concerns about this trend. Silicon Valley’s motto for success, “move fast and break things,” has led companies such as Uber and Theranos to break laws and cut corners. This ethos is not compatible with the Hippocratic doctrine of primum non nocere. Venture capital companies evaluate success in terms of growth of consumers and revenue, with little rigor applied to quality assessment. In fact, Pear Therapeutics is unique in achieving US Food and Drug Administration approval for a prescription digital therapeutic. The National Institute of Mental Health itself acknowledges that there are currently no national standards for evaluating the effectiveness of the hundreds of mental health applications that are available and recommends that consumers ask their health care providers for recommendations. In response, the American Psychiatric Association has developed a framework for evaluating mental health applications but still leaves the work of evaluating effectiveness up to individual health care professionals. Quality assurance is needed not just for products (eg, digital therapeutic tools) but also for services rendered by companies that connect clinicians with patients.

Other specific challenges that VC-backed start-ups must confront include privacy concerns, ability to adapt to personalized needs, applicability for individuals with serious mental illness, and payer adoption. A recent study of 36 mental health applications showed that 92% transmitted data to third parties, but only 69% had a privacy policy. Furthermore, clicking an “I accept” button on a lengthy privacy policy does not constitute informed consent to share protected health information. In addition, digital products are highly structured to facilitate scale, but this uniformity may provide overly narrow solutions for patients, for whom comorbidity is the rule rather than the exception. Few of these companies focus on serving the population with serious mental illness, creating a gap between where investment goes and where it is most needed. Without insurance adoption and reimbursement, only individuals able to pay out of pocket or those whose employers pay for these products will be able to access these innovations, further increasing the mental health equity divide.

Possible Advantages to VC-Led Innovation in Mental Health Care

Despite these concerns, VC-backed start-ups may accelerate mental health care innovation. Companies supported by VC rely on the idea of scale—the ability to grow quickly to serve a large population to maximize return on investment. In the traditional mental health care setting, dissemination of evidence-based treatments is a major challenge because treatments take place as one-on-one encounters over several months. Venture capital companies subsidize start-ups to constantly produce new iterations of their models to generate proof of concept and to refine their product or service as it evolves. This market-based, “survival of the fittest” approach means that companies only succeed if patients use and perceive benefit from these products and services. Given their consumerist mindset, VC-backed mental health companies’ strength is their transparency with diagnosis, treatment process, and costs. These are all steps forward for mental health care in the United States.

The mental health care landscape is changing rapidly, and VC-backed for-profit companies represent a significant force driving these changes. Although the value of this trend is yet to be fully realized, the rise in VC investment in mental health care offers an opportunity to scale treatments that work and address mental illness at the population level. However, quality control, privacy concerns, and severe mental illness are major issues that need to be addressed. As the demand for digital solutions to mental health concerns continues to rise, we will have to wrestle with this question: can VC-backed mental health start-ups move fast without breaking anything?

https://jamanetwork.com…

Comment:

By Don McCanne, M.D.

Mental health has always seemed to be more or less of an orphan-child of medicine. Although for decades many efforts have been made to reduce inequities in mental health care, tremendous voids remain.

In my practice the affluent patients were able to afford the mental health care that they needed, but the majority of my patients were not. Maybe the acutely psychotic would be locked up for 72 hours, but then they were released to followup that frequently did not seem to exist. The Medi-Cal PPO for which I was a network provider had only one psychiatrist in its network, not in our community, though even he was not available after he was arrested on morals charges. Because I already worked extended hours throughout my career and really didn’t feel competent in providing mental health services anyway, my patients got the short shrift. As I fantasized about the nation eventually enacting and implementing a single payer national health program, I had to take satisfaction in the belief that some day soon mental health services would be available for all, though I was clearly wrong about “soon.”

In the meantime, we have witnessed a dramatic growth in the medical-industrial complex. Venture capitalists have become a major player. As this article mentions, mental health has presented the economic mismatch of high demand with inadequate supply, creating the aggressive pursuit of mental health and wellness as an investment opportunity. The article mentions legitimate concerns related to private investment in mental health, but, from a broader perspective, the culture of the business model in health care exists on a much lower ethical plane than does the culture of the professional service model. The authors state that the venture capital model can be advantageous since it can lead to greater innovation (a term that applies primarily to the business of medicine), and grow quickly to “maximize return on investment.” It is difficult to imagine a worse model of expanding mental health services – passing more health care dollars to capitalists.

The bottom line is still the same. We desperately need a single payer model of an improved Medicare for All to make all health care, including mental health services, affordable and accessible for everyone. I don’t understand why we don’t have it. Maybe I need some counseling.

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RAND: Private insurers overpay hospitals

Private Health Plans in the U.S. Pay Hospitals 247% of What Medicare Would Pay

RAND, September 18, 2020

Prices paid to hospitals nationally during 2018 by privately insured patients averaged 247% of what Medicare would have paid, with wide variation in prices among states, according to a new RAND Corporation study.

The study notes a steady increase in hospital prices, rising to the 2018 average level from an average of 224% of Medicare costs in 2016 and 230% of Medicare costs in 2017.

The analysis, which includes information from more than half of the nation’s community hospitals, is a broad-based study of prices paid by private health plans to hospitals.

“This analysis provides the most-detailed picture ever of what privately insured individuals pay for hospital-based care relative to what the government pays for people insured through Medicare,” said Christopher Whaley, the study’s lead author and a policy researcher at RAND, a nonprofit research organization.

If employers and health plans participating in the study had paid hospitals using Medicare’s payment formulas, total payments over the 2016–2018 period would have been reduced by $19.7 billion, a potential savings of 58%.

“The rising gap between public and private hospital prices is a cause for concern and raises questions about the efficiency of the employer market,” said Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation, which sponsored the project. “The goal of this work is to arm employers with data so they can negotiate more effectively. Curbing excessive spending on employer health insurance is in the public interest.”

Spending on hospital services accounts for approximately 44% of total personal health care spending for the privately insured, and hospital price increases are key drivers of recent growth in per capita spending among the privately insured.

Other findings from the study include an observation that hospital costs within individual states and hospital systems vary widely. Researchers also examined whether the observed differences in prices could be explained by differences in the quality of care. However, they did not find a strong relationship between prices and two widely-recognized metrics of quality and patient safety, or that variation in hospital prices is explained by differences in Medicare and Medicaid patient populations.

A large portion of private health insurance contracting for hospitals is done on a discounted-charge basis where the insurer agrees to pay a percentage of billed charges. By contrast, Medicare issues a fee schedule that determines the price it will pay for each service, with adjustments for inflation, hospital location, the severity of a patient’s illness and other factors.

RAND researchers suggest that private insurers may want to move away from discounted-charge contracting for hospital services and shift to contracting based on a percent of Medicare or another similar fixed-price arrangement, often called reference-based pricing.

“In the case of specific high-priced hospitals, there may be justification for the unusually high prices, such as offering specialized services or a well-deserved reputation for higher-quality care,” Whaley said. “However, if two hospitals have similar quality, then any difference in prices may be harder to justify.”

https://www.rand.org…

The full report can be downloaded at a link through this website:
https://www.rand.org…

From the Conclusion of the full report:
“Although many hospitals do face increasing costs, such as growing employment and personnel costs, increased needs for investments in electronic health records, and other technologies, the results of this study show that some hospitals are still able to charge much lower prices than other hospitals.”

Comment:

By Don McCanne, M.D.

Hospitals pay much higher prices for privately insured care than they do for the government programs Medicare and Medicaid. This difference is not due to higher quality care, but rather it is due to hospitals’ market power in being able to contract with the private insurers for higher prices, whereas the government programs use fixed fee schedule prices. Further, this study shows that the wide variation in prices paid demonstrates that low income hospitals are still able to provide high quality care.

Also, the evidence indicates that higher private insurance prices did not correlate with lower prices paid by government programs. The report states, “the absence of a correlation between hospital prices and payer composition does not support the argument that higher hospital prices are in place to offset underpayments by Medicaid and Medicare.”

Considering our very high health care prices in the United States, and considering that the private insurers have been ineffective in controlling hospital prices, shouldn’t that make you think that we should consider changing our health care financing system? Other nations that use global budgets to finance hospitals, much like budgeting fire departments, have been much more effective in controlling excess hospital spending.

If you consider the historical health care spending curves in the United States and Canada, they were about the same until Canada enacted their single payer systems in the provinces. Canada then bent their cost curve to sustainable levels (maybe a little bit too low) whereas ours has continued on its unsustainable trajectory.

How can we continue to look at these studies and then do nothing beyond occasional tweaking while leaving the private insurance industry in control of much of our health care spending? About $600 billion is wasted on the administrative burden created by this industry while they can’t even get pricing of hospital care right. We don’t need the insurers, but we do need the hospitals. We just need to fund them appropriately.

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Don’t argue against government healthcare based on private insurance data

By James Fieseher, M.D.
Seacoastonline.com (Portsmouth, N.H.), September 18, 2020

In a recent “Guest View” by Rockingham County Commissioner Kevin St. James, he concludes that “Government control won’t fix health care.” He cited data to support his conclusions.

There is a certain familiarity with the data that he cited. They coincide almost exactly with the information distributed by the private insurance industry.

This industry has a virtual “lock” on health insurance in this state and this country, which has helped to make them among the most profitable companies in the US.It is no wonder they would distribute skewed data to keep those profits high.

Let’s start with taxes. Mr. St. James correctly points out that “according to some estimates, payroll taxes might increase as much as $2,300 annually.” That would be true only if a single-payer system was based solely on payroll taxes.

However, since the average American pays between $10,000 – $36,000 annually for private health care, most people would save between $6,000 – $32,000 annually. If you think you pay less than that on healthcare, you should consider the amount your employer is paying for your health insurance as well.

Additionally, the US government is already paying $5,900 per capita on healthcare now, or roughly 11.2% of GDP. Those numbers are taken from 2016 data (American Journal of Public Health, June 2016) and I suspect the current figures are even higher. For comparison, in the same year Canada spent $4,351 (in American dollars) per capita or 10.2% of GDP. This doesn’t take into account that Canada’s system covers everyone, not the 85% covered in the US.

Caveat emptor: GAO finds brokers frequently sell non-compliant health plans

GAO report finds brokers offered false info on coverage for pre-existing conditions

By Jessie Hellmann
The Hill, September 16, 2020

Some health insurance brokers provided misleading or false information to potential customers about whether their plans covered preexisting conditions, according to an undercover audit completed by the nonpartisan Government Accountability Office.

The audit, requested by Senate Democrats, sought to determine whether companies selling health plans exempt from Affordable Care Act coverage requirements were being honest about the limitations of the plans, which tend to be cheaper but aren’t comprehensive and typically don’t cover preexisting conditions like cancer or diabetes.

In 31 “undercover phone calls” in which employees of the GAO posed as customers looking for health insurance that covered their preexisting conditions, eight of the sales representatives “engaged in potentially deceptive marketing practices,” the agency concluded.

In those instances, representatives sold GAO employees limited benefit plans that don’t cover preexisting conditions, including memberships to health care discount programs that don’t actually qualify as insurance.

For example, the report states, one sales representative told a GAO employee they were purchasing a comprehensive health insurance plan, but instead sold them two limited benefit insurance plans that don’t cover preexisting conditions.

“During the call, we repeatedly informed the sales representative that we had diabetes and had recently been seeking treatment for the condition. However, the application filled out by the sales representative on our behalf, which we later obtained, stated that we had not been treated for or diagnosed with diabetes for the past five years,” the report states.

This indicates that the broker may have intentionally falsified information on the application, which allowed the application to be submitted and the insurance policy to be purchased, but would not allow health care services related to our pre-existing condition to actually be covered under the terms of the policy.”

Some of the sales representatives refused to let GAO employees see the policy documents before they agreed to buy it.

Insurance brokers can be paid higher commissioners for selling limited benefit plans, while they earn a flat dollar amount for ACA-compliant plans.

https://thehill.com…

GAO report (29 pages):
https://www.gao.gov…

Comment:

By Don McCanne, M.D.

Supposedly the Affordable Care Act requires all insurance plans to cover preexisting conditions, but that is not quite true. Plans that may be exempted from covering preexisting conditions include certain grandfathered plans, short-term limited duration plans, limited benefit plans, health care sharing ministries, and association health plans. Even Medigap plans can be denied to individuals who failed to enroll when they first became eligible. Also at risk is the preexisting coverage mandated by the Affordable Care Act that will be subject to a Supreme Court hearing shortly after the November election.

The GAO report confirms that the confusion created in the insurance marketplace exposes would be buyers to unscrupulous practices that may leave them without the coverage they thought they were purchasing, or they may be left unprotected merely because of the complexity in the fragmented insurance market that creates confusion as to just what the plans do cover.

In the midterm election, the Republicans campaigned on promising to cover preexisting conditions at the same time that they supported the repeal of the Affordable Care Act which would have removed such protections from the insurance marketplace. Since they have not offered an ACA replacement plan, their support for covering preexisting conditions was a hollow promise. Although some of the Republicans still contend that preexisting conditions should be covered, they have not made it a major issue in this election since they still have no replacement plan, and they don’t want to be caught with their plans down again.

Under a single payer Medicare for All plan, this issue goes away. Everyone is completely covered forever. It is astonishing that so many Americans reject Medicare for All while accepting Trump’s support of short-term junk insurance that leaves patients vulnerable to massive medical debt. There must be some loose screws around. We’d better tighten them up.

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We have another billion patients to take care of

The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion

By Gene Bukhman, MD, Ana O Mocumbi, MD, Prof Rifat Atun, FRCP, Prof Anne E Becker, MD, Prof Zulfiqar Bhutta, PhD, Prof Agnes Binagwaho, PhD, et al.
The Lancet, September 14, 2020

We live in an era of unprecedented global wealth. Nevertheless, about one billion people in low-income and lower-middle-income countries (LLMICs) still experience levels of poverty that have long been described as “beneath any reasonable definition of human decency”, in the words of former World Bank president, Robert McNamara. This Commission was formed at the end of 2015 in the conviction that non-communicable diseases and injuries (NCDIs) are an important, yet an under-recognised and poorly-understood contributor to the death and suffering of this vulnerable population. The aims of the Commission were to rethink global policies, mend a great disparity in health, and broaden the global health agenda in the interest of equity.

Conclusion: global solidarity for NCDI Poverty and universal health coverage

Propelled by a 2001 UN General Assembly Special Session, the first decade of the 21st century saw dramatic growth in development assistance for HIV. In many cases HIV financing has had collateral benefits for those afflicted by other conditions, but it has not been sufficient. We have estimated that around 85% of the poorest billion live in countries with a per-capita GDP of less than US$1600 in 2015 exchange-rate US dollars. Simply put, these countries do not have the domestic resources to address even their most urgent health-care needs.

NCDIs have been understood by development agencies and multilateral institutions as an emerging problem associated with ageing, urbanisation, and economic growth, rather than a constituent part of the most extreme poverty. The 2011 UN High-Level Meeting on NCDs was greeted with hope for a new era of global solidarity despite the 2008 financial crisis. These hopes have not materialised. Our Commission has shown that little development assistance for NCDIs has been mobilised for NCDIs over the past decade, and that almost none has gone to the poorest countries.

The framing of NCDs that crystallised through the 2011 UN High-Level Meeting was, in part, a solution to the perceived weakness inherent in the heterogeneity of a large array of non-infectious conditions. This Commission proposes that this complexity should be recognised as an inescapable part of the NCDI burden in the poorest populations. More than that, this complexity should be leveraged to build global solidarity and to catalyse structural reforms for quality and innovations in integrated service delivery for the world’s poorest and most vulnerable people.

To begin to remedy the shocking neglect of NCDI Poverty by rich countries, this Commission is launching an NCDI Poverty Network. This Network is composed of a growing group of National NCDI Poverty Commissions and their allies. The Network will work over the next decade to catalyse financing and technical partnerships to support implementation of integrated delivery strategies for locally prioritised interventions. The Network will also work closely with The Lancet and the NCD Countdown 2030 Group to report on progress toward locally identified goals. In doing so, we hope that this Commission will elevate an emerging NCDI Poverty movement and accountability mechanism that will contribute to health and shared prosperity for all.

Addressing NCDI Poverty offers a chance for the poorest countries to build durable, high-quality health systems. It also presents an important occasion to act on the underlying social determinants of disease such as housing, household energy, food insecurity, education, and transportation. In order to be successful, these countries will require greater global commitments to health equity. Private philanthropic organisations have small resources at their disposal but can have an outsized effect on policy and research. We ask that, when funding disease-specific initiatives, these organisations consider the poorest billion and recognise the need to invest in integrated strategies that drive health system improvements.

Bilateral donors must increase their investments in health in the poorest countries. When funding NCDIs as part of UHC expansion pathways, bilateral donors and multilateral institutions must also begin with the poorest billion in mind. Prospects exist to build on existing investments and to crowd-in resources for NCDI Poverty in priority countries and populations. Financing to address treatment gaps in the poorest countries should not be neglected even as resources should also be increased to support common goods for health such as research, policy, and coordination.

We call on WHO to expand its UHC monitoring and NCD action plan after 2020 to address the diverse set of diseases and conditions recognised as NCDIs in its own Global Health Estimates; intervention priority setting at WHO to give due consideration to equity (including condition severity and distribution among the poorest) in addition to cost-effectiveness and feasibility; and WHO to strengthen its work on integrated service delivery for NCDIs, and particularly to invest in development of technical packages for first-level hospitals.

NCDI Poverty is one of the largest gaps and largest opportunities for UHC and global health equity in the SDG era. The Director General of WHO has called for one billion more people to benefit from UHC by 2023. The scope of UHC recognised by this commitment must be broadened to include NCDI Poverty. Consistent with the SDG pledge that, “no one will be left behind”, and the SDG commitment, “to reach the furthest behind first”, the next billion to benefit from this more inclusive conception of the UHC should be the poorest billion.

https://www.thelancet.com…

Comment:

By Don McCanne, M.D.

I have always been concerned about the inadequacies of health care programs in poor nations. Who hasn’t?

A few decades ago, as I was approaching retirement, I wanted to become part of a movement to ensure that the entire world has affordable access to all essential health care services. The need was so great. But first we needed to address the health care deficiencies in our own nation so that we could stand as an example to all other nations. We certainly had enough funds, but we needed to fine tune our system by improving Medicare and expanding it to cover everyone. That was the easy step that we could take immediately and then move on to addressing the rest of the world’s health care problems.

Easy step? Oh my!

The Director General of WHO has called for taking care of one billion more people by 2023, while reaching the furthest behind first. Considering the efforts of President Trump to reduce the efforts on improving health care in the United States, it is no wonder that he withdrew both funding and membership in the WHO as they embark on this international effort to provide care for the poorest one billion people in the world.

But the need is so great that we should start supporting the WHO effort now. As far as the comparatively minor effort required in the United States, we can do that simultaneously. PNHP would gladly provide guidance on Medicare for All. We should be able to complete that task in 2021, and then move on to help with the goal of expanding care to another one billion people by 2023. And they told us that Medicare for All was a tough haul. That’s the easy part.

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

There’s no racial justice without health justice

By Toby Terwilliger, M.D.
The (Newark, N.J.) Star-Ledger, September 16, 2020

A number of recent high-profile police killings of Black citizens, most notably the May 25th murder of George Floyd, have forced a national reckoning with our history of racism and injustice. The Black Lives Matter movement has dramatically shifted public opinion and has awakened a renewed sense of urgency to confront racism head-on. The movement has rightfully been indignant of police brutality and a broken criminal justice system. But the fight for racial justice cannot stop there. Black lives must be seen to matter in education, housing, the workplace, and all other facets of life if we can ever hope to achieve racial justice.

Perhaps no institution has stolen more Black lives than our broken healthcare system. Every year, 45,000 Americans die due to inadequate health insurance, a disproportionate number of whom are Black. This has resulted in significant disparities in health and longevity. Blacks are more likely to suffer from chronic illnesses, to die from preventable causes, and to die during pregnancy or childbirth than other race. Perhaps most starkly, the life expectancy of a Black man in his 40s today is six years shorter than that of a white man of the same age.

Not only does the current system cut years off of Black persons’ lives but it also disproportionately disadvantages Black families. Blacks are more financially burdened by medical costs and declare bankruptcy at higher rates due to medical bills than other races. In this way, similar to mass incarceration, our broken healthcare system steals parents away from their children, casts families into financial ruin, and perpetuates a cycle of poverty. It is time to treat racial justice as inextricable from health justice.

How can we achieve health justice? The answer is complicated and starts with investment in black communities, reforming medical education to train more black health care providers, and redesigning clinical trials to include more minority participants. But one thing is certain: we cannot hope to achieve health justice without providing universal, affordable healthcare and this is best accomplished through a single-payer healthcare system.

Single-payer engenders equity in several ways:

First, it eliminates uninsurance as a barrier to care. Currently, one in five Black persons is uninsured, meaning that millions of Black Americans go without primary care or preventive health services every year. It is time we guarantee access to these services to everyone. Doing so will go a long way toward reducing disparities in health outcomes.

Second, it eliminates out-of-pocket expenses, helping many Black families break free from the cycle of poverty and improving health outcomes. Parents would no longer be forced to choose between putting food on the table or paying for their child’s medications and, crucially, no family would ever again be forced into bankruptcy because of medical debt. When families no longer have to worry about medical bills, they are free to invest those resources into their children and their community.

And third, it eliminates the marriage of insurance with employment. Single mothers working multiple part-time jobs will be able to afford healthcare for their children. Others may choose to become self-employed or start a business when the burden of employer-sponsored insurance is lifted. This will help to achieve an economy in which blacks can fully and equitably participate, especially in sectors from which they have been historically excluded.

This new wave of anti-racist activism is still in its infancy. The Black Lives Matter movement has made it impossible to ignore the inequalities in policing and criminal justice any longer. A necessary corollary to this movement must be the demand for health justice. We must press our elected leaders to support legislation that promotes health justice, most saliently of which are proposals for single-payer healthcare. For if we truly hope to make black lives matter, then we must create a healthcare system that values the lives of black patients as much as the lives of white ones.

Dr. Toby Terwilliger is a Jersey City resident and a physician at the Rutgers New Jersey Medical School in Newark.

https://www.nj.com…

Let’s help cities join the Medicare for All bandwagon

Long Beach Mayor Robert Garcia Launches Medicare For All Advocacy Group

By Harry Saltzgaver
The Grunion, September 10, 2020

Mayor Robert Garcia said Thursday, Sept. 10, he and the mayor of Oakland have created an organization to promote Medicare for All in the country as a whole.

The announcement was in the form of a press release out of Garcia’s office. Oakland Mayor Libby Schaff is partnering with Garcia to create Mayors for Medicare for All (Mayors 4 Medicare).

One of the group’s goals, according to the release, is to have a resolution of support in front of the U.S. Conference of Mayors to be adopted as a policy position of that group.

The organization supports Medicare for All legislation introduced by Senator Bernie Sanders and Congresswoman Pramila Jayapal. A single-payer health care system would cover all Americans, including vision, dental, hearing, prescription drugs, mental health care and more.

“The clearest lesson from the COVID-19 crisis is that healthcare must be a right for all — and not a path to bankruptcy and deeper racial disparities,” Schaaf said in the release. “We’re mobilizing local leaders to build a national movement so the next Congress will adopt legislation that brings healthcare access to all.”

There already is a logo and a website — mayors4medicare.com — that includes a place for mayors to sign up and basic information about the group.

https://www.gazettes.com…

Mayors for Medicare for All

Our coalition has 3 goals:

  1. Create a network of mayors who will endorse Medicare for All.
  2. Submit a formal resolution of support for Medicare for All to the U.S. Conference of Mayors for adoption and as a policy position of the conference.
  3. Work with the next administration and Congress to adopt Medicare for All.

https://mayors4medicare.com

Medicare for All Would Help End Racial Disparities in the South

We must take a stand against a for-profit health care system that too often devalues Black lives.

By Jason Williams, Amelia Parker
Common Dreams, September 9, 2020

The coronavirus pandemic and ongoing protests over racial disparities in the U.S. have highlighted just how broken our health care system is, especially for Black Americans.

As local elected officials, we have witnessed first-hand in our cities how our for-profit health care system fails so many of our residents.

In Louisiana, Black people account for 53% of all coronavirus deaths in Louisiana despite making up 32% of the state population, according to the Louisiana Health Department. Black coronavirus patients also made up three-fourths of hospitalization in the state.

These disparities are underscored by broader racial trends. Black children in New Orleans are 3.5 times more likely to be uninsured than white children—8.5% compared to 2.5%—and Black adults are twice as more likely to be uninsured than whites—32.3% to 16.6%.

In Tennessee, Black residents make up 12% of the population, but account for 33% of coronavirus deaths. Black Tennesseans are 40% more likely to be uninsured than White Tennesseans.

Latinx communities are also experiencing a disproportionately high rate of positive COVID-19 cases in our communities. In Knox County, Tenn. Latinxs represent 30% of the county’s positive and probable COVID-19 cases, while only representing 5% of the county’s total population. A study in New Orleans Parish, La., found that 20% of Hispanics tested positive to COVID-19 vs. just 3% of Whites. Latinx Tennesseans are three times as likely to be uninsured that White Tennesseans, and Latinx Louisianans are 3.6 times as likely to be uninsured then White Louisianans.

In this moment of reckoning on racism in so many aspects of society, we must take a stand against a for-profit health care system that too often devalues Black lives.

Our economic health depends upon our physical health. This is not a red issue or a blue issue, it’s a red white and blue issue. The future of the U.S. is depending on universal health care.

That’s why the New Orleans and Knoxville City Councils joined cities and towns across the country in passing resolutions recently in support of Medicare for All. These resolutions send a powerful signal to Congress that our cities stand with the majority of Americans who demand guaranteed health care.

Jason Williams is the New Orleans City Council President.

Amelia Parker is a Knoxville City Council Member.

https://www.commondreams.org…

Comment:

By Don McCanne, M.D.

When you study all of the inefficiencies and injustices of our health care system, it does not take much to understand the health care issues that cities face. Although some of our larger cities are able to supply some of the basic infrastructure in health care, perhaps with the backup of counties and states if they are so inclined, the role of the federal government is essential.

If you look at the Medicare program as a model, you can easily see that it would be possible for a federally financed program to ensure health care for everyone. We would merely need to improve Medicare and then expand it to cover everyone as a single payer Medicare for All program.

Today’s articles demonstrate that some city officials do recognize that the solution for their cities’ health care deficiencies would be to establish a national Medicare for All program. We should encourage our city governments to seriously consider this approach and help them to establish a national movement of Cities for Medicare for All, or Mayors for Medicare for All, or whatever name floats. Let’s just do it.

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

Medicare for All Explained Podcast: Episode 42

Interview with Prof. Matthew Lawrence

September 15, 2020

Emory University law professor Matthew Lawrence outlines both the benefits and the drawbacks of state-based single-payer programs. He says one notable challenge is that the Department of Health and Human Services would have to approve the use of federal dollars earmarked for Medicare, Medicaid, CHIP, and other programs to be used in a state’s single-payer program. Unfortunately, both current and previous administrators have dismissed this idea.

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

https://medicareforallexplained.podbean.com

Are lung function algorithms perpetuating health disparities experienced by Black people?

By Adam W. Gaffney, Steffie Woolhandler, and David U. Himmelstein
STAT, September 15, 2020

“I can’t breathe” became a rallying cry against racism in the wake of the deaths of George Floyd and Eric Garner at the hands of the police. But chokeholds are far from the main cause of race-based disparities in respiratory deaths in the U.S.

The Covid-19 pandemic is more likely to asphyxiate Black people than white people. They are also more likely to die from asthma, pneumonia, and non-Covid-19 acute respiratory distress syndrome.

Many studies have found that, on average, Black individuals have lower lung volumes than white people. Race-based lung function algorithms — equations used to convert raw lung volumes into age-, sex- and height- adjusted metrics that are more interpretable and useful to physicians — assume that lower lung volumes are expected, and hence “normal,” in Black people. Yet the widespread racial disparities in respiratory illness should provoke a reappraisal of the appropriateness of race-specific prediction equations that use statistics to “adjust away” the racial gap in lung function.

By using these lung function algorithms, are we blinding ourselves (and society) to the health harms of structural racism, effectively normalizing lung damage that Black Americans suffer from dirtier air, dirtier jobs, and substandard medical care?

Today’s race-based lung-volume algorithms rest on more than two centuries of assumptions and observations. In 1783, Thomas Jefferson argued that “difference[s] in the structure in the pulmonary apparatus” made Black people particularly suited for plantation labor, as the scholar Lundy Braun describes in her history of the spirometer, an apparatus used to measure lung volumes. The spirometer, first developed in the 1840s, is still used today. It measures how much air an individual breathes out and in, and how fast. The device made it possible to objectively measure the volume of the lungs, and hence their function. Soon after its development, Samuel Cartwright, a plantation owner and prominent physician in the South, found that Black slaves had smaller lung volumes than white people.

Lower lung function in Black Americans was subsequently documented in other contexts, including assessments of large, well-conducted, nationally representative samples. In the U.S., Black individuals have, on average, lower values on two key tests relative to white individuals: forced expiratory volume in one second (FEV1), which is the amount of air an individual can forcefully exhale in one second, and forced vital capacity (FVC), which is total amount of air an individual can forcefully exhale.

The FEV1 and FVC are difficult to interpret when given as they are measured, in liters of air. That’s because lung volume gets smaller with age, is larger in taller individuals, and is smaller in women than in men.

An understanding of these relationships led to the development of prediction lung function algorithms that convert FEV1 and FVC measurements in liters into a percent predicted adjusted for age, sex, and height. At the same time, longstanding observations of racial differences led to so-called correction factors that “adjust” for race, and later, to racially specific prediction equations that basically do the same thing. One of us (A.G.) uses them with his pulmonology patients, as is standard practice.

Here’s an example of how these equations work: Using one commonly used prediction equation, an FEV1 of 3.5 liters would be in the normal range (91% of predicted) for a 40-year-old, 6-foot-tall Black man, but the exact same value would be considered abnormally low (78% of predicted) for a 40-year-old, 6-foot-tall white man.

Using race-adjusted lung function algorithms has important social and medical ramifications. The percentage predicted values are used in surveillance programs to detect the development of lung disease in potentially hazardous workplaces. For individuals who already have lung disease, they are used to guide the selection of medical therapies, surgical interventions, and decisions about lung transplantation. The United Network for Organ Sharing, which administers the only network in the U.S. for organ procurement and transplantation, incorporates the percent predicted FVC in its algorithm for assigning priority for getting an organ, with individuals who are sicker being assigned a higher priority.

The upshot is that two otherwise identical patients may be treated differently based on the color of their skin: a white patient might receive treatments not offered to a Black patient; might be referred for lung transplantation earlier in their disease course; and could be assigned a somewhat higher priority for receiving a lung.

If the aforementioned Black man with an FEV1 of 91% predicted actually had a better prognosis than the white man with an FEV1 of 78% predicted, even though both had an identical FEV1 of 3.5 liters, the use of these race-specific equations might be appropriate, with the race-specific equations more accurately reflecting each individual’s prognosis than the use of a colorblind equation, which would suggest they had similar prognoses. But there is no evidence this is the case, and the lone study of the issue suggests the opposite: that Black and white individuals of the same age, sex, height, and FVC (expressed in liters) have similar long-term mortality.

The use of race-specific lung function algorithms, then, may be leading to inappropriate — and inadvertently discriminatory — differences in diagnosis, protection from occupational exposures, and treatment. Similar concerns have been raised about the use of race-based kidney function equations, prompting petitions that have led multiple institutions to abandon them, and national nephrology societies to reassess their use.

But in the case of lung function, there’s a hitch: Using spirometry equations without adjusting for race would increase the number of Black individuals diagnosed with restrictive lung disease, a type of disorder characterized by smaller lungs, sometimes due to scarring. Whether the potential benefits of fewer missed diagnoses would outweigh the harms of mislabeling some healthy people as having a lung disease is currently unknown.

Clinical implications aside, an important underlying question is why Black Americans have smaller lung volumes than their white counterparts. Nature or nurture? Genes or environment?

The strong correlation between lung volume and socioeconomic status argues against a solely genetic cause. Studies in many nations have demonstrated a class gradient in lung function, suggesting that social disadvantage — perhaps mediated by exposure to air pollution, inadequate nutrition, occupational hazards, lung infections, and other exposures — accounts for some or all of the “racial” difference. Yet even studies that statistically adjust for socioeconomic status, by controlling for income and education, still find substantial racial differences in spirometric measures.

And therein lies a conundrum. Statistical adjustments for differences in education and current income can’t fully account for the disadvantages that racism imposes on African Americans. The legacy of slavery and discrimination has led to a wide gap in housing and wealth between white and Black families, forcing them to endure less-healthy living and working conditions than white people with similar incomes and education.

Black people in America have endured racism since 1619, and as Floyd’s and Garner’s deaths make painfully clear, racism persists today. Until we eliminate redlining, unequal access to housing and medical care, racially biased hiring and job assignment, environmental racism, and the psychosocial toll that racism imposes, we cannot know whether Black people’s lower-than-average lung function is normal, or merely the norm.

Adam Gaffney is a pulmonary and critical care physician at the Cambridge Health Alliance and an instructor in Medicine at Harvard Medical School. Steffie Woolhandler and David U. Himmelstein are primary care physicians and professors in urban public health at the City University of New York Hunter College and lecturers in Medicine at Harvard Medical School. The authors serve as leaders of Physicians for a National Health Program, a nonprofit organization that favors expanding insurance through a single payer program. None receive compensation for that work, though some of Gaffney’s travel on behalf of the organization has been reimbursed by it.

https://www.statnews.com…

“Why do we have racial health inequities?” panel

PNHP president-elect Dr. Susan Rogers moderated a panel discussion for DSA’s Black Health + Black Liberation webinar series on September 14, 2020. Dr. Rogers was joined by Drs. Claudia Fegan (PNHP’s national coordinator), Linda Rae Murray (former APHA president), and Mary Bassett (former commissioner, NYC Department of Health and Mental Hygiene) to address the historic, economic, social, and political roots of racial health inequities.