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Setting the Record Straight on Medicare for All: An Open Letter From 560 Physicians and Medical Students

By Steffie Woolhandler and David Himmelstein
The Huffington Post, February 28, 2016

The following statement has been signed by more than 560 physicians and medical students. It was crafted by Andrea Christopher, M.D., Fellow in General Internal Medicine at Harvard Medical School, Adam Gaffney, M.D., Fellow in Pulmonary and Critical Care Medicine at Massachusetts General Hospital and Harvard Medical School, and the two of us, Drs. Steffie Woolhandler and David U. Himmelstein. Other physicians and medical students are invited to read and sign the statement here: medicare-for-all.us

Setting the Record Straight on Medicare for All: An Open Letter From 560 Physicians and Medical Students

The renewed debate over the merits of single-payer health reform has been marred by misleading claims that such reform is unnecessary and unaffordable. We write to set the record straight.

Despite the advances of the Affordable Care Act (ACA), the health care financing system continues to inflict needless suffering on our patients. Nearly 30 million Americans remain uninsured, and co-payments, deductibles and insurers’ narrow networks obstruct care for many more. Insurers skim billions from premiums, and impose expensive and time-consuming paperwork on doctors, nurses and hospitals.

Studies in the most trusted journals have quantified the bureaucratic savings achievable through single payer reform. We devote 31 percent of medical spending to administration, vs. 16.7 percent in Canada – a difference of $350 billion annually. And single-payer systems in Canada, the UK and Australia all use their bargaining clout to get discounts of 50 percent from the prices drug companies charge our patients. The potential savings on bureaucracy and drugs are enough to cover the uninsured, and to upgrade coverage for all Americans – a conclusion affirmed over decades by multiple analysts, including the Congressional Budget Office and the Government Accountability Office.

Recent critics of Medicare for All warn of large increases in government spending, but fail to note that these would be fully offset by savings on private insurance premiums and out-of-pocket costs. Their forecasts of massive surges in doctor visits and hospital care conflicts with past experience of coverage expansions. When 15 million Americans gained insurance under the ACA in 2014, hospital admissions didn’t budge. No surge in hospital use or doctor visits occurred when Medicare and Medicaid were rolled out, or when Canada’s single-payer system started up; doctors saw sick and poor patients more often, but their healthy, wealthy patients a bit less often.

Experience in many nations over many decades provides convincing evidence that single-payer reform is both medically necessary and economically advisable.

In addition to Drs. Gaffney, Himmelstein, Christopher and Woolhandler, this statement has been signed by more than 560 other physicians and medical students.

http://www.huffingtonpost.com/steffie-woolhandler/setting-the-record-straig_24_b_9341782.html

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Comment:

By Don McCanne, M.D.

With the recent often inaccurate and ill-advised debate taking place in the media over the financing of single payer it is imperative that the record be set straight on the basic, irrefutable facts of single payer. Physicians and medical students who are well informed on the true facts should sign this open letter so that the nation understands clearly that we can ensure that absolutely everyone has free choice of health care in a system that is affordable for everyone, through an improved Medicare-for-All.

Go to medicare-for-all.us to sign the letter.

Colleagues should be encouraged to sign as well. Non-physicians are also encouraged to endorse this letter by signing on to a companion list at this same website.

In a separate release, Steffie Woolhandler explains the background that makes this action an imperative:

“The recent attacks on single payer reform by some liberal economists and politicians are mystifying.  When I met with Hillary Clinton some years ago she acknowledged that single payer would be the cheapest and most efficient way to cover all Americans.  Her only objection then was that single payer wasn’t politically feasible.  Now she’s charging that the numbers don’t add up.  And economists who once projected large savings from single payer, are now saying the opposite, without citing any new data.  They’re playing political games at the expense of the truth.”

Again, please go immediately to medicare-for-all.us to sign the open letter.

AP-GfK Poll: Support shaky for Sanders ‘Medicare for all’

By Ricardo Alonso-Zaldivar and Emily Swanson
AP GfK, February 25, 2016

At first blush, many Americans like the idea of “Medicare for all,” the government-run health system that’s a rallying cry for Democratic presidential candidate Bernie Sanders.

But mention some of the trade-offs — from higher taxes to giving up employer coverage — and support starts to shrivel.

That’s the key insight from an Associated Press-GfK poll released Thursday. The survey also found that people’s initial impressions of Sanders’ single-payer plan are more favorable than their views of President Barack Obama’s health care overhaul.

A slim plurality of 39 percent supports replacing the private health insurance system with a single government-run, taxpayer-funded plan that would cover medical, dental, vision and long-term care, with 33 percent opposed. Only 26 percent say they support Obama’s hard-won health care law.

Asked whether they would continue to support Sanders’ plan if their own taxes went up, under a third of initial supporters of the plan would keep backing it. About 4 out of 10 flipped to opposition.

About the same share of initial backers would ditch single-payer if it meant that people had to give up employer coverage. Twenty-eight percent would continue to support it.

Higher taxes and an end to employer coverage are both a given under the Sanders plan, which would replace private coverage with a taxpayer-funded program, while also offering more generous benefits such as no deductibles and no copayments, as well as coverage for long-term care.

“That’s pie in the sky,” said Patricia Combs, a retired junior-high math teacher from Springboro, Ohio. “It sounds really good, but I don’t think it’s attainable … people would complain about their taxes being raised.”

Elizabeth Medina of Chicago, an office manager not currently working, said she worries that quality would slip.

“Overall it sounds terrific,” she said. “Yeah! Let’s go for it! But Europe and Canada have their problems with the single-payer system … it’s subpar.”

The poll found that 51 percent of initial single-payer backers would switch to opposition if it took longer for new drugs and treatments to become available. Only 14 percent would continue to support the plan. Such an outcome could happen if drugmakers were required to prove that new medications are therapeutically superior to existing ones. The current standard is that new drugs be safe and effective.

Additionally, 47 percent of initial supporters would reconsider if “Medicare for all” meant longer wait times for non-emergency medical services. That could happen if budget-conscious administrators encouraged doctors and hospitals to be parsimonious in using high-tech imaging. Only 18 percent of poll respondents would continue to support the plan in that case.

Overall, the poll found that health care remains a top issue for Americans, with three-fourths calling it extremely crucial or very important.

Topline

HC15. Would you favor or oppose replacing the current private health insurance system in the United States with a single government-run and taxpayer-funded plan like Medicare for all Americans that would cover medical, dental, vision, and long-term care services?

  39%  Total support
       18%  Strongly support
       21%  Somewhat support

  26%  Neither support nor oppose

  33%  Total oppose
       12%  Somewhat oppose
       22%  Strongly oppose

   2%  Refused/Not answered

HC15a. Would you support or oppose replacing the health insurance system in the United States with a single government-run plan if it meant:

  Your own taxes would increase
    28%  Support
    32%  Neither support nor oppose
    29%  Oppose

  Some people needed to switch doctors
    33%  Support
    37%  Neither support nor oppose
    29%  Oppose

  It took longer for new drugs and treatments to become available
    14%  Support
    34%  Neither support nor oppose
    51%  Oppose

  Longer wait times for nonemergency medical services
    18%  Support
    35%  Neither support nor oppose
    47%  Oppose

  People needed to give up other coverage like employer coverage
    28%  Support
    32%  Neither support nor oppose
    39%  Oppose

  The new system would replace Medicare for seniors
    37%  Support
    35%  Neither support nor oppose
    26%  Oppose

http://ap-gfkpoll.com/featured/findings-from-our-latest-poll-32

Topline
http://ap-gfkpoll.com/main/wp-content/uploads/2016/02/AP-GfK_Poll_February-2016-topline_health.pdf

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Comment:

By Don McCanne, M.D.

Most polls place support for a single payer Medicare-for-all national health program at about 60%, with some variation based on labels, framing, and polling technique. Yesterday’s Kaiser poll placed it at 50%. This new Associated Press GfK poll places it at about 40%, but it is unusual in that over one-fourth of those polled expressed no preference.  Of those expressing a preference, 54% were supportive and 46% opposed. But there was something else that was also very unusual about this poll.

Yesterday’s Kaiser poll demonstrated that the views on single payer were malleable. When asked about negative features that allegedly are associated with single payer, support declined, whereas support increased when asked about positive features. In this AP-GfK poll they were asked only about allegedly negative features, and support declined. But what were these negative features?

*  Your own taxes would increase – But no mention was made of the savings in premiums, out-of-pocket expenses and other taxes that would more than offset the new taxes, resulting in a net savings.

*  Some people needed to switch doctors – But that is a characteristic of private plans with their narrow networks whereas single payer provides free choice of health care professionals.

*  It took longer for new drugs and treatments to become available – There is no way that the pharmaceutical industry is going to walk away from a $3 trillion market.

*  Longer wait times for nonemergency medical services – Responsible stewards would use capacity adjustment and queue management to prevent excessive queues, as has been done successfully in several other nations.

*  People needed to give up other coverage like employer coverage – But they would be trading that for a superior program with more comprehensive coverage, reduced out-of-pocket costs and greater choices in health care.

*  The new system would replace Medicare for seniors – Who would want to continue with the current Medicare program that pays for only about half of health care when you could have an improved Medicare with more generous benefits?

Why would the Associated Press conduct such a deceptive poll at a risk of impairing its credibility? When you read the AP release, you can’t help but come to the conclusion that it was designed to slam presidential candidate Sen. Bernie Sanders and his support of Medicare for all. They even included a gratuitous comment from an unemployed office manager to the effect that the single payer system is “subpar” like in “Europe and Canada” – an absolute falsehood.

Whatever the intentions of the Associated Press, we must make every effort to dispel the deceptions and disseminate the true facts about single payer Improved Medicare for All. The health of America is at stake.

Kaiser Health Tracking Poll: February 2016

By Bianca DiJulio, Jamie Firth, Ashley Kirzinger, and Mollyann Brodie
Kaiser Family Foundation, February 25, 2016

The February Kaiser Health Tracking Poll asked the public about broad options for changing the health system that are currently being discussed and finds more Americans (36 percent) say policymakers should build on the existing law to improve affordability and access to care than any other option presented.  Sixteen percent say they would like to see the health care law repealed and not replaced, 13 percent say it should be repealed and replaced with a Republican-sponsored alternative, and 24 percent say the U.S. should establish guaranteed universal coverage through a single government plan.

As debate continues over the idea of universal coverage through a single government plan, the survey finds the public divided, with half saying they favor the idea and 43 percent saying they oppose it, and some opinions swayed after hearing counterarguments. In addition, majorities of Democrats and independents favor the idea, compared to just 20 percent of Republicans. Most Americans think that if guaranteed universal coverage through a single government plan was put into place, uninsured and low-income people would be better off, but there is little consensus among the public about how it would impact their care personally.

This month’s poll also explores the public’s reaction to a few terms used to describe the idea of expanding health insurance coverage to all Americans. Majorities say they have a positive reaction to the terms “Medicare-for-all” and “guaranteed universal health coverage” and fewer say the same for “single payer health insurance system” and “socialized medicine.”  About half (53 percent) of Democrats say they have a very positive reaction to “Medicare-for-all” compared with 21 percent who say the same for “single payer health insurance system.”

Next Steps for the Health Care System

While health care ranks fourth as an important voting issue, presidential hopefuls have proposed a range of visions for the future of the health care system, from the full repeal of the Affordable Care Act (ACA) to the adoption of a universal government plan. The survey finds that when given four broad approaches for the future of the health care system that are currently being discussed, Americans opinions are split with the largest share reporting that they favor building on the ACA and the existing system. Overall, 36 percent say lawmakers should build on the existing law to improve affordability and access to care, 24 percent say the U.S. should establish guaranteed universal coverage through a single government plan, 16 percent say they would like to see the health care law repealed and not replaced, and 13 percent say it should be repealed and replaced with Republican-sponsored alternative.

A closer look at views across parties shows that a third of Democrats (33 percent) favor the idea of universal coverage through a single government plan but more Democrats (54 percent) say they would prefer to build on the existing health care law. A roughly similar share of independents (26 percent) say the U.S. should establish guaranteed universal coverage through a single government plan, and 36 percent say lawmakers should build on the existing health care law. The majority of Republicans (60 percent) say they would like to repeal the health care law whether it’s replaced or not, although 21 percent say they would like to build on the existing law and 9 percent say they would like universal coverage through a government plan.

How Malleable are Americans’ Opinions of Guaranteed Health Coverage From a Government Plan?

Although half of the public says they favor having guaranteed health insurance coverage through a single government health plan, some can be swayed by counterarguments made by critics. For instance, 20 percent overall shift their opinion from favor to oppose after hearing that guaranteed coverage through a single government plan would “require many Americans to pay more in taxes,” 20 percent say they now oppose the idea after hearing that it would “give the government too much control over health care,” and 14 percent say they now oppose it after hearing that it would “eliminate or replace the current health care law.” On the other side of the debate, those who originally said they opposed the idea were also persuaded by arguments, although fewer changed their opinions after hearing the arguments. About one in 10 changed their stance from oppose to favor after hearing that guaranteed coverage would “ensure that all Americans have health insurance as a basic right” (13 percent), that it would “reduce health insurance administrative costs” (11 percent), and that it would “eliminate all private health insurance premiums, co-pays, and deductibles paid by employers and individuals” (11 percent).

Impact of Coverage Through Single Government Plan

Most Americans think that if guaranteed universal coverage through a single government plan was put into place, uninsured and low-income people would be better off (60 percent and 57 percent, respectively). Fewer say that middle class people (34 percent) and people like them (31 percent) would be better off, which is roughly similar to the shares who say these same groups will be worse of or not be impacted much at all. Most (63 percent) say it would not have much impact on wealthy people, just 14 percent say they would be better off and 18 percent say they would be worse off. Democrats and independents are more likely than Republicans to report that all people would be better off through a single government plan.

The country has not had a substantial public debate about single payer legislation recently and there is little consensus among the public about how enacting guaranteed universal coverage through a single government plan would impact their personal health care. Roughly four in 10 say that they think the cost, quality, availability of health care treatments, and choice of doctors and hospitals would stay about the same as it is under the current health care system. About a third say these measures would get worse if universal coverage was put into place and around two in 10 think these measures would get better. Not surprising considering their stances on the idea of guaranteed universal coverage, majorities of Republicans say each measure would likely get worse if such a plan was enacted, while at least half of Democrats say each would likely stay about the same. Additionally, those under age 50, Black and Hispanic Americans, and those with lower incomes are more likely than their counterparts to say that these measures will get better.

Wording Matters

Politicians and pundits use a variety of terms to describe the idea of expanding health insurance coverage to all Americans and this month’s poll explores the public’s reaction to a few of these terms. Nearly two-thirds (64 percent) of Americans say they have a positive reaction to the term “Medicare-for-all” and more than half (57 percent) say they have a positive reaction to the term “guaranteed universal health coverage.” Less than half of Americans report a positive association with the phrases “single payer health insurance system” (44 percent) and “socialized medicine” (38 percent).

Similar to the public at large, more Democrats report having a positive reaction to “Medicare-for-all” and “guaranteed universal health coverage” than say the same about “socialized medicine” or “single payer health insurance system.” Additionally, more Democrats have positive reactions to all of the terms than Republicans and independents do. Around half of Democrats report a very positive reaction to “Medicare-for-all” (53 percent) and “guaranteed universal health coverage” (44 percent), while fewer Republicans say the same for each (17 percent and 9 percent, respectively). Two in 10 Democrats report very positive reactions to “socialized medicine” (22 percent) and “single payer health insurance system” (21 percent), while fewer than one in 10 Republicans do.

Topline

4.  Which of the following comes closest to your view of the future of the US health care system?

  16%  The health care law should be repealed and NOT replaced

  13%  The health care law should be repealed and replaced with a Republican-sponsored alternative
 
  36%  Lawmakers should build on the existing health care law to improve affordability and access to care

  24%  The U.S. should establish guaranteed universal coverage through a single government plan

  6%  None of these/Something else

  4%  Don’t know/refused

5.  Do you favor or oppose having guaranteed health insurance coverage in which all Americans would get their insurance through a single government health plan?

  50%  Favor
       27%  Strongly favor
       23%  Somewhat favor

  43%  Oppose
       13%  Somewhat oppose
       30%  Strongly oppose

  7%   Don’t know/Refused

19.  I am going to read you a list of terms. Please tell me if you have a positive or negative reaction to each term.

a.  Socialized Medicine

    38%  Positive
         15%  Very positive
         23%  Somewhat positive

    49%  Negative
         19%  Somewhat negative
         30%  Very negative

    12%  Other

b.  Medicare-for-all

    64%  Positive
         36%  Very positive
         27%  Somewhat positive

    29%  Negative
         15%  Somewhat negative
         14%  Very negative

    6%   Other

c.  Single payer health insurance system

    44%  Positive
         15%  Very positive
         29%  Somewhat positive

    40%  Negative
         21%  Somewhat negative
         19%  Very negative

    17%  Other

d.  Guaranteed universal health coverage

    57%  Positive
         28%  Very positive
         29%  Somewhat positive

    38%  Negative
         15%  Somewhat negative
         22%  Very negative

    6%   Other

Report:
http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-february-2016/

Topline:
http://files.kff.org/attachment/topline-methodology-kaiser-health-tracking-poll-february-2016

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Comment:

By Don McCanne, M.D.

About half of Americans would prefer a single government health plan for everyone, according to this poll. However, when offered several choices, more would prefer to build on the current system (36%) than would prefer to establish a single government plan (24%). Also, followup questions show that the opinions of a single government plan are quite malleable, depending whether the query has a positive or negative slant.

The malleability of opinion and the poor understanding of the benefits of single payer demonstrate that the public still has a relatively weak understanding of precisely what a single payer system is. We need to intensify our educational efforts.

Perhaps more disconcerting is that more people would prefer to build on the Affordable Care Act than to establish a single government plan. The message of the incrementalists seems to be carrying the day. People believe that we can simply tweak the current system and achieve the same goals as single payer.

What people haven’t grasped are the fundamental differences between the financing infrastructures of our fragmented multi-payer system and a well designed single payer system. Recent Quote of the Day messages describing some of the flaws in our current system have asked the question, “What incremental change would fix this particular problem?” The answers don’t come easy.

It’s easy to say that we can build on the Affordable Care Act by gradually covering more people and by controlling spending by eliminating waste, but these are wishes, not policies. In most instances, there is no simple patch that would work, but rather most changes increase the administrative complexity, add significantly to the costs, and fall short of fully correcting the specific problems addressed.

This is a very important message that we have to deliver. Our current financing infrastructure is not particularly amenable to incremental patches. It is imperative that we replace our flawed infrastructure with one that automatically addresses the problems that we still face in health care financing. Single payer would do that.

This poll also tested labels for a single payer system. Close to two-thirds had a positive reaction to the term, “Medicare-for-all.” People also had a positive reaction to “guaranteed universal health coverage,” but that doesn’t mean much and has been misused as a label for systems that are neither guaranteed nor universal. Yet people seem to be split or confused by the term, “single payer health insurance system.”

“Medicare-for-all” does seem to be preferred, but some opponents are quick to point out the deficiencies in our Medicare program. Adding “improved,” as in “Improved Medicare for All,” defuses that challenge.

So do not let people get away with saying that we’ll simply build on the system we have. Demand that they define the precise incremental steps and how each would move us significantly closer to truly affordable care for absolutely everyone. If you keep pushing them they’ll eventually have to describe a single payer system because patches to our current system just won’t get us there.

Bad Debt Is the Pain Hospitals Can’t Heal as Patients Don’t Pay

By John Lauerman
Bloomberg Business, February 23, 2016

A type of pain that hospitals thought they had relieved has come back with a vengeance: it’s called bad debt.

Hospitals have long struggled to collect bills when patients aren’t covered by insurance — creating delinquent accounts. The Affordable Care Act was supposed to relieve some of that strain by helping pay for coverage for millions of Americans and expanding Medicaid in some states to cover the poor.

Yet while millions of people have gained coverage since Obamacare became law in 2010, there’s also been an increase in insurance that comes with high deductibles and cost-sharing. Under those plans, the first few thousand dollars of annual medical expenses come out of patients’ wallets. That’s money that hospitals like Childress Regional Medical Center in the Texas Panhandle region are unlikely to collect.

“It feels like a sucker punch,” said John Henderson, the nonprofit hospital’s chief executive. “When someone has a really high deductible, effectively they’re still uninsured, and most people in Childress don’t have $5,000 lying around to pay their bills.”

The rate of uninsurance in the U.S. has fallen to 9.1 percent from 15.7 percent in 2009. Yet in the first nine months of 2015, about 36 percent of the U.S. insured were covered by high-deductible or consumer-directed health plans that can require considerable out-of-pocket payments, compared with about 25 percent in 2010, according to a CDC survey.

Hospitals are feeling the pressure from those patients. Community Health Systems Inc. operates 195 hospitals in 29 states and is the U.S.’s second-biggest for-profit U.S. hospital chain. This month, it revised its fourth-quarter 2015 provision for bad debt up by $169 million — and said that 40 percent, or about $68 million of that amount, was from patients being unable to pay deductibles and co-payments. Patient bankruptcies also contributed, the company said.

While higher out-of-pocket charges can lower what insurance costs up front, it means more costs for patients on the back end. Under individual Obamacare mid-level “silver” plans, the annual deductible was $2,556, and under less expensive, low-level “bronze” plans it was $5,328 in 2015, according to the Kaiser Family Foundation.

Outside of Obamacare, deductibles are becoming more common, as well. Last year, 81 percent of coverage people got through work came with a deductible, up from 70 percent in 2010, according to Kaiser. The average deductible in a high-deductible, individual plan gained through work was $2,099 last year.

Rural hospitals have been hit particularly hard. Minnesota has long had high rates of care coverage, and many employers have switched to high deductible offerings, according to Joe Schindler, vice president of finance for the Minnesota Hospital Association. Last year, bad debt rose by 20 percent to $425 million at the association’s 140 member hospitals.

http://www.bloomberg.com/news/articles/2016-02-23/bad-debt-is-the-pain-hospitals-can-t-heal-as-patients-don-t-pay

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Comment:

By Don McCanne, M.D.

The Affordable Care Act (ACA) was supposed to make health care affordable, yet many hospitals are finding that patients are generating more bad debt. A large portion of that is due to the inability of patients to pay the high deductibles and other cost sharing required  by their insurance plans. Patient bankruptcies also compound the problem.

Deductibles are used by insurers to shift some of the spending to patients so that the insurers can keep the premiums for their plans competitive. But much has been written about how these deductibles create financial burdens for patients. And when the patients cannot pay the deductibles, physicians and hospitals are faced with bad debt. With greater use of higher deductibles, the problems with debt will surely increase.

This is a problem inherent in the model of reform perpetuated by ACA. Various policies such as the deductibles are developed to comply with the private insurance model. How would the incrementalists fix this problem? There are too many moving levers.

What we should have instead is a system in which the policies are developed to comply with the needs of patients. Deductibles can be eliminated if we do away with premiums as a means of financing health care.

The financing of a single payer system is not through individual premiums but rather is through a single universal risk pool that is funded equitably through progressive taxes, making health care affordable for everyone. Medical debt simply goes away.

Clinton resurrects public option

By Dan Diamond
Politico Pulse, February 23, 2016

Hillary Clinton is bringing back the “public option,” a liberal health reform that so far has gotten little attention this campaign cycle as Bernie Sanders has pushed an even more progressive single-payer plan.

The public option — initially conceived as a government-run alternative to private insurance — was backed by Clinton in her 2008 campaign and was the subject of intense debate during the drafting of the Affordable Care Act. However, Democrats abandoned the measure after Senate moderates said they wouldn’t vote for it because it expanded the government’s role in health care too far.

Clinton is again making clear she supports a version of the public option. This time, though, she wants to allow states to opt in, according to a newly updated policy position on her campaign website.

How would it work — and why now?

Clinton appears to be suggesting that states could use the ACA’s 1332 waivers to “empower states to establish a public option choice” in 2017. It’s plausible that liberal governors and legislatures would opt in, while keeping the fight over this progressive idea largely out of Washington.

It’s unclear exactly what Clinton’s thinking is on this, however. The campaign didn’t respond to repeated requests from POLITICO to clarify its new policy language.

Just last month: Clinton said ‘we couldn’t get the votes’ for public option.

While Clinton’s spokesperson told PULSE that she has consistently backed the public option since the 2008 campaign, Clinton pointed out just last month that Congress wasn’t able to get it through during the ACA. “There was an opportunity to vote for what was called the public option,” Clinton said during a debate in South Carolina, after she rebuked Sanders’ plan as impractical. “But even when the Democrats were in charge of Congress, we couldn’t get the votes for that.”

http://www.politico.com/tipsheets/politico-pulse/2016/02/clinton-resurrects-public-option-califf-nomination-moves-forward-how-the-election-could-shape-the-market-212836

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Hillary for America

Affordable health care is a basic human right.

Hillary has never given up on the fight for universal coverage—and she won’t stop now. Building on the Affordable Care Act to expand coverage for millions of Americans, Hillary will:

*  Continue to support a “public option” — and work to build on the Affordable Care Act to make it possible. As she did in her 2008 campaign health plan, and consistently since then, Hillary supports a “public option” to reduce costs and broaden the choices of insurance coverage for every American. To make immediate progress toward that goal, Hillary will work with interested governors, using current flexibility under the Affordable Care Act, to empower states to establish a public option choice.

https://www.hillaryclinton.com/issues/health-care/

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Public Plan Option in a Market of Private Plans

By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.
Physicians for a National Health Program, May 26, 2009

The “public plan option” won’t work to fix the health care system for two reasons.

1. It forgoes at least 84 percent of the administrative savings available through single payer. The public plan option would do nothing to streamline the administrative tasks (and costs) of hospitals, physicians offices, and nursing homes, which would still contend with multiple payers, and hence still need the complex cost tracking and billing apparatus that drives administrative costs. These unnecessary provider administrative costs account for the vast majority of bureaucratic waste. Hence, even if 95 percent of Americans who are currently privately insured were to join the public plan (and it had overhead costs at current Medicare levels), the savings on insurance overhead would amount to only 16 percent of the roughly $400 billion annually achievable through single payer — not enough to make reform affordable.

2. A quarter century of experience with public/private competition in the Medicare program demonstrates that the private plans will not allow a level playing field. Despite strict regulation, private insurers have successfully cherry picked healthier seniors, and have exploited regional health spending differences to their advantage. They have progressively undermined the public plan — which started as the single payer for seniors and has now become a funding mechanism for HMOs — and a place to dump the unprofitably ill. A public plan option does not lead toward single payer, but toward the segregation of patients, with profitable ones in private plans and unprofitable ones in the public plan.

https://pnhp.org/blog/2009/03/26/himmelstein-and-woolhandler-on-a-public-plan-option/

*****

Comment:

By Don McCanne, M.D.

You remember the public option. During the drafting of the Affordable Care Act (ACA), efforts were made to include a public option – a government-run plan that would compete with the private health plans in the insurance marketplace. If the private plans proved that they could provide greater value, then they would prevail. If the government could do a better job, then the public option could expand by demand and eventually become the single payer for the nation, so supporters believed.

The original concept for the public option was to allow individuals to buy into the Medicare program instead of purchasing private insurance. There were some obvious problems. Medicare lacked some important features required of the private plans such as catastrophic coverage – establishing a maximum out-of-pocket responsibility of paying for health care. Also, the existing Medicare pool was composed of the elderly and those with long term disabilities – expensive groups to insure. The exorbitant premium that would have to be charged could not be competitive with the private plans.

It was then decided to establish a new public insurance program that was designed like the private plans and that would have to follow the same rules. The insurance industry immediately opposed this since it would be “unfair” competition considering the government resources backing up the public plan, and the inherently higher administrative costs that the private insurers face, not to mention the need to profit from their operations – profit not being a feature of a publicly-owned insurer. Several (anti-competitive) features were proposed for the public option which would give the private insurers a “fair” playing field.

The insurers were still concerned that they could not compete against even a restricted government plan, and thus they continued to oppose it. There is a basis for that concern since the private Medicare Advantage plans are able to “compete” with the traditional Medicare program only because of the overpayments that are being made to the private plans. If they were in the same playing field, the private plans would perish. Nevertheless, the issue of the public option became moot when Sen. Joseph Lieberman, with no votes to spare, threatened to kill the entire Affordable Care Act if the public option were included.

We were left with the co-ops as a substitute for the public option. The co-ops are non-profit organizations in which the insured members are the owners. Congress, under the Republicans, has refused to provide promised funds, and half of them have collapsed. They are now being used by opponents of single payer to “prove” that the government would be incapable of running a single payer system – an obvious non sequitur.

Since the enactment of ACA there have been endless calls to add a public option. Single payer failed to gain traction because of the pervasive meme that single payer was not politically feasible. But if we could just get a public option, that would automatically evolve into a single payer system, they said.

Then along came Bernie Sanders. He carried the message that not only was single payer politically feasible, it was a moral imperative to achieve health care justice for all.

To the surprise of Hillary Clinton and her campaign staff, Bernie Sanders came out of nowhere and gained traction carrying the single payer banner, and, as a result, has become a genuine challenge to her candidacy.

Hillary Clinton has always been an opponent of single payer and instead has supported the private insurance industry. Some have misinterpreted a statement of hers many years ago as supporting the fact that we would have single payer in the United States. But that statement was not in support of single payer but rather was her threat to us that if we did not accept her managed competition model of reform, we would have single payer.

So what was her campaign to do? They decided to bring back the concept of a public option to appease those who were turning to Sanders because of his advocacy of single payer. They are relying on the meme that the public option is our door to single payer (even though it is not true). But look at what her version of the public option is.

She says we should build on ACA. She has proposed no new federal public option legislation but she is merely suggesting that the states look at Sec 1332 of ACA which authorizes waivers for limited innovations on a state level. Imagine the difficulties that states would have, within the confines of Sec 1332, in building their own intra-state public plan. Unless they used private insurance innovations such as high deductibles, narrow provider networks, and tiered services, the premiums would be unaffordable to most. A single payer system would be funded equitably through progressive taxes, but you could not do that with a public option since that is only one plan in a multi-payer system.

In 2009, David Himmelstein and Steffie Woolhandler explained in very brief terms why the public option is a flawed concept (reproduced above). Hillary Clinton is now showing us how it is a diversion from the reform we really need – single payer. It is up to us, the people, to convince our politicians that single payer is what we want. It will not happen without us.

Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.

Pence seeking help from Congress in Medicaid dispute

By Maureen Groppe
Indianapolis Star, February 21, 2016

Gov. Mike Pence wants Congress to get involved in his dispute with the Obama administration over the evaluation of Indiana’s alternative Medicaid program.

Pence has accused the administration of hiring an evaluator that is biased against Indiana’s approach.

Indiana is one of a handful of states that received permission to not follow some federal rules when expanding Medicaid coverage under the Affordable Care Act.

One of the conditions of such waivers is that the demonstration program be evaluated to see whether it’s meeting the expected result. Indiana must submit an interim evaluation of the program by mid-2016.

For example, Indiana is testing whether requiring participants to make monthly contributions to a health account that can be rolled over if not used for health care reduces the use of unnecessary care.

That feature is based on high-deductible insurance plans with health savings accounts that are becoming increasingly common in private insurance coverage.

Pence argues that the Urban Institute, one of the evaluators chosen by the federal government to assess Indiana’s plan, has previously been skeptical of using the health savings account model for Medicaid recipients.

Pence wrote Health and Human Services Secretary Sylvia Burwell in December, asking that the federal review be dropped as the Healthy Indiana Plan has already been evaluated by a state-hired contractor.

In a Feb. 10 response, Burwell said the federal evaluation will not duplicate the state’s analysis, and a rigorous evaluation will help the federal government determine whether other states should be allowed to use Indiana’s model.

Pence said he is “wholly unsatisfied” with that response, and will ask the GOP-controlled Congress to review the agency’s vendor selection process.

While Pence said Burwell always worked in good faith with him while they negotiated the terms of Indiana’s alternative program, there are people “deep in the bureaucracy” who are “very antagonist towards consumer driven health care.”

“The administration wanted Indiana — and still wants every state — to just expand traditional Medicaid,” he said. “We have the most significant Medicaid reform in the 50-year history of the program, and it’s working.”

A coalition of health care and other advocacy groups wrote a letter last month in support of the federal government’s evaluation of HIP 2.0. The coalition — which includes Families USA, the March of Dimes and the American Cancer Society Cancer Action Network — said there can be a conflict of interest with state-contracted evaluations.

“When a state pays an organization to assess the merits of its own program there is the potential that the evaluator’s objectivity will be compromised,” the coalition wrote to the director of the Center for Medicaid and CHIP Services.

The groups said aspects of Indiana’s program are potentially harmful to beneficiaries and need to be evaluated before the federal government decides whether other states can adopt them. Those features include the option of charging monthly payments to recipients below the poverty line, blocking coverage for those above poverty who miss their monthly payments, and the overall complexity of HIP 2.0.

http://www.indystar.com/story/news/2016/02/20/pence-seeking-help-congress-medicaid-dispute/80663058/

The RWJF/Urban Institute report that Pence argues shows a bias against using healthy savings accounts in Medicaid:

http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2015/rwjf420603

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Comment:

By Don McCanne, M.D.

Gov. Mike Pence of Indiana wants to select his own facts for a report to CMS confirming that their consumer-directed health program for Medicaid, authorized by a Sec. 1115 waiver, is meeting Medicaid requirements for the patients.

They have already independently contracted with the Lewin Group to provide a report to CMS, but numerous organizations have expressed the concern that this report could be biased because of the conflict of interest. CMS has contracted with the Urban Institute, but Gov. Pence objects because Urban has produced a previous report expressing some concerns about the option to charge premiums for individuals living in poverty and about the administrative costs and inefficiencies of health savings accounts that are used in Indiana’s program. Also there is concern about Medicaid patients being locked out of care if they are in arrears with their premium payments.

Indiana’s program is driven by ideology rather than by objective application of health policy principles. Pence touts their success at “applying consumer-health care principles to the Medicaid population.” It is more important for him to require patients to demonstrate individual responsibility through sharing in the costs of care than it is to ensure that they do receive the care that they need. It has been demonstrated that requiring payments creates barriers to care, particularly for low-income individuals.

Imagine instead having one national standard program that automatically includes everyone, gives them free choice of their health care professionals, and removes financial barriers to care. We could have that with a single payer national health program, as long as we keep ideologues like Pence out of the way.

Making Medicare Advantage Payments More Accurate

By Edwin Park
Center on Budget and Policy Priorities, February 16, 2016

Anticipating the Centers for Medicare and Medicaid Services’ (CMS) expected announcement Friday of preliminary payment rates and policies for Medicare Advantage insurers in 2017, insurers have pushed for changes to the “risk adjustment” system — which raises or lowers payments to plans based on their enrollees’ health.  Insurers claim the system undercompensates them for high-cost enrollees with chronic conditions.  We favor making the system as accurate as possible, but that should include reducing overpayments to insurers as well.

To be sure, risk adjustment tends to underpredict health spending for high-cost individuals in poorer health.  The Medicare Payment Advisory Commission (MedPAC) suggests that CMS make several changes to better account for higher spending by people with multiple chronic conditions and low-income beneficiaries eligible for both Medicare and Medicaid.

But Medicare Advantage risk adjustment also overcompensates insurers for healthier, low-cost enrollees.  For example, Avalere Health research, which insurers have cited favorably, shows risk adjustment overpredicting spending among people with no chronic conditions by 26.9 percent and among people with one or two chronic conditions by 5.1 percent.  That’s critical because Medicare Advantage enrollees are healthier than those in traditional Medicare, on average.

CMS could reduce Medicare Advantage overpayments by doing more to address “upcoding,” which the Congressional Budget Office, the Government Accountability Office (GAO), and academic research cite as a long-standing problem.  The risk adjustment system measures enrollees’ health using a “risk score” based on patient diagnoses; upcoding occurs when the risk scores that plans submit for their enrollees rise over time — making enrollees appear increasingly unhealthy — without actual changes in their health.

Risk scores have risen 9 percent faster in Medicare Advantage, on average, than in traditional Medicare for comparable beneficiaries, MedPAC estimates.  This leads to excessive payments to Medicare Advantage plans.

To compensate for upcoding, health reform requires CMS to adjust Medicare Advantage’s risk adjustment system by at least a minimum amount each year.  CMS has only applied the minimum required adjustment in recent years.  A larger adjustment, which MedPAC believes is warranted, would reduce overpayments to Medicare Advantage plans.

CMS could also reduce upcoding by excluding health assessments from risk score calculations unless they’re later confirmed in treatment settings, as MedPAC will likely recommend in its March report to Congress.  Medicare Advantage plans increasingly provide health assessments of their enrollees; for example, a nurse may come to a patient’s home to do a physical exam.  CMS has found that some insurers mainly use these assessments to “collect” diagnoses in order to raise enrollees’ risk scores for purposes of risk adjustment, rather than to improve follow-up care or identify illnesses requiring treatment.  In fact, CMS had proposed excluding these kinds of assessments but dropped this change in the face of industry opposition.

http://www.cbpp.org/blog/making-medicare-advantage-payments-more-accurate

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2017 Medicare Advantage and Part D Advance Notice and Draft Call Letter

CMS.gov, February 19, 2016

Today, CMS released proposed updates to the Medicare Advantage (MA) and Part D programs through the 2017 Advance Notice and Draft Call Letter. Through these policies, CMS is proposing updates to the program designed to improve the accuracy of payments to plans serving beneficiaries who are dually eligible for Medicare and Medicaid.  

CMS is proposing updates to the Risk Adjustment Model used to calculate payments to Medicare Advantage plans and to the Star Rating system used to evaluate plan performance. In both cases, the updates reflect a public process through which CMS shared research findings and solicited public comment.

Expected Average Change in Revenue:  3.55%

Risk Adjustment Model

CMS is proposing to implement a new Risk Adjustment Model for 2017. The proposed new model has separate coefficients for partial benefit dually eligible beneficiaries, full benefit dually eligible beneficiaries, and non-dually eligible beneficiaries.  These proposed changes will improve the precision of the payments made to plans, including increases in payments for plans serving full benefit dually eligible beneficiaries.

Coding Pattern Adjustment

Each year, as required by law, CMS makes an adjustment to plan payments to reflect differences in diagnosis coding between Medicare Advantage organizations and fee-for-service (FFS) providers. In CY 2017, CMS proposes to make an adjustment reflective of the statutory minimum.

Using Encounter Data

CMS calculates risk scores using diagnoses submitted by FFS providers and by Medicare Advantage organizations. Historically, CMS has used Medicare Advantage diagnoses submitted into CMS’ Risk Adjustment Processing System (RAPS). In recent years, CMS began collecting encounter data from MA organizations to develop more accurate payment models. In 2016, CMS began using diagnoses from encounter data to calculate risk scores, by blending encounter data-based risk scores with RAPS-based risk scores. In 2017, CMS is proposing to continue using a blend, using a higher percentage of encounter data-based risk scores.

Star Ratings – Adjusting for Socioeconomic Status

CMS is proposing to implement a new analytical adjustment for a subset of Star Rating measures that is meant to adjust for plans serving dually eligible enrollees and/or enrollees receiving the low income subsidy, as well as enrollees with disabilities. Through this interim adjustment, CMS seeks to more accurately capture true plan performance, while work continues by the HHS Assistant Secretary for Planning and Evaluation (ASPE) and measure stewards in this important area.

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-02-19.html

CMS Advance Notice of Methodological Changes for Calendar Year (CY) 2017 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2017 Call Letter (over 220 pages):

https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2017.pdf

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AHIP, Coalition for Medicare Choices Launch Nationwide Ad and Grassroots Campaign to Protect Medicare Advantage

AHIP, January 28, 2016

As CMS prepares to release proposed Medicare Advantage payment policies, AHIP’s Coalition for Medicare Choices (CMC) is launching a coast-to-coast mobilization of its 2 million Medicare Advantage beneficiaries who are calling on Washington to protect their coverage from further cuts.

“Medicare Advantage is the game-changer. It’s the foundation for innovative, high-quality care delivery that seniors and the country demand,” AHIP President and CEO Marilyn Tavenner said. “CMS should protect millions of beneficiaries who depend on Medicare Advantage and strengthen — not undermine — the program moving forward.”

https://www.ahip.org/News/Press-Room/2016/AHIP,-Coalition-for-Medicare-Choices-Launch-Nationwide-Ad-and-Grassroots-Campaign-to-Protect-Medicare-Advantage.aspx

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Comment:

By Don McCanne, M.D.

Today CMS released proposed updates for the 2017 Medicare Advantage (MA) plans. It appears that, once again, CMS will be co-conspirators with the insurance industry in increasing net MA payment rates when the Affordable Care Act requires reduction of the MA overpayments.

The Medicare Payment Advisory Commission (MedPAC) has recommended that CMS apply a larger adjustment to the MA risk adjustment system to reduce overpayments to the MA plans. Yet, once again, as with prior years, CMS is making “an adjustment reflective of the statutory minimum.”

Another example is that the MA plans have been using “encounter data” to upcode the diagnoses of the MA patients. Home visits are made, not by the health care providers but by representatives of the MA insurance plans, in order to find other disorders that can be used to pad the diagnostic list, making these patients appear sicker than they really are, thus qualifying the MA plans for higher payments than warranted. MedPAC is expected to recommend excluding encounter data from risk score calculations unless they are later confirmed in treatment settings. Yet, CMS is instead proposing to use a higher percentage of encounter data-based risk scores.

Instead of a reduction in payments, CMS is proposing a 3.55% increase.

CMS invites comments through March 4, 2016 before the final publication on April 4, 2016. During that time, AHIP, the insurance lobby organization, will be negotiating with CMS for further adjustments that will favor the MA plans. Each year that has resulted in additional innovative chicanery that further thwarts the intent of ACA to reduce MA overpayments. Since the new President and CEO of AHIP is Marilyn Tavenner, the former Administrator of CMS, it is anticipated that the negotiations on behalf of the MA plans will be quite successful.

Ensuring success of the MA plans is part of the plot to eventually privatize Medicare – converting it into a premium support system (vouchers) for a market of private plans that will displace the traditional Medicare program. The value of the voucher equivalents will erode with time, shifting ever more of the costs to the Medicare beneficiaries. It will be disastrous.

By this time it was expected that MA plan enrollment would begin to decline since the private insurance industry is incapable of providing comparable benefits at the same or lower costs than traditional Medicare, because their administrative costs are significantly higher than those of the traditional program, plus they need to return a profit to their investors. They have been profitable only because they have continued to be successful in enrolling healthier, less costly patients while at the same time receiving overpayments from the government.

Thus this conspiracy reenacted each year to use innovative payment schemes (chicanery) is vital to this industry. Members of AHIP’s Coalition for Medicare Choices will, once again, pressure members of Congress to cajole CMS into “saving” the Medicare Advantage plans through whatever accounting tools they can find (all with a wink and a nod). What is surprising is that this has not provoked the outrage of taxpayers. But maybe this is not so surprising after all since hardly anyone recognizes the terrible crime that is taking place before our very eyes.