PNHP

Should health insurance options control retirement decisions?

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Should health insurance options control retirement decisions?

If Obamacare Exits, Some May Need to Rethink Early Retirement

By Austin Frakt
The New York Times, February 27, 2017

Here’s another possible consequence of repealing the Affordable Care Act: It would be harder for many people to retire early.

Americans reaching 65 become eligible for Medicare. Before reaching that age, some can get retiree coverage from their former employers. But not very many companies, especially small ones, offer medical insurance to retirees. If early retirees are poor enough, they could turn to Medicaid. To retire early, everybody else would need to turn to the individual health insurance market. Without the subsidies and protections the A.C.A. put in place, health care coverage would be more difficult to obtain, cost consumers more where available, and provide fewer benefits than it does today.

But it is clear that with A.C.A. repeal on the table, people contemplating early retirement may need to reconsider.

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NYT Reader Comments:

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

It seems that our goal should be to remove financial barriers to health care for all of us so we can get the health care we need when we need it.

So why do we make it difficult by establishing such arbitrary qualifications for health coverage: employment status (employer-sponsored plans), older age (65 for Medicare), younger age (CHIP), income (Medicaid), prior military service (VA), ethnic heritage (Indian Health Service), temporary unemployment (COBRA), or whatever?

This complexity contributes greatly to the profound administrative waste in our system – now over a half a trillion dollars a year that could be recovered, according to a report this month in the Annals of Internal Medicine. It also increases instability in our health care with ever-changing provider networks, creating a degree of fragmentation that is unique in the U.S. health care system.

It would be so much simpler and efficient to improve Medicare so that it is appropriate for all ages, and then automatically include everyone, using an equitable method of funding that would be affordable for all.

With the difficulty that Congress is having with decisions on how to improve health care financing, why don’t they finally take a serious look at a proven model that has worked well in other nations – a single payer national health program – in the form of an improved Medicare for all?

https://www.nytimes.com…

Amid GOP Attacks on Health Care, the Movement for Single Payer Is Growing

By Michelle Chen
Truthout, Feb. 27, 2017

This could be the moment that the country finally comes to its senses on single payer, according to Dr. David Himmelstein, co-founder of the advocacy network Physicians for a National Health Program (PNHP).

Facing the inevitable collapse of an unsustainable system, “now there’s much more…appetite for addressing the fundamentals,” Himmelstein said.

One proposal for enacting single payer is simply extending and fortifying the basic infrastructure of Medicare, the centralized plan covering seniors over 65. Even Medicare in its current form is not a pure single-payer program: It suffers from its own funding gaps and contains major coverage deficits patched by semi-privatized or market-based care. (Republicans are now poised to exacerbate these gaps with post-ACA reforms that would replace it with more private, fee-based programs, which could destroy publicly subsidized care generally, endangering both Medicare for seniors and Medicaid for low-income families.)

However, as a blueprint for a workable single-payer network, the popular program could form a politically acceptable foundation for a universal health plan.

According to a recent cost analysis published by Drs. Himmelstein and Steffie Woodhandler, another PNHP co-founder, an enhanced “Medicare for all” system, which would consolidate private insurance schemes into a single, unified care network covering every patient, would save the public a total of more than $610 billion in 2017 alone, including more than $100 billion in reduced drug costs, primarily by cutting administrative waste and bloat, and integrating all services under a transparent, uniform cost structure. Patients, meanwhile, would be guaranteed lifetime coverage without insurance fees or premiums, and no risk of exclusion from coverage.

full article:
http://www.truth-out.org…

Appalachia needs a single-payer health system

By Katie Lee
Johnson City (Tenn.) Press, Feb. 26, 2017

We are all aware that the recent election is likely to bring change in the health care system of this nation, but we have a choice to make. During these tumultuous times in health care policy, the way forward is not to strip 20 million Americans of their health care by repealing the Affordable Care Act  without a replacement. Instead, we should pursue the most equitable and just option — a single payer health care system.

No, this is not “socialized medicine,” which would mean both the financing and delivery of care are government funded. We already have a form of this system for our veterans, and it leaves much to be desired. What a coalition of 20,000 physicians, medical students, and other health professionals propose is a “Medicare-for-all” system.

The ACA has taken necessary steps toward a universal system, but it has fallen short. Among the most popular components are the right to remain free from discrimination for a pre-existing condition, young people remaining on their parents’ plans until they turn 26, and equity in plan cost between men and women.

Yet, approximately 27 million people remained uninsured after the landmark legislation was passed and an acceptable reduction in cost was not truly achieved. Supporters of the ACA aimed to bend the curve on ever-increasing health care expenditures and while this was accomplished, they still accounted for 18 percent of GDP last year.

The United States remains the only developed country with for-profit insurance companies and only one of three developed nations that does not guarantee health care. We are spending the largest amount per capita ($8,000 plus) on health care expenditures of any nation in the world, but without the best outcomes.

The leading cause of bankruptcy in the United States is medical bills, and an estimated 45,000 deaths annually can be attributed to lack of health insurance. Over 100 million Americans forgo professionally recommended medical care due to cost each year. Clearly, we have work to do. A single-payer system by way of a Medicare-for-All structure would allow coverage for all Americans and would actually reduce spending.

Not all states chose to expand Medicaid, including approximately half of those traditionally included in the Appalachian region, leaving lower income earning adults in a gap between Medicaid and marketplace subsidies. Americans were left with artificial lines between states that create headaches for Tri-Cities area patients daily, when the nearest hospital to rural dwellers may be across state lines.

Social workers in our local hospitals work tirelessly to coordinate care for patients leaving Tennessee hospitals, but needing follow-up in West Virginia, Virginia or Kentucky where their health insurance coverage and state law differs. Paying employees to navigate these complexities is currently unavoidable, but it is my hope that a more streamlined, simple system could render these duties unnecessary.

Today we waste about a third of our health care dollars to overhead, administrative costs and insurance profits. Physicians cite administrative burden as one of the leading causes of burn out, leading to decreased quality of care.

With a single-payer system for all Americans, we reduce this waste and instead direct these funds toward medical care. There is an additional benefit of freeing up physicians to spend longer appointments with patients as needed or increase patient volume.

Moreover, Americans living in rural areas face a physical access to care issue in addition to cost barriers. This makes seeking appropriate preventive care visits and screening tests even more important. It is a well-known fact that it is cheaper to prevent a chronic illness than to treat it long-term.

Consequently, removing the cost barrier to preventive services in Appalachia while we work to improve the number of physicians and hospitals in rural areas is morally imperative but also cost effective.

Uninsured Americans cited lack of affordability and unemployment as their top two reasons for their insurance status. While the national unemployment rate in 2014 was around 6 percent, in the more economically depressed parts of Appalachia that figure reached as high as 14 percent. Increased levels of unemployment in the region together with state policies declining Medicaid expansion contribute to higher uninsured rates, and consequently poorer health outcomes.

Our mixed system including employer-based health coverage is a relic of a time when most employees remained in the same job for decades and is inappropriate for the more dynamic, shifting workforce of today. Transition away from employer-based care would prevent workers from fearing a job change lest they lose their insurance, freeing workers to pursue innovative, entrepreneurial positions they might otherwise have foregone.

The 45th President of the United States has praised the concept of universal health care multiple times in the past, citing the improved mortality rates and reduced costs per capita in countries with this structure. In order to capitalize on his promise to take care of “the forgotten” in the United States, including those living in the impoverished communities of coal country, I urge the president to reconsider a Medicare-for-all system.

Not only will it help make this country “great,” it is the right thing to do.

Katie Lee is an aspiring medical professional with a passion for social justice issues. She is a graduate of Vanderbilt University and lives in Johnson City.

http://www.johnsoncitypress.com…

We Represent the Future

By Adam Gaffney, M.D.
Jacobin, Feb. 26, 2018

When future historians chronicle how Medicare for All was finally won, the current moment may prove to be a crucial turning point in their narratives, albeit one contained, most likely, in the earlier chapters. Scholars will have to probe why single payer emerged with such potency at this moment. Proponents have been steadfastly advancing the cause for decades, but it took Bernie Sanders’s insurgent primary campaign to push single payer into the political spotlight.

And it was only last year, amid all the lurid dysfunction and savagery of Trump’s first months in office, when activists helped thwart the Republicans’ Obamacare repeal efforts while simultaneously achieving a historic advance for Medicare for All. For the first time, single-payer bills won support from a majority of Democrats in the House, and — after Sanders’s new bill launched in September — more than a third of those in the Senate. More and more legislators, it seems, knew which way the wind was blowing.

Why now? Because, as historians might one day note, we are at the intersection of two related crises: one in health care, the other in politics.

The first of these may seem like nothing new. There have been health care injustices in America for as long as America has had a health care system. Hospitals once turned away the poor and uninsured in the throes of illness; facilities were once viciously segregated; reproductive rights were once not much more than aspirations. But we also made progress: from the civil rights era, which realized Medicare and Medicaid, to the passage of the Affordable Care Act (ACA), which expanded insurance coverage to twenty million people. But if American health care used to be so much worse, why is it in crisis now?

In part because, despite such wide-ranging reform, the system’s injustices remain unresolved, pervasive, and deadly.

The figures tell the story. Even without Republican rollbacks, twenty-eight million have no insurance, and, according to the Commonwealth Fund, some forty-one million are underinsured. A substantial portion of the nation — predominantly those of low and middle income and disproportionately people of color — cannot afford to see doctors, pay for medicine, or go to the emergency room.

Families who bought silver plans on the Obamacare marketplace still have $8,292 deductibles, but less than half of American households can cover even a $4,000 deductible. Patients take twice-a-day medications only once, skip doses, or fail to fill their prescriptions to save on co-payments. And of course, people die — tens of thousands of people a year — because they lack coverage.

But the crisis in American health care isn’t simply that the aca didn’t go far enough: it’s that there’s no aca 2.0 available to finish the job. Real progress has been made, but the incremental reforms left us with a deeply inhumane system. Meanwhile, the Right is on the prowl, offering a slew of tired, malicious nostrums about personal responsibility, while liberal reformers have mostly run out of ammunition. But the Left has not, and single payer is now the only potent policy weapon still on the table.

Today’s second crisis comes from the larger political economy. Decades of rising inequality have left a substantial proportion of the population wondering if any politician actually represents them. The unequal health care system only exacerbates the problem: wage stagnation has come with rising health care costs, further squeezing workers’ take-home pay. A recent study in the American Journal of Public Health found that, after accounting for income devoted to health care expenditures, economic inequality is even worse than we thought: these costs effectively push an additional seven million people into poverty.

Discontent with the status quo helps explain the unprecedented success of a democratic socialist in the 2016 primary. But the neoliberal crisis has sparked a resurgence in right-wing populism as well. An odious billionaire has risen to power at the head of a right-wing government that spews pollution, slashes the safety net, vilifies immigrants, and redistributes wealth upwards with great efficiency and vengeance.

We should see the Medicare-for-all movement as a powerful response to both crises. It will transform health care, mandating a social right to equitable care, free at point of use. Everyone in the nation will enjoy comprehensive benefits without provider networks, co-pays, or deductibles.

Almost everyone — sick and well, insured and uninsured — has something to gain from this system. Single payer’s universalism is its strength, and the reason we can win it. But the Medicare-for-all movement is both a means and an end: it will clearly make for a happier and healthier nation, but it can also can become a unifying issue within a larger egalitarian political project at a moment of political crisis.

One day, when we read the history of how, against incredible odds, a single-payer national health program was finally created, we will come upon an early chapter that chronicles how Medicare-for-all advocates survived in the political wilderness. We’ll hear about how activists cut their teeth, built coalitions, crafted policy, drafted bills, won over politicians, launched campaigns, swayed opinions, and mobilized the grassroots. It will tell the story of ordinary people forging a powerful movement; it will tell the story of our present.

Fortunately, the next chapter isn’t so far in the future. It will describe how the movement was tempted by — but ultimately rejected — weak and diversionary counterproposals, how it broadened its base, how it skirmished with powerful corporate lobbies with near-bottomless war chests, and how it finally pushed a robust single-payer health care program onto the national legislative agenda.

Let’s forge ahead, confident as the architect of the National Health Service, Nye Bevan, was when he said that “the tides of history are flowing in our direction, that we are not beaten, that we represent the future…”

https://jacobinmag.com…

Listening to Trump voters who have ACA coverage

What They Want in a Health Care Plan

By Jennifer Tolbert and Larisa Antonisse
Kaiser Family Foundation, February 22, 2017

In order to gain a better understanding of the personal experiences of Trump voters with health coverage provided through the ACA and the changes they would like to see in the health system moving forward, the Kaiser Family Foundation (KFF) held focus groups with individuals who voted for Trump in cities in three battleground states: Grand Rapids, Michigan; Columbus, Ohio; and Harrisburg, Pennsylvania.

FOR MANY, MARKETPLACE COVERAGE HAS NOT LIVED UP TO EXPECTATIONS

* Three years into the implementation of the Marketplaces, participants still seemed overwhelmed by their plan choices and confused about key aspects of their plans.

* Participants were particularly frustrated by unaffordable out-of-pocket costs associated with high deductibles.

* The high cost of prescription medications was a common complaint and many Marketplace participants did not believe their plan protected them from these costs.

* Participants also expressed frustration at receiving surprise medical bills for services they thought were covered.

WHAT THEY WANT IN A REPLACEMENT PLAN

* When asked what they would want in an ACA replacement plan, participants’ top priority was coverage that was more affordable—affordable premiums, but most importantly, affordable out-of-pocket costs.

* They also wanted more help for people like them.

* Access to doctors and hospitals was another priority for participants.

* Participants wanted simplification of health plan choices and greater transparency from the insurance companies.

VIEWS OF REPUBLICAN PROPOSALS

* Participants rejected the idea of high deductible plans, even when coupled with premium tax credits to cover the premium and Health Savings Accounts (HSAs) to save for out-of-pocket costs.

* While there was general support for the concept of an HSA, many did not understand what they were and said they did not have the savings, or would not be able to save enough during the year, to cover the out-of-pocket costs associated with a plan with a high deductible.

* Participants also rejected the concept of basing tax credits solely on age regardless of income.

* Frustrated by the complexity and uncertainty of the current system as well as proposals to replace it, several participants advocated for a single-payer system modeled on the Canadian health care system.

http://kff.org…

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Comment:

By Don McCanne, M.D.

These focus groups were uniquely composed of Trump supporters in battleground states who also received health care coverage through the Affordable Care Act. Were they, like many conservatives, supporting the repeal of ACA – a leading issue for Donald Trump in his campaign? If they were not satisfied with ACA, then what did they want?

They remain concerned about three of the leading problems with today’s private health plans – high premiums, high deductibles, and narrow provider networks. Their top priority was affordability – affordable premiums and affordable out-of-pocket expenses. They also want greater access to physicians and hospitals than the narrow networks allow, and they do not want to receive surprise medical bills from out-of-network providers. They also want simplification of health plans (the greatest simplification being single payer).

Although some look upon Trump supporters as being conservatives who want to reduce the role of government, actually several in this group were able to pull together the policy issues and come to the conclusion that, to reduce “the complexity and uncertainty of the current system,” we should enact “a single-payer system modeled on the Canadian health care system.”

President Trump, these are your supporters. You need to read the article from the Annals of Internal Medicine: “Single-Payer Reform: The Only Way to Fulfill the President’s Pledge of More Coverage, Better Benefits, and Lower Costs” by Steffie Woolhandler, MD, MPH and David U. Himmelstein, MD You can download it at this link:

http://annals.org…

Trump says reform is now

Trump: ObamaCare replacement coming in ‘a couple of weeks’

By Max Greenwood
The Hill, February 18, 2017

President Trump said on Saturday that a plan to replace the Affordable Care Act will come “in a couple of weeks.”

“We are going to be submitting in a couple of weeks a great healthcare plan that’s going to take the place of the disaster known as ObamaCare,” he said at a campaign rally in Melbourne, Fla. “It will be repealed and replaced.”

“Just so you understand, our plan will be much better healthcare at a much lower cost,” he added.

http://thehill.com…

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Trump: Tax reform plan is ‘very well finalized’ but will come after ACA repeal

By Jacob Pramuk
CNBC, February 22, 2017

President Donald Trump said Wednesday that a Republican tax reform plan is nearly done but reiterated it will come after an Affordable Care Act repeal measure.

“Before we do the tax — which is actually very well finalized — but we can’t submit it until the health care statutorily or otherwise,” Trump told reporters before a White House budget meeting. “So we’re doing the health care — again moving along very well — sometime during the month of March, maybe mid-to-early March, we’ll be submitting something that I think people will be very impressed by.”

http://www.cnbc.com…

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Comment:

By Don McCanne, M.D.

Health care reform is going to happen right now. This week members of Congress in town hall meetings throughout the nation are facing thousands of angry citizens who are demanding single payer reform. Wait a minute. Is that right?

Not exactly. The message that they are hearing is they do not want to lose the benefits of the Affordable Care Act but rather they want something better.

Where is that resounding voice of the people demanding single payer reform? President Trump needs to see the new article published this week in the Annals of Internal Medicine that shows him how he actually can provide his wish of  “much better healthcare at a much lower cost.” But he will never see the article if we don’t make enough noise to penetrate the right-wing guard that is surrounding him.

The article he needs to see immediately:

Single-Payer Reform: The Only Way to Fulfill the President’s Pledge of More Coverage, Better Benefits, and Lower Costs

By Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD

http://annals.org…

Single-payer health care touted with American Care act on chopping block

By Katie Lannan
Lowell (Mass.) Sun, Feb. 23, 2017

BOSTON — With President Donald Trump and congressional Republicans pledging to repeal the federal Affordable Care Act, some backers of single-payer health care are holding up their preferred system as an alternative.

Making the shift to a national single-payer system could save more than $504 billion annually in administrative costs, according to a pair of Harvard Medical School lecturers writing this week in an American College of Physicians medical journal.

In an article published Tuesday in the Annals of Internal Medicine, Dr. Steffie Woolhandler and Dr. David Himmelstein called a publicly financed single-payer system “the only way” to fulfill Trump’s campaign promises of more coverage, better benefits and lower costs.

An executive order Trump signed Jan. 20, the day of his inauguration, established the administration’s policy “to seek the prompt repeal” of the Affordable Care Act and directed department and agency heads to “encourage the development of a free and open market in interstate commerce for the offering of health-care services and health insurance, with the goal of achieving and preserving maximum options for patients and consumers.”

Woolhandler and Himmelstein say proposals floated by House Speaker Paul Ryan and Health and Human Services Secretary Tom Price would “shrink the coverage of poor and low-income persons in the United States” and could shift costs onto patients and state governments.

They say replacing the current insurance system with a “single, public plan covering everyone for all medically necessary care” — similar to an expanded Medicare program — could allow for better benefits at a lower cost, with savings used to extend coverage to the 26 million people who remain uninsured.

In Massachusetts, where the uninsured rate is below 3 percent, past efforts to establish a state-level single-payer system have failed to gain much traction on Beacon Hill.

Sen. Jamie Eldridge, who filed legislation that would set up “Medicare for all” in Massachusetts, called the 21 co-sponsors signed onto his bill this session “the largest we’ve had in about six years.” There are 200 members in the Legislature.

“I certainly am a strong supporter of maintaining and protecting the ACA at the federal level, but clearly there are discussions by mostly Republicans in Congress about repealing it and changing it,” Eldridge told the News Service. “And I think it’s an interesting opportunity, interesting time, for single-payer advocates like myself because if you did see changes at the federal level, I think there would be an opportunity to advocate for single-payer health care more strongly at the state level.”

Rep. Denise Garlick of Needham has also filed a “Medicare for all” bill, while Rep. Jennifer Benson of Lunenburg and Sen. Julian Cyr of Truro are sponsoring legislation that would require the state to measure its health-care spending against projected spending under a single-payer system. If the “single-payer benchmark” showed greater savings, state officials would be charged with developing an implementation plan to move towards single-payer.

Versions the Medicare-for-all and single-payer benchmark bills were each included in dead-end study orders last session.

“I think people are realizing that as much as the ACA had protections around pre-existing medical conditions, that it did provide expanded Medicaid, that for a lot of sort of working-class, middle-class families, they probably saw their premiums go up significantly because the ACA wasn’t really designed to reduce health-care costs, it was really designed to cover more people,” Eldridge said. “So if we’re looking to do both in an environment where federal funding could be cut to Massachusetts or other aspects of the ACA, is it time for Massachusetts to take the next step?”

Gov. Charlie Baker has proposed a slate of health-insurance market reforms. His $40.5 billion fiscal 2018 budget includes an annual assessment on certain employers without at least 80 percent of their workers covered by employer-sponsored health care, rate growth caps for health-care providers, a five-year moratorium on new coverage mandates, and additional consumer transparency efforts aimed at helping patients understand the cost of care.

With health-care costs continuing to climb — hitting $57.4 billion in 2015, according to the Center for Health Information and Analysis — and exceeding state spending benchmarks, efforts are underway to rein in medical spending. Senators are studying cost containment practices used in other states, and a commission seeking to address unwarranted variations in prices charged by different providers is due to release its report next month.

Woolhandler and Himmelstein are both professors at the City University of New York’s Hunter College.

http://www.lowellsun.com…

Brooklynites cheer single-payer health care at congressional town hall

Democrats in Congress are working to protect the ACA, but some New Yorkers aren’t giving up on universal health care

By Caroline Lewis
Crain’s New York Business, Feb. 23, 2017

The future of the Affordable Care Act has been a major point of contention at town hall meetings convened by members of Congress across the country in recent days, with some Republican politicians drawing ire in their districts. At an overflowing and overwhelmingly friendly town hall Wednesday night hosted by Rep. Yvette Clarke in progressive Brooklyn, the Democratic congresswoman predictably defended the ACA.

But audience members, who numbered in the hundreds, showed their most enthusiastic support for an alternative that gets far less attention in the political sphere: universal health care.

A universal, or single-payer, health system would provide everyone access to taxpayer-funded health care, eliminating the need for consumers to sign up for public, private or employer-funded plans.

Democrat-backed bills have long been kicking around the New York Legislature and the U.S. Congress that propose variations on that system. Sen. Bernie Sanders, Democrat of Vermont, championed a “Medicare for All” concept during his presidential campaign. But such proposals haven’t come close to achieving bipartisan support.

The New York Health Act—sponsored by Assemblyman Dick Gottfried and Sen. Bill Perkins, both Manhattan Democrats—passed the majority-Democratic state Assembly in the last two sessions, but it has been stalled in the Republican-controlled Senate.

Of the dozens of audience members who posed questions to Clarke and her invited speakers, just one directly addressed the future of the ACA.

“We could increase subsidies and we could expand Medicaid further, but those are just Band-Aids, not proper solutions,” the young man asking the question began. “At what point will congressional Democrats come out in full force in full support of universal, single-payer health care?”

After sustained applause and cheers from the crowd, Clarke replied, “You’re talking my kind of language. I’ve been for single-payer health care ever since I’ve been in Congress.”

Clarke suggested that the reason there’s pushback against the ACA is that it’s “taking us down that road.”

While President Barack Obama paid lip service to a single-payer system during his 2008 campaign, the Affordable Care Act has maintained a diverse insurance market.

The law did greatly expand the number of people enrolled in government-funded and subsidized insurance plans, though, particularly in New York. As of Jan. 31, more than 2.4 million people signed up for Medicaid through the state’s Obamacare marketplace. The state also has enrolled more than 665,000 people in its Essential Plan, a federally subsidized option created under the ACA for New Yorkers earning less than twice the federal poverty level who don’t qualify for Medicaid.

Clarke is one of 63 members of Congress, all Democrats, who have signed onto the Expanded and Improved Medicare for All Act, calling for single-payer health care. But she said her focus remains on organizing constituents to resist the proposed repeal of the ACA.

Some New Yorkers might have a “certain level of comfort that we have a Democratic state that does to a certain degree do everything it can to preserve the right to health care,” Clarke told Crain’s after the event.

Grassroots efforts to pressure Congress to preserve coverage and federal funding are essential, she said.

“We’re continuing to promote the need for the ACA and to encourage New Yorkers to make their preference known for the ACA, because it would be catastrophic to our health care infrastructure if this is repealed without any replacement,” she said. “And who knows what type of replacement they would offer in any event.”

http://www.crainsnewyork.com…

Why is life expectancy worse in the United States?

Future life expectancy in 35 industrialised countries: projections with a Bayesian model ensemble

By Vasilis Kontis, PhD, James E Bennett, PhD, Colin D Mathers, PhD, Guangquan Li, PhD, Kyle Foreman, PhD, Prof Majid Ezzati, FMedSci
The Lancet, February 21, 2017

Summary

Background
Projections of future mortality and life expectancy are needed to plan for health and social services and pensions. Our aim was to forecast national age-specific mortality and life expectancy using an approach that takes into account the uncertainty related to the choice of forecasting model.

Methods
We developed an ensemble of 21 forecasting models, all of which probabilistically contributed towards the final projections. We applied this approach to project age-specific mortality to 2030 in 35 industrialised countries with high-quality vital statistics data. We used age-specific death rates to calculate life expectancy at birth and at age 65 years, and probability of dying before age 70 years, with life table methods.

Findings
Life expectancy is projected to increase in all 35 countries with a probability of at least 65% for women and 85% for men. There is a 90% probability that life expectancy at birth among South Korean women in 2030 will be higher than 86·7 years, the same as the highest worldwide life expectancy in 2012, and a 57% probability that it will be higher than 90 years. Projected female life expectancy in South Korea is followed by those in France, Spain, and Japan. There is a greater than 95% probability that life expectancy at birth among men in South Korea, Australia, and Switzerland will surpass 80 years in 2030, and a greater than 27% probability that it will surpass 85 years. Of the countries studied, the USA, Japan, Sweden, Greece, Macedonia, and Serbia have some of the lowest projected life expectancy gains for both men and women. The female life expectancy advantage over men is likely to shrink by 2030 in every country except Mexico, where female life expectancy is predicted to increase more than male life expectancy, and in Chile, France, and Greece where the two sexes will see similar gains. More than half of the projected gains in life expectancy at birth in women will be due to enhanced longevity above age 65 years.

Interpretation
There is more than a 50% probability that by 2030, national female life expectancy will break the 90 year barrier, a level that was deemed unattainable by some at the turn of the 21st century. Our projections show continued increases in longevity, and the need for careful planning for health and social services and pensions.

Funding
UK Medical Research Council and US Environmental Protection Agency.

From the Discussion

By contrast, projected life expectancy is lower in countries with higher levels of young adult mortality and major chronic disease risk factors, and possibly less effective health systems. These countries also tend to have higher social inequalities, which might lower national life expectancy by affecting the entire population or through the poor health of the worst-off social groups and communities, which in turn affects the national average. Notable among poor-performing countries is the USA, whose life expectancy at birth is already lower than most other high-income countries, and is projected to fall further behind such that its 2030 life expectancy at birth might be similar to the Czech Republic for men, and Croatia and Mexico for women. The USA has the highest child and maternal mortality, homicide rate, and body-mass index of any high-income country, and was the first of high-income countries to experience a halt or possibly reversal of increase in height in adulthood, which is associated with higher longevity. The USA is also the only country in the OECD without universal health coverage, and has the largest share of unmet health-care needs due to financial costs. Not only does the USA have high and rising health inequalities, but also life expectancy has stagnated or even declined in some population subgroups. Therefore, the poor recent and projected US performance is at least partly due to high and inequitable mortality from chronic diseases and violence, and insufficient and inequitable health care.

http://www.thelancet.com…

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Comment:

By Don McCanne, M.D.

This study predicts an increase in life expectancy for 35 industrialized nations but notes that the recent and projected performance in the United States is poor. That is “at least partly due to high and inequitable mortality from chronic diseases and violence, and insufficient and inequitable health care.”

More diligent application of beneficial public policies would improve our outcomes. Particular notable is the inequitable health care in our country. It is not that we lack sufficient funds. We are already spending $3.2 trillion – more than enough to provide quality health care for all. It is rather that we fail to elect individuals who understand and would support public policies that would make this a better nation.

This is shameful. We could act to change our course, but we, as a nation, have accepted mediocrity instead.

President Trump, here’s how to fulfill your pledge of more coverage, better benefits, and lower costs

Single-Payer Reform: The Only Way to Fulfill the President’s Pledge of More Coverage, Better Benefits, and Lower Costs

By Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD
Annals of Internal Medicine, Ideas and Opinions, February 21, 2017

Although Republicans’ proposals seem unlikely to achieve President Trump’s triple aim — more coverage, better benefits, and lower costs — single-payer reform could. Such reform would replace the current welter of insurance plans with a single, public plan covering everyone for all medically necessary care — in essence, an expanded and upgraded version of the traditional Medicare program.

Savings Available to Expand and Improve Coverage Under Single-Payer Reform, 2017

$ (billion)

220.0 – Insurance overhead and administration of public programs
149.3 – Hospital administration and billing
75.3 – Physicians’ office administration and billing
503.6 – Total administration

113.2 – Outpatient prescription drugs

616.8 – Total administration plus outpatient prescription drugs

This morning (Feb 21) AIM decided to allow free access to this article:
http://annals.org…

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Single-payer reform is ‘the only way to fulfill the president’s pledge’ on health care: Annals of Internal Medicine commentary; Researchers estimate administrative savings at $504 billion annually

Physicians for a National Health Program, Press Release, February 21, 2017

Proposals floated by Republican leaders won’t achieve President Trump’s campaign promises of more coverage, better benefits, and lower costs, but a single-payer reform would, according to a commentary published today [Tuesday, Feb. 21] in Annals of Internal Medicine, one of the nation’s most prestigious and widely cited medical journals.

Republicans promised to repeal the Affordable Care Act on the first day of the Trump presidency. But the health reform effort has stalled because Republicans in Congress have been unable to come up with a better replacement and fear a backlash against plans that would deprive millions of coverage and raise deductibles.

In today’s Annals commentary, longtime health policy experts Drs. Steffie Woolhandler and David Himmelstein warn that the proposals by Speaker Paul Ryan, R-Wis., and Secretary of HHS Tom Price would slash Medicaid spending for the poor, shift the ACA’s subsidies from the near-poor to wealthier Americans, and replace Medicare with a voucher program, even as they would cut Medicare’s funding and raise the program’s eligibility age.

Woolhandler and Himmelstein review evidence that, in contrast, single-payer reform could provide comprehensive first-dollar coverage to all Americans within the current budgetary envelope because of vast savings on health care bureaucracy and profits. The authors estimate that a streamlined, publicly financed single-payer program would save $504 billion annually on health care paperwork and profits, including $220 billion on insurance overhead, $150 billion in hospital billing and administration and $75 billion doctors’ billing and paperwork. They estimate that an additional $113 billion could be saved each year by hard bargaining with drug companies over prices. A table in the paper summarizes these savings.

The savings would cover the cost of expanding insurance to the 26 million who remain uninsured despite the ACA, as well as “plugging the gaps in existing coverage – abolishing copayments and deductibles, covering such services as dental and long-term care that many policies exclude.”

The lead author of the commentary, Dr. Steffie Woolhandler, is an internist, distinguished professor of public health and health policy at CUNY’s Hunter College, and lecturer in medicine at Harvard Medical School. She said: “We’re wasting hundreds of billions of health care dollars on insurance paperwork and profits. Private insurers take more than 12 cents of every premium dollar for their overhead and profit, as compared to just over 2 cents in Medicare. Meanwhile, 26 million are still uninsured and millions more with coverage can’t afford care. It’s time we make our health care system cater to patients instead of bending over backward to help insurance companies.”

Dr. David Himmelstein, the senior author, is a primary care doctor and, like Woolhander, a distinguished professor at CUNY’s Hunter College and lecturer at Harvard Medical School. He noted: “We urgently need reform that moves forward from the ACA, but the Price and Ryan plans would replace Obamacare with something much worse. Polls show that most Americans – including most people who want the ACA repealed, and even a strong minority of Republicans – want single-payer reform. And doctors are crying out for such reform. The Annals of Internal Medicine is one of the most respected and traditional medical journals. Their willingness to publish a call for single payer signals that it’s a mainstream idea in our profession.”

The Annals of Internal Medicine is the flagship journal of the American College of Physicians (ACP), the nation’s largest medical specialty organization with 148,000 internal medicine physicians (internists), related subspecialists, and medical students. In 2007, the Annals published a lengthy policy article in which the ACP said a single-payer system was one pathway to achieving universal coverage. In early 2008, the journal published a study showing 59 percent of U.S. physicians support “government legislation to establish national health insurance,” a leap of 10 percentage points from five years before.

Today’s commentary is believed to be the first full-length call for single payer, or national health insurance, that the journal has published in its 90-year history.

https://www.pnhp.org…

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Comment:

By Don McCanne, M.D.

There are two reasons why this article from the Annals of Internal Medicine is so important.

As the Democrats proved with ACA and the Republicans are now learning by coming up essentially empty handed in their search for reform that would meet President Trump’s goal of more coverage, better benefits, and lower costs, building on our fragmented multi-payer system cannot possibly meet these goals. This article explains why the Republicans, working with the Democrats, need to turn to the single payer model if they wish to achieve President Trump’s admirable goals (“insurance for everybody… much less expensive and much better,” Washington Post, January 15, 2017). With the reform process currently taking place, this article could not be more timely.

The other reason this is important is that it represents an acknowledgement of the editors of the Annals of Internal Medicine – a publication of the American College of Physicians – that single payer needs to be a prominent part of the national dialogue on reform. In fact, today (Feb 21) the article was featured as a banner headline on the opening page of the journal’s website. Those who read the major medical journals regularly understand what a breakthrough this is.

Today is the day. The time has come to steamroller all of the other vacuous policy proposals on health care reform and mount the flag of health care justice for all in America. Begin by distributing widely the article, “Single-Payer Reform: The Only Way to Fulfill the President’s Pledge of More Coverage, Better Benefits, and Lower Costs,” (link above).

Simple solution

By Anne Scheetz, M.D.
Chicago Sun-Times, Letters, Feb. 20, 2017

As Phil Kadner notes in his Feb. 15 column about the Republicans’ threat to repeal Obamacare, for health insurance companies, “It’s all about profit.” Their stocks have recently posted the highest gains of any sector of the S&P 500, and their CEOs receive millions in compensation.

Meanwhile, in 2016, some 27 million Americans remained uninsured; 63 million adults went without needed health care because of cost; 70 million adults had difficulty paying medical bills; and 46 million adults were paying off medical debt.

Health insurance companies add zero value to health care, while the administrative complexity they create generates at least $500 billion per year of waste, enough to provide high quality care for all of us..

There’s a simple solution: Get the insurance companies out of health care by passing and implementing national improved Medicare for all. Its time has come.

http://chicago.suntimes.com…

Can the actuaries design a more effective and equitable financing system?

Actuarial Challenge: Announcement of Round One Results

Robert Wood Johnson Foundation

The Actuarial Challenge, sponsored by the Robert Wood Johnson Foundation (RWJF), brings actuaries together to explore approaches to stabilize the individual health insurance market. The Challenge is administered by Milliman, Inc. and actively promoted by the American Academy of Actuaries and the Society of Actuaries. Support for the Actuarial Challenge is being provided by the Robert Wood Johnson Foundation.

The Challenge kicked off in late September. Almost 70 participants registered, comprising 20 teams. Initial papers were submitted by December 9th. The papers each presented a proposal of various ways in which the individual health insurance market could be reformed. The proposals were not intended to be comprehensive, but to offer ideas on different ways to improve certain aspects of the current system. A panel of five judges (all actuaries) reviewed each paper and ultimately selected five papers to move on to the next round. Round Two involves the selected teams working with Milliman to model their proposals to illustrate the potential financial impact on the individual health insurance market.

Round Two Proposals

Individual Market Redux
Revises rating to allow a wider premium range by age (5-to-1) and limited consideration of an enrollee’s health status in setting premium rates via an automated process (up to an additional 50% of premium). Uses contributions to individual health savings accounts for mid/low income consumers to replace premium and cost sharing subsidies. Revises risk adjustment methodology and restores a reinsurance mitigation program. Uses Medicaid reimbursement levels and increases health cost transparency. Increases penalties for not obtaining health insurance, but allows more benefit plan design flexibility. Reduces mandated benefits based on scientific evidence and use of an independent board. Incentivizes payment reform, integration of healthcare information, implementation of clinical best practices, and value-based care.

Why Not BE HIP?
Establishes a nationwide Basic Essential Health Insurance Plan (BE HIP) covering a core set of services/benefits set by federal regulation. Allows purchase of state regulated standardized supplemental plans (benefit riders) to offset cost sharing (i.e., upgrade to richer benefits). Automatic enrollment and/or penalty of full cost of basic plan if not enrolled. Uses a risk adjustment program and reinsurance to protect insurers. Premium equalization process to account for socioeconomic variations between insurers in a given market. Premium subsidies use similar methodology as the Patient Protection and Affordable Care Act (ACA), although percentages may differ.

The Simplifiers
All residents receive a fully publicly-funded preventive plan and must purchase an insurance plan for non-preventive services. Insurers must offer a standard plan but may offer additional plans subject to state regulations such as actuarial soundness, minimum coverage levels and loss ratios. Premiums will be limited to significantly lower and more affordable levels. A simplified, permanent publicly funded risk mitigation program based on reinsurance formulas will result in reduced premium. Hospital costs will be reduced by payment at Medicare reimbursement levels. Drug costs will be lowered by allowing purchase from qualified international locations. Simplified low-income premium discounts will be available. Penalties equal to the lowest cost insurance plan will apply for non-coverage. Lifetime universal Medical ID cards will be used to monitor enrollment, provide electronic medical records, and act as low-interest credit cards to pay for premiums and out-of-pocket medical expenses. Exchanges will act simply as informational websites.

Panoptic
Uses auto enrollment into newly defined catastrophic plans to enforce participation, and combines the individual and small group markets (with no self-funding allowed in the small group market). Consumer can add benefits through purchase of supplemental benefit riders. Block funds for subsidies provided from federal to state for the state to administer. Elimination of dual regulation to reduce expenses. Allows wider rating for age (5-to-1) and lowers or eliminates minimum medical loss ratios. Continues risk adjustment and restores reinsurance for up to five years. The equivalent of cost-sharing reduction (CSR) funds would be deposited into a consumer’s health savings account (HSA), if eligible. Use reference-based benefit pricing for provider fees. Encourages risk contracting with both upside and downside risk to the provider. Eliminates direct-to-consumer advertising. Eliminates grandfathered and transitional business. Focuses on consumer accountability by providing consumers with improved cost transparency and other resources to help them make educated decisions regarding their healthcare.

King of Carrot Flowers
Creates three pools in the individual market: (1) Over 250% FPL (federal poverty level) with state regulated underwritten market, (2) Under 250% FPL with federally funded underwritten and subsidized market, and (3) Special Needs (High Risk) Pool with a federally-funded, highly-subsidized market for individuals with persistent high costs or uninsurable conditions. Guarantee issue, but requires continuous enrollment. Incentivizes providers to manage care. Encourages tax parity between individual and group market by capping group tax deductions. Allows more tax-favored health savings account contributions.

Milliman will work with these five selected teams to model their proposals in February and March. The five Round Two teams will be able to incorporate the modeling results in their final papers.

Other Proposals

Nine other teams have the opportunity to refine their papers for possible exposure on the Actuarial Challenge website (which is hosted by the American Academy of Actuaries) or as decided by the RWJF at the end of the Challenge.

The Mod Squad
Increases incentives to first-time enrollees, but with significant penalties for not obtaining coverage after first year…

JHU Actuarial Club
Provides enhanced benefits (e.g., gym membership, fitness classes, preventive services, etc.) in insurance coverage to encourage younger individuals to purchase…

Policy Proposal for Healthy Behavior Incentive (“HBI”) Plans
Healthy Behavior Incentive Plans encourage a partnership between the insured, insurer, and health care provider to maintain well-being rather than just reimbursement for expenditures…

Underwriting and Premium Rating using Risk Adjustment
Focuses on improving market stability through increased enrollment of lower cost individuals by revising the rating basis to better align with expected costs…

Team DC
Increases individual market penalties to encourage more enrollment by young and healthy uninsured, and mitigate developing anti-selection spiral in the individual market…

Team ACA Version 2.0
Proposes changes to the subsidy and risk adjustment programs…

Consulting Actuaries for Sustainable Healthcare
Insurance reforms to improve actuarial soundness, and provider price & quality reforms, to address unsustainable underlying healthcare spending…

True Health
Develops actuarial incentive compensation for physicians who are effective at addressing the underlying cause of patient health conditions by using the “food as medicine” concept…

A Social Insurance Solution To Health Care Finance
Proposes to use a social insurance model to replace all current health insurance (across all markets). Covers all legal residents in the program through a payroll tax for funding. Insurance plan would cover preventive care and catastrophic care (exceeding 7.5% of income). Low income families would receive additional assistance similar to Supplemental Nutrition Assistance Program (SNAP) benefits. Routine care would be funded by individuals, but administered through a central fund, billing patients as with a credit card. Administrators must negotiate with providers, but must make all fees available to the public.

http://challenge.actuary.org…

About the Actuarial Challenge:
http://challenge.actuary.org

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Comment:

By Don McCanne, M.D.

In designing a health care financing system that is efficient and effective in ensuring affordable access to health care, it seems that the nation’s actuaries should be up to the task. So it is informative to see what recommendations were elicited when the Robert Wood Johnson Foundation, assisted by Milliman, Inc., issued the Actuarial Challenge, calling for an exploration of approaches to stabilize the individual health insurance market.

Of the proposals submitted, five were selected to move into the second round to work with Milliman to model their proposals to illustrate the potential financial impact on the individual health insurance market. Although some proposals would introduce improvements into the individual insurance market, they all would increase administrative complexity and none would ensure affordable coverage for all participants in the individual market.

Nine other proposals were selected for possible posting on the Actuarial Challenge website, although they do no move into round two. They too are quite disappointing except for one proposal – A Social Insurance Solution To Health Care Finance – that seems to acknowledge the importance of a universal system. Though even that proposal requires cash payments for all routine care except preventive care and catastrophic care charges exceeding 7.5% of income. We have plenty of studies to show that the excessive out-of-pocket costs of this model would leave too many people broke and without the care they need.

Except for the social insurance model, the authors of the proposals limited themselves to solutions for the individual market – a relatively small sector of health care – which is understandable since that was the challenge they were given.

There are two predominant disappointments with the submissions for this challenge. The first is that it should be intuitive that the problems of the individual market cannot be resolved with patches limited to that market. The solutions require a fundamental change of the financing infrastructure of our entire health care system, and the actuaries should acknowledge that in their proposals.

The other disappointment is in the nature of the various recommendations. They seem to lack a sensitivity to the imperative to address issues of health care justice, ensuring an equitable system to bring affordable care to everyone, whether just in the individual market or throughout the entire system – the latter actually being the moral imperative.

The model that would work is already well understood – a single payer national health program, aka an improved Medicare for all. Maybe we can teach the actuaries something, though it would be difficult. I will say that I once was a speaker at a national meeting of actuaries, and I did find that there was some insight amongst the members, but that didn’t translate into policy recommendations.