The New York Times, November 5, 2020

https://www.nytimes.com…

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Learning From November 3: A Wake-Up Call for Public Health

By Sandro Galea, M.D., M.P.H., Dr.P.H.
Milbank Quarterly, November 4, 2020

This was supposed to be an election about health. For the first three years of his presidency, Donald Trump presided over what appeared to be a robust economy, which he made the foundation of his re-election campaign. Polls last year suggested economic gains that could place Trump in a favorable position for re-election. Then, in 2020, there came a novel coronavirus, which became known as COVID-19. As of now, more than nine million Americans have been infected with COVID-19, and over 233,000 have died, a story that rightly has dominated the national conversation.

In response to this crisis, the president acted in direct opposition to public health and medical advice, sometimes seeming to reject the very existence of COVID-19, and making this outlook central to his re-election platform. This seemed at dramatic odds with how the country felt about COVID-19. Polls suggest that Americans consider COVID-19 to be an important threat—in June, 66% of Americans said they were worried about exposure to the disease. This concern is, of course, consistent with reality, with hundreds of thousands of Americans dying and many more becoming infected with the virus.

This set the stage for an election that seemed to be entirely about health. This dramatic health concern dominated public attention like no other in 100 years, and the election featured two candidates, one of whom—Vice President Biden— contended that he would follow the advice of public health experts in order to control the pandemic, while the other—President Trump— suggested little concern about COVID-19, an attitude in direct opposition to what the general population seemed to think about the pandemic.

All of this pointed to an election that would see the votes align with public perception of the virus, bringing Vice President Biden swiftly to power. That is not, of course, what has happened. While the election results remain uncertain, it is now clear that, regardless of who will eventually win, there was no dramatic sweep for Biden, and voters remain as evenly divided about the candidates as they were four years ago in the close race between Donald Trump and Hillary Clinton. This is the case despite the President’s apparent misalignment with the public’s attitude towards the pandemic.

So, what happened? What does this teach us? There is much, of course, that goes into the science of elections and voting, and one could focus much attention on the mechanics of voter influence, on efforts to suppress the vote, and on candidates’ efforts to persuade voters by making claims that may not hew exclusively to the truth. However, I would argue that this moment conveys two key insights, both of which are directly applicable to our understanding of health.

First, this moment teaches us humility in how we think about the importance of health. While the COVID-19 pandemic has been overwhelmingly an issue about health, and while it has captured public attention, with poll after poll showing that people care deeply about the pandemic, it is not at all clear that voters were willing to take the necessary steps to mitigate the virus. It is not at all clear that the steps involving widespread economic shutdown were palatable to the population despite its concern with the virus. This should be a critical wake-up call for those in public health. Simply speaking, health, on its own, was not enough to sway the election, and voters showed, decisively, that despite overwhelming concern about the pandemic, they were not willing to put aside everything else in the service of maintaining their health. This runs dramatically counter to public health thinking around the importance of the approaches necessary to contain the virus, which often involve substantial economic sacrifice, including lockdowns. This was seen, for example, in the recent John Snow Memorandum, which was drafted to repudiate the Great Barrington Declaration, the latter document suggesting a different approach to the pandemic that de-emphasized widespread lockdowns. Fundamentally, public health’s call in the past year has been premised on the notion that we should do nothing but ensure, to the best of our ability, that as few people as possible get the disease, and that anything falling short of this goal is unacceptable. The election shows us that message is not well received, and we have failed to articulate a message, through the political fog, that is well received and is responsive to what a large swath of the population wish for their health.

Second, I think this moment also teaches us about the deep divisions that characterize the country. I realize much has been written, and much more will be written, about how these divisions influence the electorate, and the implications of this for the election, in general, and for public health, in particular. I would argue that centrally, in the COVID-19 context, these divisions have widened the gap between those who are socioeconomically advantaged and those who are socioeconomically disadvantaged, with the former group largely advancing approaches to contain the pandemic that have disproportionately affected, and indeed harmed, the latter group. The economic challenge of COVID-19 has been deeply unequal, with job losses suffered by higher earning populations early in the pandemic largely returning, and lower earning workers remaining out of work. Simply put, those of us who are in a position of privilege have been perceived as proposing efforts to contain the virus that fundamentally affect and hurt those who are not in a position to make these recommendations or to implement these policies. This is, of course, a reflection of the undercurrents of socioeconomic division—which often overlap with racial/ethnic divides—that characterize the country. It is a stark reminder that there are socioeconomic divides in the country that are inextricable from the public perception of any public health decision or recommendation, even those that address the most consequential pandemic of this century.

In articulating these observations, I am simply trying to extract insight from this moment that is relevant to how we think about health. It seems that, at core, health is understood among the public to be a means to an end, not an end in itself. That end is being able to live a life as full and unencumbered as possible. Despite the public’s concern about sustaining the means to this end, the population is not overwhelmingly willing to sacrifice all aspects of their life at the behest of health. This seems particularly to be the case when the burden of sustaining these means falls disproportionately on a group that is not dictating the terms of what these measures must be.

I realize that there are many other complexities at work in this election, but I suggest that these points, in the light of this historic and perplexing day, are the most urgent takeaways of the moment. It seems fair to attribute agency to the voters who have, at this moment, spoken in a way that is different from how we in public health might have expected. It seems to me that it falls to us in public health to learn from what has happened, to think carefully about what the meaning of health is to a population, and to consider the role that socioeconomic and other divides play in shaping public attitudes. The issues raised by this election outcome suggest the need to redouble our effort to bridge the gaps between socioeconomic haves and have nots, and health haves and have nots, and to see health as a path toward doing so.

Sandro Galea, a physician, epidemiologist, and author, is dean and Robert A. Knox Professor at Boston University School of Public Health.

https://www.milbank.org…

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Comment:

By Don McCanne, M.D.

Sandro Galea is one of the great intellectuals in public health in the world today. With our worsening health care crisis due to the COVID-19 pandemic, and with the failure of the most important players in the pandemic – the people – to join together to ameliorate and eventually end this crisis, there is a compelling need to listen to the words of Professor Galea.

We are in the third and worst wave of this crisis. People are understandably very unhappy in being exposed to the potentially disastrous impacts on their health, not to mention the profoundly negative social and economic impact of the pandemic. Yet far too many have decided to abandon the best recommendations of our public health experts, and, instead, politicize it by following the bizarre lead of our president who has rejected health policy science in favor of… well, whatever it is that he is trying to do. It is no coincidence that the divide in our responses to the pandemic seems to match the political divide demonstrated by the election results this week.

But the concerns about the health of the nation are not evenly divided. When you find that you are in places where pandemic precautions are an imperative, the mask count is very high. Yet political functions led by our president have a very low mask count and exhibit entirely inadequate social distancing. Though most of us have at least some concern, it is difficult to know what percentage of our nation is willing to throw caution to the wind and ignore the best advice of our public health experts.

Some of us were actually naive enough to believe that the belligerent rejection of public health science by our president – a position that has contributed to the tragic trends noted in the pandemic curve above – would cause Americans to reject this callous carelessness by replacing our current president with someone who presumably would acknowledge the seriousness of the crisis and attempt to address it with essential government functions that are absolutely required to reduce the terribly tragic impact of the pandemic. Yet the nation remained split on what type of leadership we need in this time of crisis.

There are no simple answers, but everyone should try to understand Galea’s message. That is the first step we must take as we then come together to heal. It takes only a few to propagate the novel coronavirus. How are we going to bring them into our community tent designed for all if half of us support their ways through our political choices?

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By Joseph D. Bruch, B.A.; Alexander Borsa, B.A.; Zirui Song, M.D., Ph.D.; Sarah S. Richardson, Ph.D.
JAMA Internal Medicine, August 24, 2020

An influx of private equity involvement in women’s health care has garnered attention and scrutiny. Over the past decade, private equity firms have increasingly invested in or acquired hospitals, physician practices, laboratories, and biomedical device companies. Private equity firms use capital from corporations or wealthy individuals to invest in and acquire organizations and generally sell their holdings within 3 to 7 years. Proponents argue that they produce economic value by increasing operational efficiency while maintaining or improving the quality of care. Critics fear that the need to quickly achieve high returns on investments may conflict with the quality and safety of care or exacerbate health inequities.

We document formerly non–private equity women’s health care companies, including physician networks, practices, and fertility clinics, that gained a private equity affiliation between 2010 and 2019.

https://jamanetwork.com…

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Private Equity, Women’s Health, and the Corporate Transformation of American Medicine

By Lawrence P. Casalino, M.D., Ph.D.
JAMA Internal Medicine, August 24, 2020

In this issue of JAMA Internal Medicine, Bruch and colleagues inform us that during the past decade, private equity firms have acquired or invested in large numbers of obstetrician-gynecologist medical groups. Most of these acquisitions and investments occurred during the past 3 years.

The article by Bruch and colleagues adds another specialty to the list of physician specialty areas—notably dermatology and ophthalmology—for which recent articles have described private equity activity. We can anticipate that additional reports of growing private equity acquisitions in other specialties (eg, gastroenterology) will soon follow. Articles to date are similar in 3 ways. First, they report rapidly increasing private equity acquisitions in a given specialty. Second, they report a similar private equity modus operandi across specialties: acquire a relatively large platform practice (called target companies by Bruch and colleagues) in a given geographic area, then acquire smaller practices in that area and group them into the same organization as the platform practice; use debt to finance the acquisitions and assign that debt to the acquired practices; find ways to increase net revenue from the agglomerated practices; and sell the agglomerated practices within 3 to 5 years for considerably more than the price paid by the private equity company. Third, the articles, with 1 controversial exception, lack data on the performance—in quality and cost of care, or in physician or patient satisfaction, of private equity-owned practices.

In the absence of data, conceptual arguments can be made for and against private equity acquisition of medical practices. Private equity advocates argue that the firms bring much-needed capital that enables practices to invest in better information technology and to grow by adding physicians and/or acquiring practices. They argue that private equity firms bring management expertise to help with this growth, to make the business side of the practice operate more smoothly and relieve physicians of the burden of running the business, and to deal with regulatory demands and standardize patient safety processes. They also claim that private equity firms give physicians more autonomy than other potential purchasers of practices (notably, hospitals and health insurance companies), that they are better at managing practices than other purchasers, and that they make it possible for physicians to diversify their assets (by investing the money they are paid for their practice instead of having all of it tied up in the practice).

Opponents of private equity argue that the intense pressure on firms to generate returns for their investors (private equity firms generally project a return of 20% annually averaged across the 3 to 5 years before a practice is sold) is not compatible with putting patients’ interests first and not compatible with physician professionalism and its commitment to put patients’ interests first. They also argue that it is an intolerable burden for practices to pay off the loans that private equity firms used to acquire them and that private equity claims for skill in managing practices are exaggerated. Opponents do not necessarily see a benefit to practices merging or being acquired and point out that as a private equity firm acquires market share in a community, it may be able to demand higher payment rates from health insurers, which may be good for the physicians but not for their patients.

Attitudes toward private equity are likely shaped by attitudes toward physician professionalism and toward the corporate transformation of American medicine. This transformation has been occurring for decades and has been accelerating in recent years, as Bruch and colleagues point out. For better or for worse, the United States is moving from a system based on small, independent physician practices to physicians being employed by large corporations (including hospital systems, health insurers, and private equity firms), from small, independent community hospitals to multihospital systems (including hospitals owned by private equity firms), and from small, not-for-profit health insurers to a small number of very large national and regional insurers.

Conceptually, the advantages and disadvantages of corporate medical care parallel those described above for private equity. Corporate medical care lacks the human scale and flexibility of small physician practices and may lack the close, ongoing relationships among physicians, patients, and staff sometimes present in these practices.

Physicians in independent practices in the United States face a medical environment that is complex and rapidly changing with a high level of uncertainty about the future. Competition from hospital, private equity, and insurer-employed physicians is rapidly increasing, as are the pressures on practices from increased use of information technologies and increased rewards and penalties by health insurers and Medicare based on measures of physician performance. It is not surprising that many physicians are seeking shelter from the storm by selling their practices to corporate entities.

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

All around us we see private equity firms moving into health care. A recent Quote of the Day discussed private equity acquisition of hospitals. Today’s message discusses private equity acquisition of women’s health care practices as an example of the trend to cluster specific specialties into new corporate entities.

These equity firms may profess to infuse quality and efficiency into the systems they create, but their true objective is not altruism. Their interest is found in their label: equity, the more the better.

Their modus operandi: 1) acquire a relatively large platform practice in a given specialty, 2) then acquire smaller practices in the same geographic area and merge them into the platform practice, 3) use debt to finance the acquisitions and assign that debt to the acquired practices, 4) find ways to increase net revenue from the agglomerated practices, and 5) sell the agglomerated practices within 3 to 5 years for considerably more than the price paid by the private equity company. Conveniently, the debt is left with the practices they purchased, and the equity investors walk away with the money.

How does this benefit the patients? How does this benefit the health care professionals? We know how it benefits the equity firm investors, but does anyone seriously contend that this is what health care should be about? But that’s what it has become.

We just had an election that shut down any further discussion of a health care financing system that would provide freedom to patients and their health care professionals to ensure that everyone would have the health care that they need in a system that would be affordable for each of us: single payer, improved Medicare for All. Instead, we are moving forward with a system that puts the squeeze on the people of our nation and the productive segment of society as we move most of the wealth to the top. For those who think that they are going to move to the top, they must realize that the people already there are not going to make room up there for the rest of us.

Maybe Medicare for All really is a better idea after all.

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By Adam Gaffney, M.D., M.P.H.; David Himmelstein, M.D.; Steffie Woolhandler, M.D., M.P.H.
Health Affairs Blog, October 29, 2020

Findings of increasing uninsurance after 2016 accord with results of other governmental and non-governmental surveys. Most likely more than 2 million individuals lost health coverage during the first three years of the Trump administration. A further, more substantial increase in 2020 seems almost certain to occur. Projections based on unemployment data during the pandemic suggest that 5 to 7 million additional Americans will join the ranks of the uninsured this year.

Based on the ACS coverage data, we estimate that between 3,399 and 10,147 excess deaths among non-elderly US adults may have occurred over the 2017-2019 time period due to coverage losses during these years. Using the NHIS figures for coverage losses yields a higher estimate (between 8,434 and 25,180 non-elderly adult deaths attributable to coverage losses), while the CPS figures yield an estimate of 3,528-10,532 excess deaths among non-elderly adults. These figures do not completely capture the population effects of coverage loss, as they exclude the excess deaths that would likely result from coverage losses among children. In 2020 and beyond, we can project even more loss of life if, as expected, millions more lose health coverage due to the economic downturn associated with the pandemic.

Declining insurance coverage during the Trump administration has hence come at a heavy cost in physical and mental health, financial security, and loss of life. However, larger policy changes may lie ahead that could have even greater health impacts. In November, the Supreme Court will hear arguments in the case California v. Texas. If, as the Trump administration has urged, it entirely overturns the Affordable Care Act, 19.9 million individuals could lose health coverage. Based on the same approach as outlined above, we estimate that this coverage loss would lead to 22,892 – 68,345 excess deaths among nonelderly adults annually. The life and health ramifications of this case — and of November’s election — are enormous.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

The negative life and health ramifications of the health policies supported by the current administration are enormous. It is hoped that today’s election will result in a shift to adopting policies that will have a positive impact on the life and health of the people of our nation. Regardless, after the election we will have to exercise people power no matter who wins.

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By James G. Kahn, M.D., M.P.H.
Emeritus Professor of Health Policy, University of California, San Francisco

Last week saw the passing of two amazing leaders in the pursuit of health care justice in the United States – one who operated at the highest political, policy, and academic levels, and one who worked tirelessly at the grassroots with the most vulnerable. Phil Lee and Don Bechler led and inspired us for decades in the ongoing struggle for a health system that benefits everyone. I had the distinct honor of knowing and working with both of them.

Philip R. Lee was 96, with a storied career spanning more than 50 years in government and academia. I met Phil in 1987 when he invited me to do an AIDS cost research project at the Institute for Health Policy Studies (now named for him) at UCSF. I extended my association with him in 1989 as a health policy fellow at IHPS. He was the ultimate networker, with a massive double Rolodex, when those were physical items. He knew everyone in health policy and often had hired and/or mentored them. He was the person in DC who, as Assistant Secretary for Health under LBJ, told U.S. hospitals: if you want Medicare money, no more racially segregated wards. After serving as UCSF Chancellor, he started IHPS as the first ever academic health policy unit in the U.S. He served another stint as Assistant Secretary for Health under Bill Clinton. He was and is a guiding light for many of us: with Phil, it was always about public service and improving health. He consistently projected his vision, his determination to achieve that vision, and his encyclopedic knowledge of people and ideas. He guided me in my fellowship days. One small memory comes to mind. I jotted on a piece of paper something like “Health services research is the study of how outcomes (mortality, cost, etc) in operating health systems vary according to location, type of provider, patient characteristics, etc.” Phil saw it, and said, that’s a great definition, where did you get it? “I made it up.” To this day, this approval from Phil is one of my proudest moments. I’m sure thousands will mourn his loss and recall his greatness. Millions benefited – and continue to benefit – from his leadership.

Don Bechler (73) followed a different and also awe-inspiring path. Don trained and worked as an airplane mechanic. He worked intensively in 1994 on the California Prop 186 single payer ballot initiative. In the late 1990s he was laid off from his airline job, and started full-time organizing around single payer, supported for living expenses by single payer colleagues. He had an unswerving devotion to work at the grassroots level with community members and groups, in mirror image to Phil’s hobnobbing with presidents and prominent academics. I wonder if they knew each other; I hope so. Don was a wonderful colleague in the single payer movement, appreciating the role of research like mine. I was always honored when Don called to request a talk about one economic issue or another. But for Don the core focus was people, the vulnerable and downtrodden, those who would be helped by truly universal health insurance. I remember when I saw him at a Bernie speech at Zellerbach Hall at UC Berkeley in 2016. We were chatting in line and I asked him, “So, realistically, is single payer happening?” – this question to a guy who lived each day as if it must. He became thoughtful, “There’s too much money vested in what we currently have.” Oddly, I wasn’t put off or disconcerted by that. I redoubled my efforts. Don was an inspiration: every day he worked for what was right and just, despite the odds. Don signed off of every email with “You are great! Don.” I try to pass that sentiment forward with my colleagues in the fight for health justice.

A Biden win in the election tomorrow saves democracy. It doesn’t solve health systems problems, but offers a platform for moving forward. Phil and Don will inspire us as we fight for that crucial next step.

More about them:
https://en.wikipedia.org…
https://healthpolicy.ucsf.edu…
https://www.legacy.com…

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By Dan Grunebaum
HealthCareInsider, October 29, 2020

Concerns About Healthcare and Debt

• 56% of U.S. adults said they were either somewhat or very concerned that a health situation in their household could lead to bankruptcy or debt.

Medical Debt

• Nearly three in ten (28%) respondents to the poll said they carry medical debt.
• Of those who reported having medical debt, 65% had debts exceeding $1,000.
• Surprise medical bills can be a source of medical debt.
• Three in ten respondents (28%) reported having received a surprise medical bill in the past year (since October 2019).

Lack of Savings

• Only just over half (57%) of U.S. adults contacted for the survey said they have savings to pay medical bills.
• 21% said they have no savings. 29% had $3,000 or less (excluding none), and 28% more than $3,000.
• Among all respondents, 32% had $500 or less in savings; 21% had no savings at all, while 11% had $1 to $500 on hand.

Cost Top Reason to Skip Healthcare

• Just under half of U.S. adults (46%) postponed healthcare services in the past year.
• Of those who did, over three in ten (32%) respondents said they didn’t seek healthcare services because they couldn’t afford it.
• Of respondents who reported no health insurance (13% overall), more than half (53%) said they could not afford it.

Low Comprehension of ACA Subsidies

• Despite some U.S. adults saying they lack health insurance due to cost, many are unaware they could qualify for financial help.
• Over half (52%) of respondents didn’t know whether you can receive an Affordable Care Act subsidy (a tax credit) to help pay for health insurance if you aren’t eligible for Medicare.

Politics and Healthcare

• Over four in ten (44%) pollees said they trust the Democratic Party most to ensure they and their family can obtain affordable healthcare.
• 28% trusted the Republican Party most. 12% said they trusted independents most to ensure they and their family can obtain affordable healthcare, and 13% were undecided.

HealthCareInsider.com commissioned YouGov PLC to conduct the survey. YouGov PLC is a research company using online panels to provide research for public policy, market research, and stakeholder consultation.

https://healthcareinsider.com…

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Comment:

By Don McCanne, M.D.

Of all wealthy nations, the United States is in first place in exposing patients to financial hardship. How long are we going to continue to look at numbers like these?

What are we doing about it? We have an election next week in which one candidate has promised us undefined “beautiful” health care while wreaking havoc on the system we do have, including asking the Supreme Court to invalidate the Affordable Care Act, and the other candidate promises to patch the Affordable Care Act with measures that will leave our highly dysfunctional financing infrastructure in place, perpetuating most of the financial hardships that patients are exposed to today (the majority of people with medical debt are insured through our flawed system).

We know what the solution is. If we enacted and implemented a well designed, single payer improved Medicare for All, we would redirect the profound waste in our system to fill the voids in health care while establishing an equitable, progressively-funded risk pool that would make health care affordable for each of us, finally ending our unique scourge of financial hardship due to medical bills. If we did this, we would not be spending any more than we already are, but we would no longer have to pretend that we have the finest health care system in the world because it would finally become a reality. What’s wrong with the best, if you can actually have it?

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By Sameh N. Saleh, M.D.; Ezimamaka Ajufo, B.M., B.Ch.; Christoph U. Lehmann, M.D.; Richard J. Medford, M.D.
JAMA Network Open, October 26, 2020

Key Points

Question: Why do individuals from Canada, the UK, and the US turn to medical crowdfunding and what factors are associated with funding success?

Findings: In this cross-sectional study of 3396 crowdfunding campaigns designed to raise monetary donations for medical expenses, female gender, Black race, and routine care were associated with a strong fundraising disadvantage. For campaigns primarily funding treatment, routine care was overwhelmingly represented in the US (77.9%), in contrast to Canada (21.9%) and the UK (26.6%), and crowdfunding primarily funding alternative therapies (16.0%) was more common for cancer (23.5%) vs noncancer (6.5%) diagnoses.

Meaning: These findings suggest that there are important differences in the reasons for medical crowdfunding across the 3 countries included in this analysis and that there are racial and gender disparities in crowdfunding success.

From the Discussion

In the US, nearly 80% of campaigns primarily funding treatment were for routine care, whereas in Canada and the UK, funding for routine care was sought about as frequently as funding for alternative, approved but inaccessible, and experimental therapies. Campaigns for routine care were negatively associated with crowdfunding success, whereas campaigns for experimental and approved but inaccessible therapies were positively associated with funding success.

Crowdfunding was initially heralded as a digital safety net or a mechanism for democratizing charity where anyone could benefit. However, anecdotal and empirical evidence suggests that crowdfunding may exacerbate socioeconomic inequities.

Conclusions

We provide a foundational descriptive analysis of MCF and factors associated with success in Canada, the UK, and the US, and highlight important differences in MCF trends between publicly and privately funded health care systems. Our findings also suggest that there are racial and gender disparities in the use and success of MCF. MCF directly (through platforms that promote the victim narrative) and indirectly (by rewarding these narratives with funding success) promotes the myth that gaps in health care funding are due to misfortune and exceptionality, rather than systemic failures. As such, MCF may entrench the systemic failures that led to its need. Thus, although crowdfunding has the potential to provide short-term relief from medical financial burden for a subset of patients, it may carry wider-reaching paradoxical societal effect for those most socially disadvantaged.

https://jamanetwork.com/…

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Comment:

By Don McCanne, M.D. 

Because of the deficiencies in our health care financing system, it is easy to see why some resort to charitable crowdfunding to help pay their medical bills. But why do Canada and the UK use crowdfunding when they have universal financing systems? The differences can give us some insight as to how the respective health care financing systems work.

Crowdfunding in the United States is used more frequently for routine care than it is in Canada and the UK for the obvious reason that their systems work better for covering routine care. In contrast, crowdfunding in Canada and the UK is frequently used for inaccessible or experimental therapies, as might be expected. To no surprise, crowdfunding for routine care is not as successful as it is for inaccessible or experimental services.

Crowdfunding is also used for alternative medicine, especially for cancer, since it is inappropriate to use public funds for care that is unproven and may be unsafe.

Sadly, crowdfunding may also exacerbate socioeconomic inequities because of racial or gender disparities. We would expect that that would be much less common under a truly equitable, universal system, though we would like to see the inequities totally disappear.

When we discuss single payer Medicare for All we frequently specify that it be a well designed system. As such, the system should work even better than those in Canada and the UK, and there should be no need for crowdfunding to pay medical bills. If experimental therapy might be appropriate then that should be funded by NIH research grants until the studies confirm effectiveness and safety.

Whether it’s a tin cup in hand, or crowdfunding in the computer age, that is no way to fund health care. Time for solidarity so we all have the health care we need.

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By Joan C. Alker, Genevieve M. Kenney, and Sara Rosenbaum
Health Affairs, October 2020

Abstract

Expansion of Medicaid and establishment of the Children’s Health Insurance Program (CHIP) represent a significant success story in the national effort to guarantee health insurance for children. That success is reflected in the high rates of coverage and health care access achieved for children, including those in low-income families. But significant coverage gaps remain—gaps that have been increasing since 2016 and are likely to accelerate with the coronavirus disease 2019 (COVID-19) pandemic and the associated recession. Using National Health Interview Survey data, we found that the proportion of uninsured children was 5.5 percent in 2018. Children continue to face coverage interruptions, and Latino, adolescent, and noncitizen children continue to face elevated risks of being uninsured. Although we note the benefits of a universal, federally financed, single-payer approach to coverage, we also offer two possible reform pathways that can take place within the current multipayer system, aimed at ensuring coverage, access, continuity, and comprehensiveness to move the nation closer to the goal of providing the health care that children need to reach their full potential and to reduce racial and economic inequalities.

SOURCES OF CHILDREN’S COVERAGE:

• EMPLOYER-SPONSORED COVERAGE: Tax-advantaged, employer-sponsored coverage is the dominant source of insurance among children in higher-income families. But for low- and moderate-income families, workplace benefits for children are increasingly unaffordable, as annual premium growth continually outstrips wage increases or might not be available at all.
• MEDICAID AND CHIP: Low- and moderate-income families without affordable employer coverage for their children rely chiefly on Medicaid and CHIP.
• MARKETPLACE COVERAGE: Subsidized Marketplace plans are an important but modest source of coverage for children, given that Marketplace subsidies are unavailable to children and adults who are eligible for other public insurance.

THE CURRENT LANDSCAPE:

Despite the major advances made, the current insurance picture for children does not include the permanent, stable coverage guarantee that the elderly enjoy through Medicare.

Coverage lapses remain a problem for children.

IMPROVING CHILDREN’S COVERAGE:

Given the limits of existing forms of coverage, there is much to be said for replacing the current system for children with a model akin to Medicare—that is, a nationwide, federally financed, single-payer public insurance plan that commences at birth and continues at least into young adulthood. Such an approach might be phased in, beginning with infants and young children, by specifying that no infant born after a certain date begins life without enrollment in the new system. This model, over time, would replace today’s multipayer arrangement and ideally would offer the full range of necessary care from preventive through long-term services and supports.

A single-payer model for children has been the subject of debate for decades, beginning soon after the passage of Medicare itself. Such an approach offers certain structural advantages: nationwide uniformity, durability, continuity, and the potential to universalize special coverage parameters that, similar to EPSDT benefits, have been expressly designed to meet the unique needs of children and adolescents. The other profound benefit of this model, and one that should be uppermost in policy makers’ minds in 2020, during the period of intense national reflection on the problem of structural racism, is that such a model could also help advance the cause of health equity relative to a multipayer model, whose components are determined by family income, as certain payers inevitably become associated with poverty and racial/ethnic characteristics—things that should play no role in determining the need for care or its quality and accessibility.

We recognize, however, that such a strategic direction involves a major overhaul of the system, with significant dislocation and commitment of new federal resources, which is very unlikely to happen quickly. Therefore, we identify two basic reform pathways that represent the next evolution of the current multipayer system for children.

One option would be to increase the mandatory income eligibility level for children under a combined Medicaid and CHIP benefit that sets the mandatory minimum level nationwide to 300 percent of the federal poverty level, which is fully federally financed.

Instead of going the Medicaid/CHIP route, policy makers could make major improvements in Marketplace coverage, including the elimination of the family glitch. Under this model, mandatory Medicaid eligibility could remain at 138 percent of the federal poverty level, while federally financed Marketplace subsidies would rise for families with incomes up to 400 percent of poverty, and subsidies that meet an affordability standard could be extended to families above that income level.

https://www.healthaffairs.org…

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‘MediKids’ Would Insure More Children

By Don R. McCanne, M.D.
Los Angeles Times, June 1, 2000

Our current efforts at reform have failed miserably. The number of children enrolled in Healthy Families has been offset by the decline in the enrollment in the MediCal program and an increase in the number of children who have lost their coverage because of termination of employment-based plans in which their parents could have been enrolled. What we need is not incremental reform, but sequential reform aimed at universal coverage.

To this end, Rep. Pete Stark (D-Ca.) and Sen. Jay Rockefeller (D-W. Va.) have introduced the MediKids Health Insurance Act of 2000 (HR 4390 and S 2515), which would establish a separate Medicare program just for children. The unique, defining feature of this act is that every child would be enrolled automatically at birth in the MediKids program. Parents could opt out only by presenting evidence of comparable private coverage. Any lapse of that coverage would cause an automatic return to the MediKids plan. When fully implemented, MediKids would assure every child of having health care coverage.

Participation would be an entitlement, as are Medicare and Social Security. The modest premium component of the funding would be collected at the time of submission of income tax returns, with a graduated discount for low-income individuals, assuring that coverage would be affordable for all.

https://www.latimes.com…

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Comment:

By Don McCanne, M.D.

Over the last half century, thanks to prior bipartisan support we have been fairly successful in ensuring health care coverage for children, but we have fallen short and coverage has deteriorated over the past three years.

The authors of the Health Affairs article excerpted above have stated it well: “there is much to be said for replacing the current system for children with a model akin to Medicare—that is, a nationwide, federally financed, single-payer public insurance plan that commences at birth and continues at least into young adulthood.”

The idea is not new. An article I wrote two decades ago discusses the MidiKids Act authored by Rep. Pete Stark and Sen. Jay Rockefeller which would have established a separate Medicare program just for children.

Also, Joe Biden is proposing lowering the age of eligibility for the existing Medicare program to age 60.

An important concept here is that these proposals would not be mere incremental steps in which patches are applied to the current highly dysfunctional financing system but rather they would be sequential steps to expand Medicare, as was originally intended when Medicare was established half a century ago.

Merely patching the current system would leave in place all of the dysfunctions that result in very high costs, profound administrative inefficiencies, lack of continuity of coverage and care, inequities in access and coverage, and would still leave millions exposed to financial hardship because of lack of adequate coverage.

Although sequential steps may seem like a better idea, they do not address the problem that Medicare itself has many serious deficiencies that need to be corrected. Also we have already waited 50 years to begin the sequential expansions, but we haven’t gotten beyond Medicare for some of the long-term disabled and ESRD coverage. If we did expand coverage to all children, how long would it be before we guaranteed coverage to those aged 18 to 65 (or Biden’s 60)? Possibly never if those prevail who believe that individual responsibility means you’re on your own rather than joining in solidarity to be our brothers’ and sisters’ keepers.

There are a great many features of a well designed, single payer, improved Medicare for All that would need to be included in a structural reform of health care financing. Though incremental tweaks are a terrible idea because they leave so many out, sequential reform building on our current system certainly has its deficiencies as well. Instead, let’s do it right and take one giant step across the chasm.

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