PNHP

Verma says value-based care provides a ‘very poor return in investment’

Verma says value-based care provides a ‘very poor return in investment’

Verma says value-based care models haven't made good return on investment

By Robert King
Fierce Healthcare, October 13, 2020

Seema Verma, the head of the Centers for Medicare & Medicaid Services (CMS), said that some value-based care payment models did not generate enough savings and quality outcomes.

Her remarks Tuesday during HLTH’s virtual conference come a few weeks after other Trump administration officials reported mixed results for bundled payment models in producing savings. Verma did tout models that required providers to take on financial risk at a faster pace, potentially alluding to the direction CMS wants to steer value-based care models.

“I think the issue we have in value-based care is that many of our models unfortunately are not working the way we would like them to,” she said. “They are not producing the types of savings the taxpayers deserve.”

It has been a “very poor return in investment,” Verma added.

Verma also gave praise to CMS’ Pathways to Success model that overhauled the program managing accountable care organizations (ACOs).

Pathways required ACOs to take on financial risk at a shorter period than the Medicare Shared Savings Program created under the Obama administration. This meant that ACOs had to pay back Medicare if it did not meet certain savings targets.

“We are already seeing significant savings and increases in quality,” Verma said of Pathways, which started in 2019.

Verma said that CMS isn’t shying away from value-based care, but she hinted at what direction the next wave of payment models could entail.

“I think it is important for providers to have skin in the game,” she said. “Just having upside risk doesn’t really produce the type of savings and quality measures that we want to see.”

https://www.fiercehealthcare.com…

Comment:

By Don McCanne, M.D.

The policy community still seems to be fixated on the rhetoric of paying for value instead of volume, as they continue to support value-based models such as ACOs. CMS administrator Seema Verma now concedes that value-based models have provided a “very poor return in investment.”

Verma, who is driven more by ideology than by health policy that is designed to serve patients first, is not exactly giving up on value-based care, but rather she is focusing on a model design “for providers to have skin in the game.” She wants value-based models that are designed for providers “to take on financial risk at a faster pace.” Instead of emphasizing upside risk that rewards providers with Medicare dollars, she is now emphasizing downside risk that penalizes providers who then have to return money to Medicare.

Verma has long supported consumer-driven health care that requires patients to assume greater risk when accessing health care, but now she also wants to transfer even more risk from the government to the providers of health care. Forget patient care; it really is about the money.

Lack of affordability is one of the greatest problems in health care today. Making health care even less affordable by transferring more risk to the patient, such as with increased deductibles and not paying for out-of-network providers, is the opposite of the direction in which we should be headed. Government programs are noted for their parsimonious payment policies, often paying less than costs of care, and thus shifting more risk to the providers can threaten especially the safety-net system – again, the wrong direction on policy.

Many decades ago Nobel laureate Kenneth Arrow explained why markets do not work in health care, and yet the wish-they-would-work ideologues keep pushing their concepts on us. Our insistence on using markets in health care, such as our heavy reliance on private health plans, has resulted in the most expensive health care system yet one of the poorest performing when considering the tens of millions with inadequate insurance or no insurance at all. Our very high spending with poor performance is proof that, in health care, the markets are not bringing us high quality at low cost.

If we had a single payer Medicare for All system, we wouldn’t have to rely on the marketplace to manage costs since the government would use patient-friendly and provider-friendly administered pricing. Those who still contend that the government can’t do it right have to recognize that all other wealthy nations are providing health care for essentially everyone at an average per capita cost of half of what we spend.

More “skin in the game” punishes those who already are suffering the burden of having medical disorders. Our health care financing system should be designed to help relive those burdens, not cause more.

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CMS: Enrollment in unsubsidized ACA plans declined by 45%

Trends in Subsidized and Unsubsidized Enrollment

Centers for Medicare and Medicaid Services, October 9, 2020

Introduction

This report provides data on enrollment trends for people who purchased on- and off-Exchange individual market health insurance plans, both with and without federal advanced premium tax credit (APTC) subsidies. These data are based on an analysis of individual market plans that participated in the risk adjustment program established under section 1343 of the Patient Protection and Affordable Care Act (PPACA) and Health Insurance Exchange effectuated enrollment data. The data provided in this report include state-specific, average monthly enrollment covering plan years 2014 to 2019. Over that period, average monthly enrollment in the individual market—including both subsidized and unsubsidized enrollment—peaked in 2016, reaching 14.5 million. Enrollment then declined by 10 percent in 2017, 7 percent in 2018, and 3 percent in 2019. Enrollment among the unsubsidized, who do not receive APTC subsidies, saw a considerable decline of 9 percent from 2018 to 2019, compared to a decrease of 1 percent in APTC subsidized enrollment. From its peak in 2016, unsubsidized enrollment declined by 2.8 million people by 2019, a 45 percent drop nationwide. From 2016 to 2019, unsubsidized enrollment declined by more than 70 percent in Arizona, Georgia, Iowa, Missouri, Nebraska, New Hampshire, Oklahoma, Tennessee, and West Virginia.

Key Findings

This report provides data on individual health insurance market enrollment trends for people who purchase health insurance with (subsidized) and without (unsubsidized) advanced premium tax credits (APTC).

  • From plan years 2016 to 2019, unsubsidized enrollment declined by 2.8 million people, representing a 45 percent drop nationally. At the state level, the percentage change in unsubsidized enrollment over this period ranged from a 4 percent drop in Rhode Island to a 90 percent drop in Iowa.
  • The most recent year of enrollment data shows that average monthly enrollment across the individual market nationally decreased by 3 percent between 2018 and 2019.
  • Eighty percent of the decrease in enrollment between 2018 and 2019 occurred among people who did not receive APTC subsidies. Unsubsidized enrollment declined by 9 percent, compared to only a 1 percent decrease in subsidized enrollment, from 2018 to 2019.
  • Though unsubsidized enrollment continued to decline in 2019, the rate of decline was substantially lower than the 24 percent drop in 2018 and the 20 percent drop in 2017. This lower rate of decline occurred as premium rates leveled off in 2019, after increasing by double-digits in 2017 and 2018.
  • Looking at state-level enrollment trends between 2016 and 2019 also shows the link between enrollment and premium trends. States with larger declines in unsubsidized enrollment tended to experience a larger increase in average premiums.
  • Review of state-level data also shows that trends in declining enrollment began from 2015 to 2016 for 10 states. Declining enrollment occurred in 44 states from 2016 to 2017, 43 states from 2017 to 2018, and 39 states from 2018 to 2019.
  • Average monthly enrollment in the subsidized portion of the market grew substantially in comparison to the unsubsidized market. The subsidized portion of the market was 140 percent larger than the unsubsidized portion in 2019, up from 122 percent larger in 2018 and 61 percent in 2017.

https://www.cms.gov…

Comment:

By Don McCanne, M.D.

To no surprise, as premiums increased in the plans offered through the ACA exchanges, the enrollment by individuals who received no subsidies (advanced premium tax credits) declined by 45%. They found the premiums to be simply unaffordable.

In contrast, the percentage of enrollees who received subsidies increased dramatically (though the actual numbers enrolled didn’t increase much – see Figure 3 at link above). In 2015, the subsidized enrollment was 24% larger than the unsubsidized enrollment, whereas, by 2019, the subsidized enrollment had grown to 140% larger.

When it was decided to reject a universal public insurance program and instead enact an exchange (market) of private insurance plans to help fill the void in coverage, the authors of the legislation rejected the efficiency and effectiveness that had already been demonstrated in our Medicare program and instead relied on the fragmented and highly dysfunctional private insurance model – a model that has not served us well.

It is understandable why people would accept private insurance when the government is providing generous subsidies for its purchase. Likewise, it is also certainly understandable why the private plans would be rejected when the enrollees were required to pay the full unaffordable premiums. Why would they want to pay hard-earned money for a private plan that had unaffordable deductibles, limited provider networks, and wasteful, costly administrative excesses? A more pertinent question is why would Congress insist on offering such a defective model of health care financing when we could have an efficient, equitable, affordable, single payer Medicare for All program that includes everyone?

The near future looks grim. Both presidential candidates have rejected the single payer model, and the likely victor has suggested more of the same, with perhaps an increase in subsidies and the addition of a private-style option which has been mislabeled as Medicare.

Our clearly dysfunctional system is working poorly for too many of us and not at all for far too many more. Why would we simply want to throw more subsidies at it when all of us could have a far better deal through a single payer program of Medicare for All?

Joe Biden keeps saying to us, “Here’s the deal.”

It’s time for us to say, “No! Here’s the deal we demand.”

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Three years of declining health coverage for children

Children’s Uninsured Rate Rises by Largest Annual Jump in More Than a Decade

By Joan Alker, Alexandra Corcoran
Georgetown University, Health Policy Institute, Center for Children and Families, October 8, 2020

Introduction

For many years, the United States was on a positive trajectory in reducing the number and rate of uninsured children; in 2016, the nation attained a historic low of 3.6 million uninsured children. This progress occurred as a result of expansions of public coverage—primarily Medicaid and the Children’s Health Insurance Program (CHIP)—and was accelerated by the implementation of the Affordable Care Act’s (ACA) major coverage expansions in 2014. As employer-sponsored insurance became increasingly unaffordable for dependents, public coverage ameliorated the impacts of private coverage losses for children. However, the number of uninsured children began to increase in 2017 as Medicaid enrollment began to decline and reached 4.4 million in 2019. This represents an increase of 726,000 children during this three-year period. The rate of uninsured children rose a full percentage point from 4.7 percent to 5.7 percent. Much of the gain in coverage that children made as a consequence of the ACA’s major coverage expansions has now been eliminated. Moreover, the most recent year of data (2018 to 2019) shows the biggest one-year loss in children’s coverage during this time period, with 320,000 more children becoming uninsured. These coverage losses occurred in a healthy economy with the lowest unemployment rate in decades prior to the economic shocks and job loss associated with the COVID-19 pandemic.

Key Findings

  • After reaching a historic low of 4.7 percent in 2016, the child uninsured rate began to increase in 2017, and as of 2019 jumped back up to 5.7 percent. This increase of a full percentage point translates to approximately 726,000 more children without health insurance since the beginning of the Trump Administration when the number of uninsured children began to rise. Much of the gain in coverage that children made as a consequence of the Affordable Care Act’s major coverage expansions implemented in 2014 has now been eliminated.
  • The number of uninsured children increased every year during the Trump Administration. The largest increase was observed between 2018 and 2019 when, despite a continued strong economy, the number of children without health insurance rose by 320,000. This increase in the number of uninsured children was the largest annual jump seen in more than a decade. Moreover, since this data was collected prior to the pandemic, the number of uninsured children is likely considerably higher in 2020, as families have lost their jobs and employer-sponsored insurance, though it is impossible to know yet by precisely how much.
  • One-third of the total increase in the number of uninsured children from 2016 to 2019 live in Texas. The state saw by far the greatest coverage loss over the period with an estimated 243,000 more children living without health coverage. Florida has the next biggest loss, adding about 55,000 children to the uninsured count over the three-year period. As a consequence, 41 percent of children’s coverage losses during the Trump Administration occurred in Texas and Florida. Twenty-nine states experienced an adverse change for children from 2016 to 2019. The only state that bucked national trends and significantly reduced its number of uninsured children during this three-year time period was New York.
  • These coverage losses were widespread across income, age, and race/ethnicity, but were largest among White and especially Latino children (who can be of any race).

https://ccf.georgetown.edu…

Full report:
https://ccf.georgetown.edu…

Comment:

By Don McCanne, M.D.

There is a special place for children in the hearts of Americans. For the last half century an extra effort has been made to provide health care coverage for children, especially through the Medicaid and CHIP programs, but also through private plans through the ACA exchanges and employer-sponsored plans that also cover dependents.

However, the reluctance to support a universal national health program inevitably left many children without coverage. American style of health care reform – incremental patches – did have some effect in reducing but not eliminating the number of children uninsured, but this has changed during the last three years – not coincidentally the years of the Trump administration. An additional 726,000 children are now without health insurance (totaling 4.4 million in 2019), and that does not include more recent losses in coverage due to job loss during the Covid pandemic, due to the threat of the public charge rule against immigrants who are here legally, and due to increased administrative barriers to enrollment in the public programs. Apparently not all Americans hold in esteem children who represent the future of our nation. But it really is disconcerting to see some of our public stewards struggle to take health care away from children.

Think again about a single payer system of improved Medicare for All… health care… for everyone… for life… health care that is affordable for each of us. Imagine an America where each year we wouldn’t find ourselves compelled to count up the number of children uninsured due to the failure of our politicians to ensure health care for everyone who needs it. Yes, the uninsured children… think of them and what that represents, and then extrapolate that to the rest of us.

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China helps the world; we hardly help ourselves

Joining COVAX Could Save American Lives

The vaccine partnership would help ensure equitable access to a COVID-19 vaccine—including in the United States—but Trump won’t participate.

By Eric A. Friedman, Lawrence O. Gostin, Matthew M. Kavanaugh, John T. Monahan, Harold Hongju Koh
Foreign Policy, September 15, 2020

In one of its latest strikes against global solidarity in the midst of the COVID-19 pandemic, the administration of U.S. President Donald Trump has declared that it will not participate in the COVID-19 Vaccine Global Access (COVAX) Facility, a global partnership that aims to support the development of a vaccine and share access to it. Trump apparently prefers, instead, a go-it-alone approach that could undermine Americans’ access to an eventual vaccine and disrupt efforts to ensure equity in its global distribution.

This move is one of a string of administration actions that have undermined the now distant-seeming tradition of U.S. global health leadership. The same week as its COVAX announcement, the Trump administration also said that it would withhold $62 million that the United States owes to the World Health Organization (WHO) for its annual dues. The administration plans to redirect the funding to other United Nations health programs. Congress had already appropriated the WHO funding, making Trump’s move the latest among his strikes against the rule of law; he has no authority to redirect funds that Congress has already allocated.

The administration’s effort to undermine WHO reached a climax in July when the United States began the yearlong process of withdrawing from the organization.

The administration has virtually invented “vaccine nationalism,” making exclusive deals with several vaccine manufacturers to ensure a supply of their vaccines for Americans, the consequences for the rest of the world being of no concern.

And now, as the world anxiously awaits a safe and effective vaccine for COVID-19, the administration announced that it will not participate in COVAX. The decision stands to undermine the most consequential area of global cooperation around COVID-19, a crisis otherwise marked by a stunning lack of global solidarity. And by denying Americans the benefits that all countries participating in COVAX will receive, the decision poses a direct health and economic threat to Americans.

The U.S. is shunning COVAX because of its link to the WHO, which the administration wrongheadedly views as being controlled by China. The vast majority of countries, 172, have joined COVAX, which is co-led by WHO, the Coalition for Epidemic Preparedness Innovations (CEPI), and Gavi, the Vaccine Alliance.

https://foreignpolicy.com…

Foreign Ministry Spokesperson Hua Chunying’s Remarks on China Joining COVAX

Ministry of Foreign Affairs, the People’s Republic of China, October 9, 2020

On October 8, China and Gavi, the Vaccine Alliance, signed an agreement, officially joining COVAX. This is an important step China has taken to uphold the concept of a shared community of health for all and to honor its commitment to turn COVID-19 vaccines into a global public good.

Currently, the COVID-19 pandemic still poses a severe threat to the safety and health of people in all countries. China continues to focus on ensuring that developing countries have equal access to appropriate, safe and effective vaccines. To that end, we have solemnly pledged to make vaccines developed and deployed by China a global public good, which will be provided to developing countries as a priority. Therefore, China has maintained close communication with COVAX with a positive attitude towards joining it. Even when China is leading the world with several vaccines in advanced stages of R&D and with ample production capacity, it still decided to join COVAX. We are taking this concrete step to ensure equitable distribution of vaccines, especially to developing countries, and hope more capable countries will also join and support COVAX. China will also strengthen vaccine cooperation with relevant countries through the COVAX network.

China will continue to work together with COVAX partners and contribute its share to the global fight against the pandemic to safeguard all human beings’ safety and health.

https://www.fmprc.gov.cn…

Johns Hopkins, Coronavirus Resource Center

Accessed October 9, 2020

United States

  • 7,605,873 Confirmed cases
  • 212,762 Deaths
  • 2.8% Case-Fatality
  • 65.03 Deaths/100K Pop.

China

  • 90,728 Confirmed cases
  • 4,739 Deaths
  • 5.2% Case-Fatality
  • 0.34 Deaths/100K Pop.

https://coronavirus.jhu.edu…

Comment:

By Don McCanne, M.D.

Today’s Quote of the Day resources are really troubling. President Trump has repeatedly condemned China for the problems that we have with the Covid-19 pandemic. Yet the United States has far more cases and deaths from the coronavirus than does China. We have almost 200 times the number of deaths per 100,000 population than does China.

This tragic pandemic cries out for world cooperation in bringing it under control and in preventing similar pandemics in the future. The World Health Organization, with the cooperation of other agencies, has brought 172 nations together in COVAX – a global partnership that aims to support the development of a vaccine and share access to it. Yet President Trump has refused to allow the United States to participate, partly because he “wrongheadedly” views WHO as being controlled by China. According to Foreign Policy, “Trump apparently prefers, instead, a go-it-alone approach that could undermine Americans’ access to an eventual vaccine and disrupt efforts to ensure equity in its global distribution.” Considering the Trump administration’s attitudes on trade, it is not unreasonable to suspect that he would like to capture the international market for Covid vaccine and knock China out of the competition.

Contrast that with the release from China’s Ministry of Foreign Affairs. “China will continue to work together with COVAX partners and contribute its share to the global fight against the pandemic to safeguard all human beings’ safety and health.” In taking this step, they express their desire “to uphold the concept of a shared community of health for all and to honor its commitment to turn COVID-19 vaccines into a global public good.”

Do we no longer believe in a shared community committed to a global public good? As I said, today’s message is really troubling.

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NEJM: Dying in a Leadership Vacuum

By The Editors
The New England Journal of Medicine, October 8, 2020

Covid-19 has created a crisis throughout the world. This crisis has produced a test of leadership. With no good options to combat a novel pathogen, countries were forced to make hard choices about how to respond. Here in the United States, our leaders have failed that test. They have taken a crisis and turned it into a tragedy.

The magnitude of this failure is astonishing. According to the Johns Hopkins Center for Systems Science and Engineering, the United States leads the world in Covid-19 cases and in deaths due to the disease, far exceeding the numbers in much larger countries, such as China. The death rate in this country is more than double that of Canada, exceeds that of Japan, a country with a vulnerable and elderly population, by a factor of almost 50, and even dwarfs the rates in lower-middle-income countries, such as Vietnam, by a factor of almost 2000. Covid-19 is an overwhelming challenge, and many factors contribute to its severity. But the one we can control is how we behave. And in the United States we have consistently behaved poorly.

We know that we could have done better. China, faced with the first outbreak, chose strict quarantine and isolation after an initial delay. These measures were severe but effective, essentially eliminating transmission at the point where the outbreak began and reducing the death rate to a reported 3 per million, as compared with more than 500 per million in the United States. Countries that had far more exchange with China, such as Singapore and South Korea, began intensive testing early, along with aggressive contact tracing and appropriate isolation, and have had relatively small outbreaks. And New Zealand has used these same measures, together with its geographic advantages, to come close to eliminating the disease, something that has allowed that country to limit the time of closure and to largely reopen society to a prepandemic level. In general, not only have many democracies done better than the United States, but they have also outperformed us by orders of magnitude.

Why has the United States handled this pandemic so badly? We have failed at almost every step. We had ample warning, but when the disease first arrived, we were incapable of testing effectively and couldn’t provide even the most basic personal protective equipment to health care workers and the general public. And we continue to be way behind the curve in testing. While the absolute numbers of tests have increased substantially, the more useful metric is the number of tests performed per infected person, a rate that puts us far down the international list, below such places as Kazakhstan, Zimbabwe, and Ethiopia, countries that cannot boast the biomedical infrastructure or the manufacturing capacity that we have. Moreover, a lack of emphasis on developing capacity has meant that U.S. test results are often long delayed, rendering the results useless for disease control.

Although we tend to focus on technology, most of the interventions that have large effects are not complicated. The United States instituted quarantine and isolation measures late and inconsistently, often without any effort to enforce them, after the disease had spread substantially in many communities. Our rules on social distancing have in many places been lackadaisical at best, with loosening of restrictions long before adequate disease control had been achieved. And in much of the country, people simply don’t wear masks, largely because our leaders have stated outright that masks are political tools rather than effective infection control measures. The government has appropriately invested heavily in vaccine development, but its rhetoric has politicized the development process and led to growing public distrust.

The United States came into this crisis with enormous advantages. Along with tremendous manufacturing capacity, we have a biomedical research system that is the envy of the world. We have enormous expertise in public health, health policy, and basic biology and have consistently been able to turn that expertise into new therapies and preventive measures. And much of that national expertise resides in government institutions. Yet our leaders have largely chosen to ignore and even denigrate experts.

The response of our nation’s leaders has been consistently inadequate. The federal government has largely abandoned disease control to the states. Governors have varied in their responses, not so much by party as by competence. But whatever their competence, governors do not have the tools that Washington controls. Instead of using those tools, the federal government has undermined them. The Centers for Disease Control and Prevention, which was the world’s leading disease response organization, has been eviscerated and has suffered dramatic testing and policy failures. The National Institutes of Health have played a key role in vaccine development but have been excluded from much crucial government decision making. And the Food and Drug Administration has been shamefully politicized, appearing to respond to pressure from the administration rather than scientific evidence. Our current leaders have undercut trust in science and in government, causing damage that will certainly outlast them. Instead of relying on expertise, the administration has turned to uninformed “opinion leaders” and charlatans who obscure the truth and facilitate the promulgation of outright lies.

Let’s be clear about the cost of not taking even simple measures. An outbreak that has disproportionately affected communities of color has exacerbated the tensions associated with inequality. Many of our children are missing school at critical times in their social and intellectual development. The hard work of health care professionals, who have put their lives on the line, has not been used wisely. Our current leadership takes pride in the economy, but while most of the world has opened up to some extent, the United States still suffers from disease rates that have prevented many businesses from reopening, with a resultant loss of hundreds of billions of dollars and millions of jobs. And more than 200,000 Americans have died. Some deaths from Covid-19 were unavoidable. But, although it is impossible to project the precise number of additional American lives lost because of weak and inappropriate government policies, it is at least in the tens of thousands in a pandemic that has already killed more Americans than any conflict since World War II.

Anyone else who recklessly squandered lives and money in this way would be suffering legal consequences. Our leaders have largely claimed immunity for their actions. But this election gives us the power to render judgment. Reasonable people will certainly disagree about the many political positions taken by candidates. But truth is neither liberal nor conservative. When it comes to the response to the largest public health crisis of our time, our current political leaders have demonstrated that they are dangerously incompetent. We should not abet them and enable the deaths of thousands more Americans by allowing them to keep their jobs.

https://www.nejm.org…

Comment:

By Don McCanne, M.D.

This great tragedy resulting in loss of life, physical suffering from illness, loss of employment, financial hardship from damage to our economy, and day in and day out angst for all of us could have and should have been partially or largely ameliorated had our government been competent and attentive. It was not. This was a massive political failure. The blame lies heavily with the president and his administration, but also with the legislators – especially those controlling the Senate – and their inadequate response, and ultimately much of the blame lies with the voters who elected and continue to support a political hierarchy that has failed us so miserably.

This incompetence is not new. For many decades we have tolerated an expensive health care system that has left tens of millions of us without any health care coverage, and tens of millions more with inadequate coverage that leaves them having to cope with financial barriers to care. We have allowed hundreds of billions of health care dollars to be redirected to extremely wasteful administrative excesses, benefiting passive investors at the cost of impaired patient access to care. This too is a political failure.

The policy science is straightforward. We know how to design a system that would provide essential health care services for absolutely everyone at a cost that each of us could afford – single payer, improved Medicare for All. The policy is easy, but we have to get the politics right. The Covid-19 pandemic and the political response to it should give us all of the lessons we need. Let’s apply them now.

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CBO: Achieving near-universal coverage

Policies to Achieve Near-Universal Health Insurance Coverage

Congress of the United States, Congressional Budget Office, October 2020

In this report, CBO describes the key features—specifically, the enrollment process, premiums, cost sharing and benefits, and the role of private insurance, public programs, and employment-based insurance—of four general approaches that could achieve near-universal coverage by using premium subsidies and different forms of automatic coverage through a default plan. Those approaches are as follows:

  • Approach 1. A multipayer system that retains existing sources of coverage while expanding eligibility for premium subsidies and providing partially subsidized default coverage through a private plan or a new public option.
  • Approach 2. A multipayer system that retains employment-based coverage and replaces the current nongroup market and the acute care portions of Medicaid and the Children’s Health Insurance Program (CHIP) with a new public program that allows people to choose between partially subsidized private plans and a publicly administered plan that provides default coverage.
  • Approach 3. A multipayer system that provides full subsidies for all people to purchase a private plan of their choice, with a default plan that provides automatic coverage to people who do not enroll in a plan on their own.
  • Approach 4. A single-payer system that acts as a default plan for all people.

(For the first three approaches, see the full report at the link below.)

Approach 4: A Single-Payer System

Under a single-payer system, everyone in the defined population would receive health insurance coverage from the same public plan, and there generally would be no role for private insurance. There would be no premiums, and to achieve deficit neutrality, such a system would need to be financed through broad-based tax revenues; that is, new mechanisms of financing also would be required. This approach would involve the most significant departure from the current health care system, and it would be an enormously complex undertaking. Under current law, people receive coverage through various public and private sources, as described earlier in this report. Under a single-payer system, there generally would be no role for employment-based insurance, and the role of other public programs, such as Medicaid and Medicare, would be greatly reduced or eliminated.

Enrollment Process. Under a single-payer system, the government would strive to enroll all people in the defined population in the public plan. People also could be automatically enrolled at the time they were issued Social Security numbers, newborns could be enrolled in hospitals, and other eligible people could be enrolled at the time they sought medical care. Some people seeking medical care would not be eligible for enrollment—because they were visiting from another country, for instance—and the enrollment system would need to confirm that they were not eligible. Because people would need to provide information to the enrollment system and some would not do so, coverage would not be completely universal.

Premiums. There would be no premiums under a single-payer system. To achieve deficit neutrality, such a system would need to be financed through broad-based tax revenues.

Cost Sharing and Benefits. A single-payer system would have lower cost sharing than the average under current law. Such a system could include no cost sharing for most services. If the single-payer system included cost sharing, there could be exceptions for certain populations, such as people with low income, children, and the disabled.

The single-payer system would provide comprehensive major medical coverage, but certain items and services, such as over-the-counter medications and cosmetic procedures, could be excluded from coverage. Existing proposals cover a more comprehensive set of benefits than many current sources of coverage, including dental, vision, hearing, and long-term services and supports, but a single-payer system could be designed without those additional benefits.

Role of Private Plans. There generally would be no role, or a very limited role, for private insurance. If private insurance was allowed, it could be limited to services not covered by the public plan. However, private insurance also could be offered as an alternative source of coverage if enrollees and providers were allowed to opt out of the single-payer system. Alternatively, private insurance could provide benefit enhancements, such as faster access to care or private rooms instead of semiprivate rooms for inpatient stays, or it could be used to access providers that opt out of the single-payer system or to seek care abroad.

Role of Employment-Based Insurance. Employment-based insurance probably would no longer exist under a single-payer health system, or its role would be greatly reduced. For instance, it might provide supplemental coverage for services not covered by the public plan or reduce cost-sharing amounts, if any.

Role of Public Programs. Most public programs, such as Medicaid, CHIP, and Medicare probably would have a limited role or be eliminated under a single-payer system. Some components of those programs could continue to operate separately and provide benefits for services not covered by the single-payer health plan. For example, Medicaid and CHIP could continue to provide long-term services and support benefits only to low-income populations, but the Medicare program would no longer exist.

Examples of This Approach. The two versions of the Medicare for All Act of 2019 include many of the features described in this approach, including no premiums, comprehensive major medical coverage, limited to no cost sharing, and no private insurance that would duplicate the benefits of the single-payer system. (See the Medicare for All Act of 2019, H.R. 1384 and S. 1129, 116th Cong.)

https://www.cbo.gov…

Yarmuth letter requesting CBO study:
https://budget.house.gov…

Hall v. Sebelius

Opinion written by Circuit Judge Brett Kavanaugh
667 F.3d 1293 (D.C.Cir.2012), No. 11–5076, February 7, 2012

This is not your typical lawsuit against the Government. Plaintiffs here have sued because they don’t want government benefits. They seek to disclaim their legal entitlement to Medicare Part A benefits for hospitalization costs. Plaintiffs want to disclaim their legal entitlement to Medicare Part A benefits because their private insurers limit coverage for patients who are entitled to Medicare Part A benefits. And plaintiffs would prefer to receive coverage from their private insurers rather than from the Government.

Plaintiffs’ lawsuit faces an insurmountable problem: Citizens who receive Social Security benefits and are 65 or older are automatically entitled under federal law to Medicare Part A benefits. To be sure, no one has to take the Medicare Part A benefits. But the benefits are available if you want them. There is no statutory avenue for those who are 65 or older and receiving Social Security benefits to disclaim their legal entitlement to Medicare Part A benefits. For that reason, the District Court granted summary judgment for the Government. We understand plaintiffs’ frustration with their insurance situation and appreciate their desire for better private insurance coverage. But based on the law, we affirm the judgment of the District Court.

https://casetext.com…

Comment:

By Don McCanne, M.D.

House Budget Committee Chairman John Yarmuth and colleagues requested this CBO study on different policy approaches for achieving universal coverage, including “how each approach could provide coverage to individuals who do not otherwise actively enroll in private or public health coverage.”

Of the four approaches in the report, the first three are not discussed here for the following reasons: 1) Although they would expand coverage, none of them reach truly universal coverage, 2) All of them are multi-payer systems that include private insurance plans which have been the source of many of the dysfunctions in our current health care financing system, 3) All of them involve profound administrative complexity which has been a source of much of the waste in our current system, not to mention the grief that these excesses have caused, and 4) All of them would significantly increase the level of per capita spending on health care when we are already spending twice the average of other wealthy nations.

The fourth model should be familiar to advocates of single payer Medicare for All since it is based on the Medicare for All Act of 2019 sponsored by Bernie Sanders in the Senate and Pramila Jayapal in the House. It is summarized above, and more details can be found at the website of Physicians for a National Health Program at www.pnhp.org.

The CBO report says that, under this model, coverage would not be completely universal “because people would need to provide information to the enrollment system and some would not do so.” However, the program is designed to automatically include everyone for life. In fact, there is legal precedent for prohibiting individuals from disclaiming their legal entitlement to Medicare Part A. D.C. Circuit Court Judge Brett Kavanaugh wrote in an opinion that although individuals did not have to accept Medicare Part A benefits, they could not disclaim their legal entitlement to those benefits. So the government can require that everyone is covered.

At any rate, this report is important since the highly credible CBO has objectively described a single payer system in terms that make it clear that it is still the only model currently under consideration that would provide truly affordable health care coverage for absolutely everyone.

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Consolidation of Three Brooklyn Hospitals Restarts Mid-Pandemic, Staff, Community, and Advocates Push Back

The state plan consolidates services across three Central Brooklyn hospitals and eliminates over 200 beds.

By Billy Richling
Bylyner, October 7, 2020

In mid-March, a $700 million state plan to restructure three central Brooklyn hospitals was put on hold to ensure the institutions could accommodate the soaring number of coronavirus patients showing up at their doors.

Now, the plan to consolidate services and eliminate over 200 beds from Kingsbrook Jewish Medical Center while merging it with Interfaith Medical Center and Brookdale Hospital is again moving forward. But this time, a group of hospital staff, community members, and advocates is pushing back.

A petition, created by Kingsbrook nurses and titled Beds Not Bodybags: Do Not Close Kingsbrook Jewish Medical Center in the Middle of a Pandemic!, has garnered over 375 signatures, including at least 240 from Kingsbrook staff. Though hospital leadership says they are prepared for a potential second wave of coronavirus cases, the petition organizers worry that unless consolidation is delayed, the area’s already vulnerable medical institutions could again be overwhelmed.

“By closing this hospital before the second wave of the pandemic, which has the possibility of being worse than the first,” the petition reads, “Cuomo is working to ensure that even more Black Brooklynites will die.”

Reshaping Healthcare in Central Brooklyn

The hospital consolidation is part of Governor Andrew Cuomo’s Vital Brooklyn initiative, a $1.4 billion plan announced in 2017 that is intended to address health, social and economic disparities in several low-income Brooklyn neighborhoods.

Kingsbrook, Interfaith, and Brookdale are at the center of the initiative’s health component. The three independent hospitals serve large numbers of Medicaid and uninsured patients and have faced financial challenges for years. At the recommendation of a state-commissioned Northwell Ventures study, the hospitals’ management was centralized in 2018 under a not-for-profit entity called One Brooklyn Health, in the hopes that doing so would create cost-saving efficiencies.

The Governor then awarded about half the Vital Brooklyn funding to One Brooklyn in the form of grants. The money, according to a press release from the Governor’s office, will enable One Brooklyn to streamline services and to implement infrastructure and technology upgrades. It will also facilitate the transformation of Kingsbrook into a “medical village” focused on providing ”primary and specialty care, emergency services, and post-acute care services.”

That transformation requires the elimination of all of Kingsbrook’s 163 inpatient medical-surgical beds, along with dozens of additional beds for patients receiving treatment for coronary issues, traumatic brain injuries, and coma recovery.

Chart taken from documents submitted to the New York State Department of Health’s Public Health and Health Planning Council in August.

The deactivation of those beds was initially set to be completed by June 30th, but was paused when the pandemic began. Now, the planned completion date is January 1st. According to hospital staff, about 40 beds have been deactivated so far.

The goal, says LaRay Brown, One Brooklyn’s President & CEO, is to rationalize services across the system, and to recenter Kingsbrook around the type of primary and specialty care that could help patients stay healthy and avoid the overnight ER visits the hospital currently offers.

“We are committed to making Kingsbrook the hospital and healthcare campus of the future,” Brown said. “Which is less inpatient capacity, but many more outpatient services.”

COVID-19 Concerns

Some Kingsbrook staffers see things differently.

“I think that the pandemic has clarified that available hospital beds continue to actually be a very important part of the public health safety net,” said Julie Keefe, a Kingsbrook nurse who helped create the petition. “And it has really revealed that Cuomo and others have already gone too far with hospital closures and bed reductions in the boroughs.”

One Brooklyn’s data shows that occupancy rates of inpatient medical-surgical beds at Kingsbrook and Interfaith have hovered around 60% in recent years, while Brookdale has remained closer to 50% occupancy.

During the first wave of the pandemic, however, staff say all three hospitals were overwhelmed. Kingsbrook employees told the New York Times that the patient-to-nurse ratio at the hospital reached 20-to-1, far higher than the 4-to-1 ratio considered best practice. The patient-nurse ratio at Interfaith’s intensive care units, meanwhile, reached four times their recommended 2-to-1 level.

“All of these hospitals were inundated with people,” said Jacinda Browne, a clerk at Kingsbrook who signed the petition.

In documents submitted to the state health department in August, One Brooklyn estimated that, when Kingsbrook closes, “approximately one third of the utilization will be retained at IMC and/or Brookdale, while the other utilization will either be captured by other area hospitals or will not materialize.”

Brown said she has been in close contact with the leadership at nearby Health + Hospitals / Kings County, a city-run institution, as the consolidation has progressed. But Kings County Hospital was itself flooded with coronavirus patients in the spring, and faces its own financial challenges.

Health + Hospitals / Kings County did not respond to a request for comment.

In any case, Brown says she is confident Brookdale and Interfaith have the capacity to handle a second wave of coronavirus cases. At the peak of the spring outbreak, she said, One Brooklyn hospitals admitted about 500 COVID-19 patients at a time; 300 who had tested positive, as well as 200 patients with severe symptoms awaiting test results.

By adding more beds to existing inpatient areas and converting beds currently designated to treat substance abuse, Brown estimates the two hospitals will have room for up to 540 COVID patients. And Kingsbrook will retain an outpatient emergency department that can treat symptomatic patients who do not require overnight stays.

“I have absolutely no concern that we can activate the necessary number of beds,” said Brown.

Brown says the greater challenge for One Brooklyn is ensuring sufficient staff are available to activate those beds. At a State Department of Health hearing last month, she suggested that National Guard staff and resources, which in the spring were deployed to field hospitals in Manhattan, should instead be directed to community hospitals in the outer boroughs.

Nevertheless, the inequity in bed counts across the city remains stark. Borough-wide, there are currently 2.2 hospital beds for every 1,000 residents in Brooklyn, far fewer than the 6.4 beds per 1,000 residents that exist in Manhattan.

A Challenging Healthcare Landscape

The drastic difference in the number of beds in each borough, advocates say, is indicative of a broader inequality that exists throughout New York’s healthcare system.

43 hospitals across the state have closed since 2003, including at least a dozen in the city, and New York’s total bed count has fallen from 74,000 to 53,000. The majority of the closed institutions were, like those managed by One Brooklyn, so-called safety-net hospitals that disproportionately serve the uninsured, Medicaid, and other vulnerable populations.

“The reason these hospitals have financial difficulties is not that they are mismanaged or that people in those communities do not need care,” said Dr. Steve Auerbach, a member of the Executive Committee of Physicians for a National Health Program’s New York chapter, which signed on to the Kingsbrook petition. “It is because of how our healthcare system, in general, is financed, in a way that systematically favors the wealthy.”

Auerbach’s organization advocates for a single-payer health program at the federal and state level, which could address such financing problems. But he and other activists point to a number of other policy decisions they say exacerbate the disparity. In 1997, for example, New York State weakened its protocols for regulated hospital reimbursement rates, allowing hospitals in wealthy areas to demand higher rates from the private insurers that serve many of their patients, which hospitals in poorer, more Medicaid-dependent neighborhoods don’t have the leverage to do.

Even programs intended to close the gap can have the opposite effect. A prime example, advocates say, is the way in which the state allocates its $1.13 billion in Indigent Care Pool (ICP) funding each year.

The ICP program, which draws from a mix of federal and state funds, is intended to stabilize hospitals that serve low-income communities. But rather than direct the money exclusively to safety-net institutions, as all other states do, New York State distributes it to a much broader selection of hospitals, including many that do not serve significant numbers of low-income people. A recent report by the anti-poverty group Community Service Society found that, in the past 20 years, New York’s safety-net hospitals received about $13.4 billion less in ICP funding than they would have if they had been located in any other state.

The pandemic has not made things easier. In April, the state passed an austerity budget that included a $400 million reduction in Medicaid payments to hospitals, alongside other cost-cutting changes that could hit safety net institutions particularly hard.

“The governor makes across-the-board cuts in Medicaid reimbursement,” said Judy Wessler, former Director of the Commission on the Public’s Health System, an advocacy organization. “If you have a hospital with a large endowment and lots of privately-insured patients, you can do okay. Safety-net hospitals have lots of patients with Medicaid. And the thing about Medicaid reimbursement is that it’s already far below what private insurance would pay.”

The structural challenges are such that, even with the savings accrued through consolidation, One Brooklyn will remain in the red for the foreseeable future. The organization’s financial projections estimate that, in three years, One Brooklyn will register a net loss of $69,127,457. The gap will be filled, as it has in the past, by state support.

Unions And Elected Officials Still Support The Plan

Several elected officials and union leaders, as well as Ms. Brown herself, said they recognized the underlying funding issues. But they continue to believe the One Brooklyn consolidation plan is the right path.

“I don’t think that we should be either-or,” said Senator Zellnor Myrie, whose district includes Kingsbrook, and who was elected in 2018, after much of the planning surrounding Vital Brooklyn had been completed. “The ultimate barometer of what is going to be successful is what allows our healthcare system to serve our constituents. And I think given the reality of the current financial situation, it’s important for us to have all options on the table.”

Myrie said his conversations with One Brooklyn and union leadership had reassured him that the consolidation did not pose a public health risk, and expressed concern at what he sees as confusion or misinformation circulating within some communities.

“Without question, there’s a breakdown in communications,” Myrie said. “It might be helpful for us to all be in the room together – the proverbial room – to ensure that we’re communicating with each other. Because if there’s not cause for panic, this is really not an ideal time to insert it.”

Myrie’s counterpart in the Assembly, Diana Richardson, was more blunt.

“Some people cause havoc and fearmongering in the community unnecessarily, as a result of bad information,” Richardson said at a virtual Civic Minded community meeting last month. Richardson has organized community discussions about Vital Brooklyn and produced a report that was incorporated into the plan.

“Kingsbrook Jewish Medical Center is not closing,” she told meeting attendees. “Will there be a transformation by way of Vital Brooklyn at Kingsbrook Jewish Medical Center? Yes, absolutely.”

Both the New York State Nurses Association and 1199 SEIU, which were closely involved in the plan’s development and organized information sessions for members in partnership with One Brooklyn leadership, remain strongly supportive.

In a statement, NYSNA called the merger “an extraordinary investment in communities historically underserved.” The Association represents 280 nurses working at Kingsbrook and 170 working at Interfaith and says they will all remain employed after the consolidation. 1199 SEIU, which represents many healthcare workers employed by One Brooklyn, declined to comment on this story.

Those who signed the petition remain unconvinced and say the distinction between closure and transformation is little more than a semantic one when so many hospital beds are at stake.

“I can’t understand why the elected officials would be so comfortable with the idea of reducing the amount of medical services in their district,” said Victor Jordan, a Brooklyn resident and member of nearby Community Board 17 who signed the petition. “I’m baffled.”

Nevertheless, without formal opposition, the consolidation continues.

Late last month, a committee of the state’s Public Health and Health Planning Council, which advises the Department of Health on construction projects and service changes in healthcare facilities, voted to recommend approval of One Brooklyn’s application to formally merge its hospitals into one corporate entity. The full Council will take up the application on October 8th, and its recommendation will then go to the New York State health commissioner, Howard Zucker, who is the final decision-maker.

https://bklyner.com…

Support for a single national health program is increasing

Increasing share of Americans favor a single government program to provide health care coverage

By Bradley Jones
Pew Research Center, September 29, 2020

A majority of Americans continue to say the federal government has a responsibility to make sure all Americans have health care coverage.

And since last year, there has been an increase – especially among Democrats – in the share saying health insurance should be provided by a single national program run by the government.

Among the public overall, 63% of U.S. adults say the government has the responsibility to provide health care coverage for all, up slightly from 59% last year. Roughly a third (37%) say this is not the responsibility of the federal government, according to a Pew Research Center survey conducted July 27 to Aug. 2 among 11,001 adults.

When asked how the government should provide health insurance coverage, 36% of Americans say it should be provided through a single national government program, while 26% say it should continue to be provided through a mix of private insurance companies and government programs. This is a change from about a year ago, when nearly equal shares supported a “single payer” health insurance program (30%) and a mix of government programs and private insurers (28%).

Most of the increase has come among Democrats and Democratic-leaning independents. A 54% majority of Democrats and Democratic leaners now favor a single national government program to provide health insurance, up from 44% last year. Support for single payer health coverage has increased among most groups of Democrats, including those who describe their political views as very liberal (up from 66% to 77%), liberal (50% to 61%) and conservative or moderate (35% to 43%).

Among Republicans and Republican leaners, a 66% majority says the government does not have the responsibility to make sure all Americans have health care coverage. Among the one-third of Republicans who say the government does have this responsibility, opinion is divided over whether or not it should be provided through a single government program or a mix of private and government programs.

Although most Republicans say it is not the government’s responsibility to ensure health coverage for all, a 54% majority says the government “should continue to provide programs like Medicare and Medicaid for seniors and the very poor.” Only 11% of Republicans say the government should not be involved at all in providing health insurance.

While divisions remain within the Democratic Party about the best way to provide health insurance, increasing shares across most demographic and ideological groups support a single national government program.

Very liberal Democrats, who in 2019 constituted 15% of Democratic registered voters, are far more likely than liberal Democrats (32% of Democrats) and moderates and conservatives (51%) to say that health insurance should be provided by a single government program.

White Democrats remain more likely than those of other races and ethnicities to support a single national program, but White, Black and Hispanic Democrats have each increased their support for a single national program by about 10 percentage points since last year.

A similar pattern emerges with age: Younger Democrats are still more supportive than older Democrats, but Democrats of all ages have increased their support over the past year.

https://www.pewresearch.org…

Question asked:
https://www.pewresearch.org…

Comment:

By Don McCanne, M.D.

The Pew American Trends Panel survey tends to provide results demonstrating lower percentages of support for a single national government program to provide health care coverage than do other polls on the topic, but that is likely due to the design of the Pew polling questionnaire.

The Pew poll asks a two part question. First they ask if it is the federal government’s responsibility to make sure all Americans have health care coverage. In the most recent poll, 63% say that it is. Then only those who say it is are asked if health insurance should be provided through a single national health insurance system run by the government or should it continue to be provided through a mix of private insurance companies and government programs. The other 37% are not asked this question but rather are asked whether or not programs like Medicare and Medicaid for seniors and the very poor should be continued. Thus if everyone who said that it was the responsibility of government to make sure that all Americans have health insurance coverage chose a single national health insurance system over a mix of private insurers and government programs, then the maximum would be only 63%, since the other 37% weren’t asked the single payer question. In the current poll, 36% chose a single national health insurance system, but that is 57% of those who were actually asked.

Compared to one year ago, about the same percentage say that health coverage should be a government responsibility, but the percentage supporting a single national program has increased over those supporting a mix of government and private programs. This would suggest that people are becoming even less satisfied with the private sector which would include employer-sponsored plans and private individual plans. This may have been precipitated by disappointment with plans that failed individuals during the coronavirus pandemic. The government is a more reliable provider of health care coverage than is the private sector, and more people are realizing that.

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Pope Francis: A better kind of politics

Fratelli Tutti; On the Fraternity and Social Friendship

Encyclical Letter of the Holy Father, Francis

Chapter Five: A Better Kind of Politics

168. The marketplace, by itself, cannot resolve every problem, however much we are asked to believe this dogma of neoliberal faith. Whatever the challenge, this impoverished and repetitive school of thought always offers the same recipes. Neoliberalism simply reproduces itself by resorting to the magic theories of “spillover” or “trickle” – without using the name – as the only solution to societal problems. There is little appreciation of the fact that the alleged “spillover” does not resolve the inequality that gives rise to new forms of violence threatening the fabric of society. It is imperative to have a proactive economic policy directed at “promoting an economy that favours productive diversity and business creativity” and makes it possible for jobs to be created and not cut. Financial speculation fundamentally aimed at quick profit continues to wreak havoc. Indeed, “without internal forms of solidarity and mutual trust, the market cannot completely fulfil its proper economic function. And today this trust has ceased to exist”. The story did not end the way it was meant to, and the dogmatic formulae of prevailing economic theory proved not to be infallible. The fragility of world systems in the face of the pandemic has demonstrated that not everything can be resolved by market freedom. It has also shown that, in addition to recovering a sound political life that is not subject to the dictates of finance, “we must put human dignity back at the centre and on that pillar build the alternative social structures we need”.

169. In some closed and monochrome economic approaches, for example, there seems to be no place for popular movements that unite the unemployed, temporary and informal workers and many others who do not easily find a place in existing structures. Yet those movements manage various forms of popular economy and of community production. What is needed is a model of social, political and economic participation “that can include popular movements and invigorate local, national and international governing structures with that torrent of moral energy that springs from including the excluded in the building of a common destiny”, while also ensuring that “these experiences of solidarity which grow up from below, from the subsoil of the planet – can come together, be more coordinated, keep on meeting one another”. This, however, must happen in a way that will not betray their distinctive way of acting as “sowers of change, promoters of a process involving millions of actions, great and small, creatively intertwined like words in a poem”. In that sense, such movements are “social poets” that, in their own way, work, propose, promote and liberate. They help make possible an integral human development that goes beyond “the idea of social policies being a policy for the poor, but never with the poor and never of the poor, much less part of a project that reunites peoples”. They may be troublesome, and certain “theorists” may find it hard to classify them, yet we must find the courage to acknowledge that, without them, “democracy atrophies, turns into a mere word, a formality; it loses its representative character and becomes disembodied, since it leaves out the people in their daily struggle for dignity, in the building of their future”.

Pope Francis’s Social Encyclical:
http://w2.vatican.va…

Short summary of Pope Francis’s Social Encyclical:
https://www.vaticannews.va…

Long summary of Pope Francis’s Social Encyclical:
https://www.vaticannews.va…

Comment:

By Don McCanne, M.D.

Once we have “a better kind of politics,” we should be able to have health care for all. Let’s work on that.

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Hawaii Was Creating A Plan For Universal Health Care. It’s Time To Return To It.

Even before the pandemic arrived on our shores, our health care system was in crisis.

By Stephen B. Kemble, M.D.
Honolulu Civil Beat, IDEAS, October 4, 2020

In 2009 Hawaii passed a law to create the Hawaii Health Authority, or HHA, and charged the group with designing a universal health care system that would cover all residents of the islands.

The HHA evoked the fundamental questions at the core of health care in the United States today. Should health care be a commodity, sold by corporations to those with the ability to pay? Or should it be a public good that is assured for all, similar to roads, schools, national parks and national security?

I was an original member of the HHA, appointed by Gov. Neil Abercrombie. The HHA met regularly from 2011 until April 2013 but at that point the Abercrombie administration pivoted away from the HHA and toward the federal government’s Affordable Care Act. The ACA was largely written by the insurance industry in order to cement the industry’s central role in health care. At the heart of the ACA was a move to expand coverage by getting greater numbers of people on competing private healthcare plans.

So, what has happened to health care in Hawaii under the ACA?

In the past decade Hawaii’s per capita health care costs have doubled, and they continue to rise at a rate of about 7% per year with no end in sight. Our physician workforce has declined precipitously, decimated by reforms promoted by the Affordable Care Act.

Even before the pandemic arrived on our shores this year, our health care system was in crisis.

To begin to understand why that’s happened, let’s go back to what existed before the Affordable Care Act went into effect. At that point, a patient’s experience of seeing a doctor in Hawaii generally followed expectations. The doctor would talk to you and examine you, make at least a provisional diagnosis and explain it to you, and formulate a plan for further diagnostic tests and/or treatment of the diagnosed conditions.

Even if — unlike in every other economically advanced nation in the world — our health care was being financed largely through corporations, the system in Hawaii was relatively stable. Needed care was generally accessible, and monthly health insurance premiums in Hawaii were among the least expensive in the country.

At that time doctors were paid with fee-for-service: They provided a service and they got paid for it. In 1974 Hawaii set itself apart from the rest of the United States by passing the Prepaid Health Care Act, mandating that employers must provide health insurance to anyone working 20 hours a week or more. Both the Prepaid Act and federal Medicaid rules assured comprehensive benefits.

The Prepaid Act also required that all employer-based insurance must be equivalent to the benefits of the state’s largest health care plan (which was then as now HMSA), a requirement that has effectively banned deductibles and limited co-pays to 10% or 20% of fees. Doctors’ fees were largely standardized due to HMSA’s dominance; other smaller plans used physician networks and fees similar to HMSA. Kaiser had its own prepaid system.

Doctors practiced in small independent practices, and all of them accepted HMSA, other employer-based plans and Medicare. Most also accepted Medicaid. Our per capita Medicare spending was the lowest in the country in 2008.

In essence, things worked. Patients got care in the expected way, and doctors knew how and how much they would be paid. The only problem was that throughout the United States, health care costs were rising faster than the cost of living, and generally faster on the continent than in Hawaii.

The ACA In Practice

The ACA introduced payment reforms called “value-based payment,” founded on the idea that health care costs in the United States were the highest in the world because doctors, paid with fee-for-service, were providing unnecessary services to their patients to make as much money as possible.

This unfounded idea ignored the fact that in the United States the per capita rates of physician visits and hospital days are relatively low compared to other developed countries — in countries in which everyone has health care, fee-for-service payments are often used and the cost of health care per capita is around half of what the United States spends.

Despite claims to the contrary, patients in the United States see doctors less frequently than patients in many other countries.

Despite the lack of any evidence of over-utilization of primary care services, value-based reform efforts have focused mainly on primary care. The “solution” to the non-existent problem of over-utilization has been to pay doctors and hospitals an up-front per patient fee, a system known as “capitation.” Since 2017 HMSA has paid primary care doctors a flat monthly fee for each patient attributed to the doctor’s practice.

Capitation introduces perverse incentives into the doctor-patient relationship. For example, a flat fee rewards doctors who skimp on care and it encourages the avoidance of sicker and more complex patients who may need more care.

There are efforts to counter these perverse incentives but they have devolved into a byzantine bureaucratic nightmare.

Under the system as it exists now, in order to receive adjusted payments, doctors are required to report detailed data on their patients so that insurers can measure the doctor’s quality of care and the patient’s severity of illness and likely cost of treatment. Doctors must now provide metrics, which necessitates their investing in extra staffing and computer systems.

Doctors who fail to provide these metrics face penalties — in the case of Medicare, a reduction in payment of 2% each year, which has caused the majority of independent Hawaii doctors to refuse new Medicare patients. In July 2019, Wallet Hub rated Hawaii 51st — worst in the nation — for finding doctors who would accept new patients with Medicare.

The ever increasing bureaucracy in the U.S. health care system is forcing doctors to spend more time with paperwork and less with patients.

In addition to being hugely cumbersome, these metrics fail to capture the true picture. Severity of illness depends on a lot more than diagnosis codes, and accurately predicting all of the factors that contribute to the cost of treatment turns out to be impossibly complex and expensive.

Doctors, hospitals and health plans can also game the system by including as many diagnoses as possible and choosing the most severe diagnosis codes — for example, classifying a patient’s illness as pneumonia with sepsis as opposed to simply pneumonia. In America today there is an entire industry of coding consultants to drive up revenues.

Here in Hawaii HMSA intended to base each doctor’s capitation rate on the doctor’s prior fee-for-service revenues but HMSA failed to account for the increased overhead necessitated by capitation. Three recent surveys found most Hawaii primary care doctors have seen their personal income decrease under capitation, many to the point that they can no longer continue an independent practice.

Coding determines how much money insurance companies will pay out. The system is ripe for fraud: Here, for example, the same patient is assigned different, more dire codes to create a much larger bill.

The only way that physicians can now maintain their incomes is to increase their number of patients, which means spending less time with each patient, which further amplifies the incentive to avoid sicker and more complex patients. A survey by Aimed Alliance just prior to the COVID-19 pandemic found 80% of Hawaii doctors blame HMSA’s capitation as a significant cause of our physician shortage. Prior to the pandemic, we were 25% short of needed doctors and losing 3% to 4% of our doctors per year. Now the losses are accelerating.

Meanwhile, with Medicaid: Our state government used to administer our Medicaid program, but by 2009 the state had turned the administration of Medicaid entirely over to insurance corporations. The corporations created numerous rules that blocked care and forced doctors to jump through all kinds of new hoops.

As a result, we have seen heightened inflation in Hawaii’s Medicaid costs, with rates rising at a rate 3% faster than the national average, and most independent Hawaii primary care doctors no longer accept Medicaid. On the neighbor islands, where many patients are on Medicaid, large number of doctors have stopped practicing altogether and departed.

Here Connecticut’s story suggests a solution. In 2000 Connecticut also contracted its Medicaid program out to competing private insurance companies. But in 2012 the state took Medicaid back. It used the resulting administrative savings to enhance fee-for-service payments to primary care doctors and to fund community-based programs for complex high-risk patients. Four years later, physician participation had improved substantially, per capita ER costs were down 25%, hospital costs were down 6% and overall per capita Medicaid costs had dropped 14%.

Where We Are

These days if a patient in Hawaii can still find a primary care doctor to see them, a typical visit starts with questionnaires about the reason for the visit, a medical history and questions required to satisfy metrics, all administered by the receptionist or medical assistant. The patient is prompted to get preventive health tests, such as colonoscopies and mammograms. They may see a physician assistant or nurse instead of the doctor.

In the last half century, health care across the United States has been smothered by bureaucracy — the number of health care administrators has soared while the number of physicians has risen very slowly. Hawaii is no exception to this trend.

If they do see the doctor, it is often briefly with little time to ask questions and minimal or no physical exam. Since the doctor is pressed for time, patients may be discouraged from coming to the office and treated over the phone, and they are more likely to be referred to urgent care or the ER, or for diagnostic imaging or to a specialist, instead of the doctor obtaining a thorough history and doing a physical exam.

Multiple studies show that the true reasons U.S. health care costs are so high are the excessive administrative demands of our current system, coupled with the fact that for-profit health care is riddled with parasites. In 2018 the CEOs of the three largest health insurance corporations each took in over $20 million in annual compensation. Some pharmaceutical company CEOs had even higher annual compensation that year, anywhere from $28.5 million to over $100 million each. The CEO of Regeneron, the company that two days ago supplied President Trump with experimental COVID-19 antibody treatment, was the highest paid CEO in the health care field that year: He took in $117.8 million.

In Hawaii, our system is actually less mercenary than in many other states. All of our hospitals are run as not-for-profit entities. All of our employer-based health care programs, while run by corporations, are not-for-profit. And three of the five corporations administering Medicaid for us are not-for-profit.

But our system is rife with huge amounts of administrative waste.

In Canada, administrative costs in the health care system are only a quarter of what they are in the United States.
The overall amount spent on health care in Canada is much lower than it is in the United States — and health outcomes in Canada are now superior to health outcomes in the United States.

The Way Forward

It is time to take another look at the recommendations of the Hawaii Health Authority.

Instead of starting with the system we have and asking, “How can we make it a little better while trying to keep all current stakeholders happy?” the HHA started by defining what a truly cost-effective system would look like and asked, “How can we get there from here?”

We recommended creating a comprehensive “all payer” system akin to what exists in several European countries, which would greatly simplify, unify and streamline health care in Hawaii.

Under this system, which would adhere to the state’s 1974 Prepaid Health Care Act, government regulation would ensure that every health plan in the state would offer the same benefits with no deductibles and minimal co-pays. Anyone who wasn’t covered by their employer or Medicare would be covered by Medicaid. Money would be saved by reducing administrative burdens and costs.

Using fee-for-service, all physicians would be paid the same fees in the same way by all payers, including Medicaid. Billing and payment would be kept as straightforward as possible. Management of care would be left to doctors and their patients. Collective negotiation between organized physicians and the state would keep physician fees reasonable for doctors, health plans and taxpayers.

The reforms recommended by the HHA would reduce overall health care costs, restore professional autonomy to physicians, assure reasonable fees and again make Hawaii an attractive place to practice medicine, including on the neighbor islands.

The HHA is already in Hawaii law as HRS 322H. All that is required now is the backing of Gov. David Ige to appoint new members who are committed to cost-effective universal health care and not the special interests of the health insurance companies.

If the governor empowers the HHA to fulfill its statutory mission, Hawaii could again have the most cost-effective health care system in the country and regain its reputation as a leader in health care.

Dr. Stephen Kemble practices psychiatry at Queen Emma Clinic and teaches it at the John A. Burns School of Medicine.

https://www.civilbeat.org…

Draining the Pool: Our Collective Responsibility to End Racism in Medicine

By Vanessa E. Van Doren, M.D.; Tracey L. Henry, M.D., M.P.H., M.S.
Society of General Internal Medicine, SGIM Forum, October 2020

I grew up in a die-hard liberal part of the country. As I have learned the myriad ways in which racism rears its head, I have discovered that my northeast “culture” perpetuates its own forms of racism and classism. This manifests as a dearth of Black people in leadership positions, huge racial disparities in income and life expectancy, subtle messaging about who is welcome, and condescension about “the South” and “flyover states,” often aimed at places with large Black populations. I love Boston—it is my home. I am proud of our high standard of education, social services, and low rates of uninsurance. But loving something doesn’t mean there is no room to improve.

I want to examine our collective discomfort with criticizing what we consider important parts of our identity, and few professions are more entwined with identity and ideas of self-worth than that of the physician. The long, expensive training, and the way our hours in the hospital pull time away from relationships and outside interests, make many of us feel like we are doctors before anything else. Challenging the traditions upon which our profession is built may mean challenging the framework for our whole personhood. It can call into question the value of the sacrifice we made to pursue this calling. Unsurprisingly, this often results in outrage and defensiveness. At the same time, to justify that sacrifice, it is immensely important that we do the uncomfortable work of evaluating whether our institutions are living up to their moral promise. If we can establish a culture where this introspection both is normalized and necessitates collective action, I believe that we can build that equitable system together.

Physician as Hero

Emory was my last interview because I canceled all subsequent ones after coming here. I knew this is where I wanted to be. Two things stood out to me that day. First, while every program had something to say about “diversity and inclusion,” Emory’s diverse program leadership exemplified this ideal. Second, the intense pride in resident and faculty voices when they talked about advocating for their patients at Grady—one of the country’s largest public hospitals—contrasted with awkward silences at many other programs when I inquired about care for uninsured patients.

I am now in my third year at Emory. I consistently am struck by the lengths to which my colleagues will go to care for their individual patients, but unfortunately, even our best is not enough. Inequality routinely plays out in horrific ways here: hospitalizations, evictions, deaths. The majority of patients I have watched die due to COVID-19 were Black and Brown. Even when I help someone get better in the hospital, I often discharge them back to the street or to unsafe housing or without needed supplies.

I am equally struck by how powerless we as healthcare workers feel in addressing, or even learning about, upstream causes of this inequality. In a state rife with voter suppression, where Medicaid is virtually impossible to access, and where long-standing racist policing leads to immeasurable harm, the challenges often feel insurmountable. Despite the expertise we develop through our work with marginalized patients, health policy and political advocacy make us nervous.

Much like our criminal justice system, the entire institution of medicine is steeped in the tradition of racism.1 Experimentation, without analgesia or consent, on Black bodies laid the groundwork for many modern surgeries and medications. For hundreds of years, Black people were excluded from care or only seen in poorer-quality segregated hospitals, and to a great extent de-facto segregated medical care continues today. Black patients are less likely to receive adequate pain control2 compared to white patients with the same injury. Even after controlling for income, Black patients receive consistently worse care and suffer worse outcomes.3 Somehow, these facts still are not routinely taught in medical schools.

Physician as Human

After the murders of Ahmaud Arbery and Rayshard Brooks in Georgia, Emory’s Internal Medicine leadership immediately condemned racist police violence, and many joined local demonstrations. They held a conference for the internal medicine faculty and residents to discuss both the impact of racism on our community and the importance of examining our own practices. One of our program directors talked about the day her eight-year-old son was seen as a threat because of the color of his skin. Another faculty member openly introspected about his own lack of barriers as a straight, wealthy, cis-gendered, able-bodied white man. Residents talked about microaggressions: both as victim and perpetrator.

By holding this conference, our leadership set an important standard—that we all internalize racism, and that the only way to reduce how much we perpetuate it is to unflinchingly examine and own up to our own biases. This is the first step in the continuous work of being anti-racist. Within a week, the program rolled out a Racism and Social Justice lecture series, highlighting racism and bias in medicine, the impact of microaggressions, and ways to advocate for structural change. With full program support, Emory residents have begun educating ourselves, lobbying our representatives about police reform and hate crimes legislation, promoting voter registration, joining street medic trainings, and soliciting donations to local grassroots organizations.

We are now considering long-term residency program reforms to address key questions: How can we increase diverse recruitment? What changes must we make to our core curriculum? How can we ensure that we apply the same standard of care to all our patients regardless of race or whether we see them at our private or public hospitals?

Draining the Pool Together

Our patients are neck-deep in water, and rather than burning ourselves out as we individually prop each person’s mouth above drowning-level, we need to work together to drain the pool.

Education about our country and profession’s history of racism must become a required competency interwoven throughout the medical curriculum. Only then can we begin to understand, respect, and bridge our Black patients’ distrust of the medical system as part of a comprehensive effort to provide equitable care. We must also examine how our own institutional policies and practices contribute to structural racism. If and when we identify such policies, we must change them. There can be no excuses.

Education about our complex healthcare system also must become a required competency if we are to be informed policy advocates. We need to retire the “physician as hero” narrative that lets us substitute feel-good stories about helping one patient for long-term advocacy and systemic change.

We must recruit a physician workforce that reflects our patient population, both for equitable patient care and to equalize access to positions of power. On a national level, the physician workforce remains overwhelmingly white and wealthy. While programs that implement diverse leadership and recruitment are mounting, we still have a long way to go.

We need to think about the connections between the educational debt, inhumane hours, and extreme hierarchies that define medical training and how this shapes physicians’ willingness to push for change. We all know that pushing leadership to make change could put a promotion or recommendation in jeopardy; this is a big reason that more physicians (particularly those still in training) do not speak up. Physician culture teaches us that the wisest course of action is to keep your head down, get through, and get yours. It is no surprise that as a group we are politically apathetic and unimaginative about envisioning better institutions. We must examine how often the phrase “this is the best we can do” shields those in power from discomfort or loss of their own privilege. And if our own concern for career advancement leads us to stop pushing when we feel similarly threatened, we must acknowledge that we may be doing the same thing.

Finally, allies must also start shouldering their share of the work and risk inherent in advocating for better systems. If we do not share this burden, it will continue to predominantly rest on women of color,4 adding to the barriers they already face in this field and disproportionately taking time away from career development and self-care. This is a very concrete way that allies can “give back some of their privilege.”

If we can move beyond our lone hero complexes to join together, and if we can be imaginative and brave enough to envision and advocate for something better, I believe we can build the system we all hoped to work within when we decided to become doctors.

Dr. Van Doren (Twitter: @vvd186) is a PGY-3 in the Emory University School of Medicine’s J. Willis Hurst Internal Medicine Residency program and a current participant in the Health, Equity, Advocacy, and Policy Track. Dr. Henry (Twitter: @docwithapurpose) is a general internist in the Division of General Medicine and Geriatrics at Emory University, an attending physician for the inpatient teaching services at Grady Memorial Hospital, and assistant health director and supervising attending in the Primary Care Center.

https://connect.sgim.org…

References

  1. Washington, HA. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. New York, N.Y.: First Anchor Books; 2006.
  2. Meghani SH, Byun E, Gallagher RM. Time to take stock: A meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Med. 2012;13(2):150-174.
  3. Bridges, KM. Critical Race Theory: A Primer. St Paul, M.N.: Foundation Press; 2019.
  4. Grubbs, V. Diversity, equity, and inclusion that matter. NEJM. https://www.nejm.org/doi/full/10.1056/NEJMpv2022639. July 10, 2020. DOI: 10.1056/NEJMpv2022639.

President Trump could still come to the rescue

Trump’s Positive Coronavirus Test Upends Campaign in Final Stretch

By Jonathan Martin, Maggie Haberman and Matt Stevens
The New York Times, October 2, 2020

President Trump’s announcement early Friday that he had contracted the coronavirus upended the presidential race in an instant, inviting significant questions about his cavalier attitude toward the pandemic and the future of his campaign just 32 days before the election.

Mr. Trump had already been trailing in the polls to Joseph R. Biden Jr., in part because of his mishandling of a virus that has unsettled the day-to-day lives of voters for over six months. He compounded his difficulties by disregarding and at times belittling the basic precautions, such as wearing a mask, that his health advisers were urging Americans to take to protect themselves.

Now, though, his personal indifference toward the virus could threaten his own health, the stability of the country and his already dimming hopes for re-election.

After the coronavirus shut down the country in March, though, Mr. Trump finally ran headlong into a foe that could not be attacked, ignored or fully overwhelmed with his usual tactics.

Yet that did not stop him from trying to effectively will it away. Not only did he repeatedly predict that the virus would fade on its own, he has also consistently minimized the threat, prodding states, schools, businesses and even athletic teams to return to normal.

Not only has he defied the advice of his health advisers on masks, he has also repeatedly mocked the practice, putting him out of step with the majority of the country and even some in his party.

https://www.nytimes.com…

NYT Reader Comment:

By Don McCanne, M.D.

Although President Trump has always been reluctant to admit an error in judgment, he has the opportunity to save perhaps hundreds of thousands of lives by doing so now. He should be frank with his ardent supporters as he explains to them why they and the rest of us must follow the science in extinguishing this scourge. Making a dent in the economy is a small price to pay for preserving human life on a wholesale basis.

https://www.nytimes.com…

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