By Tsung-Mei Cheng
Milken Institute Review, May 4, 2020

If Americans are somewhat familiar with any single-payer system, it’s the one in Canada. Here, I outline another single-payer system built almost from scratch more recently — and in a place that’s even more affluent than Canada: the island of Taiwan. Arguably the most startling aspect of Taiwan’s National Health Insurance (NHI) system is how they manage to get high-quality outcomes for a small fraction of what Americans pay — and how well they have managed the coronavirus pandemic.

Insights for the United States

Despite vast differences between the two cultures and insurance structures, Taiwan’s high-performing single-payer NHI does offer some insights.

Distributive Ethics Matter

In his final book, Priced Out, Reinhardt observed:

“Health reformers in Europe, Canada, or, say, Taiwan (which operates a government-run single-payer system) usually begin their debate on health reform by making explicit the ethical principle that should constrain health policy. … In Germany, for example, policymakers frequently recite the principle of social solidarity. … The U.S. is different … in that it has never been able to reach a politically dominant consensus on a distributive ethic for American health care. My personal experience is that merely bringing up the topic of distributive ethics for health care can easily raise the ire of an audience, because it is viewed as ‘too personal,’ ‘too political,’ and ‘too divisive.’ So instead, we prefer to discuss health reform mainly in technical terms — usually economic terms — and let social ethics fall where they may.”

The United States stands out today as the only country in the developed world that does not recognize health care as a right and have health insurance for everyone. This is an “American exceptionalism” that Americans cannot take pride in.

Cost Containment

Taiwan provides health insurance with generous benefits for its whole population at a cost of 6.1 percent of GDP, or just 36 percent of what the United States spends as a percentage of GDP. On a per capita basis, the contrast between Taiwan and the United States is even starker: Taiwan’s per capita health spending of $3,047 (in terms of purchasing power) was just 30 percent of U.S. spending per capita of $10,207 in 2017.

No Surprises or Price Discrimination

Since the government sets all health care prices, and extra billing above the government-set fee is not allowed (except for a few government-specified medical devices, such as artificial joints), Taiwan is noted for its conspicuous absence of “surprise” medical bills. By the same token, Taiwan does not have to cope with price discrimination, in which hospitals charge vastly different amounts for identical services.

Note, too, that, although hospital mergers do take place in Taiwan, such mergers only expand the market share of acquiring hospitals, but cannot create market power that increases the prices of services and products. The United States, by contrast, has seen rapid concentration in the market for hospital services precisely because size provides more bargaining power with insurers.

Indeed, it appears that consolidation on both the hospital and insurance sides of the equation in the United States has made a mockery of the idea that competition can contain prices.

Administrative Savings

The simplicity and IT-enabled efficiency of Taiwan’s NHI make its overhead cost extremely low. NHI’s administrative cost accounted for 0.87 percent of the total NHI expenditure in 2018.

This is far, far lower than the average of 3 percent of total health spending in OECD economies (in 2014), and strikingly lower than U.S. insurers, whose administrative cost is 7 percent for traditional government-run Medicare and Medicare’s private plans (Medicare Advantage) combined, and 13 percent (no misprint) for private health insurance plans. It long has been known that excessive administrative costs are a significant part of the waste in U.S. health spending.

Satisfaction

The latest NHI satisfaction poll, conducted in November 2019, showed a satisfaction rate of 90 percent, a new high for the NHI. Reasons given for patient happiness: easy access to health services, reduced financial burden of medical care and the “reasonable” premiums. Many Taiwanese-Americans continue to pay their NHI premiums and go back to Taiwan for their medical care. (Our Taiwanese-American daughter-in-law returned to Taiwan to obtain her highly technical, life-saving surgical care – DMc)

Live and Learn

Taiwan is the poster child for how a wellrun single-payer system can do the job efficiently and still enjoy high public satisfaction. Taiwanese regard the NHI as a national treasure and the guardian of social peace.

But a single-payer Medicare for All for the United States may be a bridge too far, if only because the $3.6 trillion (in 2018) American health care system has effectively been captured by interests ranging from private insurers to hospitals to physicians to organized groups of chronic illness sufferers seeking preferential access.

https://www.milkenreview.org…

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Comment:

By Don McCanne, M.D.

Tsung-Mei Cheng has provided us with another excellent article on the features of single-payer national health insurance in Taiwan. This time she also provides us with insights for the United States. The full article is well worth downloading and saving as a reference on Taiwan’s very successful single payer system.

She cites her late husband, Uwe Reinhardt, in cautioning that we have a problem with distributive ethics, limiting our reform discussions to economic terms and letting social ethics fall where they may. She points out that single-payer Medicare for All may be a bridge too far for the United States since our health care system has effectively been captured by financial interests. In contrast, the Taiwanese regard their national health insurance as “a national treasure and the guardian of social peace.”

As noted in the parenthetical comment above under “Satisfaction,” we have the utmost reason to be thankful for the services of Taiwan’s national treasure. May our health care system be transformed from a system captured by financial interests to a system that is the guardian of social peace.

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By Jessie Hellmann
The Hill, May 17, 2020

Governors facing huge budget shortfalls are eyeing cuts to Medicaid, even as millions of unemployed Americans flock to the health insurance program after losing their employer-based coverage.

States that are buckling under declining revenues and increased Medicaid enrollment due to COVID-19 say they may have no choice but to cut the program for the poor unless they get more financial support from the federal government.

Federal law requires states to balance their budgets, and during economic downturns, governors and state legislatures tend to cut costly programs like Medicaid.

Medicaid consumes about 20 percent of state budgets, with spending on the program spiking during recessions as more Americans sign up after losing their jobs.

And because this economic downturn was caused by a pandemic, Medicaid spending is expected to increase even more as beneficiaries seek care for COVID-19 testing and treatment.

Cuts would result in a devastating blow to the social safety net when it is needed most, experts say.

Federal law prohibits states receiving increased Medicaid funding from cutting benefits, increasing premiums or restricting eligibility — restrictions Congress put in place to protect beneficiaries from losing coverage during the pandemic.

That means in order to find savings, states turn to cutting provider rates, which some experts say could be disastrous.

“The Medicaid provider network is highly stressed and particularly fragile,” said Edwin Park, a research professor and Medicaid expert at the Georgetown University McCourt School of Public Policy.

“If you cut Medicaid rates, the impact on access would likely be much more harmful than even after a typical recession where states look to cut Medicaid and they look to cut provider payments.”

https://thehill.com…

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Comment:

By Don McCanne, M.D.

The COVID-19 pandemic combined with a major economic downturn, massive loss of employment, often with the loss of health insurance, has resulted in much greater demand for enrollment in the Medicaid program – a joint federal-state health insurance program for low-income individuals and families. Just at a time that state budgets are severely stressed, the increased demand for Medicaid will be very difficult to meet because of state requirements for balanced budgets. The Medicaid program is already severely underfunded, and the states do not have much in the way of other options than to further reduce payments to the providers. This could result in insolvency of the providers and a shutdown of their crucial safety net.

The mere fact that Medicaid is a welfare program makes the political support tenuous. In contrast, if they were enrolled in the popular Medicare program, the political support is already there. However, the out-of-pocket costs in Medicare are too great for those who would qualify for Medicaid. Some could qualify for the dual Medicare/Medicaid program, but that won’t work for those not otherwise qualified for Medicare.

Suppose we improved Medicare by expanding benefits and eliminating the cost sharing. That would work for both Medicare and Medicaid eligible individuals, but what about everyone else, such as those currently under financial stress who have lost their employer-sponsored plan, who do not have enough funds for COBRA extension of coverage, who do not qualify for or have the funds for the plans offered in the ACA exchanges, and who are not eligible for either Medicare or Medicaid. That amounts to tens of millions who would be left uncovered or inadequately covered. Wouldn’t it be far better to simply improve Medicare and then expand it to include everyone?

The governors are certainly familiar with the concept of the single payer model of an improved Medicare for All that is federally funded through equitable taxes. That would take care of this terrible problem they are facing in trying to get health care for everyone. Why aren’t the governors clamoring for Medicare for All? If it helps, we could arrange to space them at six feet intervals as they march on Washington.

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The Lancet, Editorial, May 16, 2020

The COVID-19 pandemic continues to worsen in the USA with 1·3 million cases and an estimated death toll of 80 684 as of May 12. States that were initially the hardest hit, such as New York and New Jersey, have decelerated the rate of infections and deaths after the implementation of 2 months of lockdown. However, the emergence of new outbreaks in Minnesota, where the stay-at-home order is set to lift in mid-May, and Iowa, which did not enact any restrictions on movement or commerce, has prompted pointed new questions about the inconsistent and incoherent national response to the COVID-19 crisis.

The US Centers for Disease Control and Prevention (CDC), the flagship agency for the nation’s public health, has seen its role minimised and become an ineffective and nominal adviser in the response to contain the spread of the virus. The strained relationship between the CDC and the federal government was further laid bare when, according to The Washington Post, Deborah Birx, the head of the US COVID-19 Task Force and a former director of the CDC’s Global HIV/AIDS Division, cast doubt on the CDC’s COVID-19 mortality and case data by reportedly saying: “There is nothing from the CDC that I can trust”. This is an unhelpful statement, but also a shocking indictment of an agency that was once regarded as the gold standard for global disease detection and control. How did an agency that was the first point of contact for many national health authorities facing a public health threat become so ill-prepared to protect the public’s health?

In the decades following its founding in 1946, the CDC became a national pillar of public health and globally respected. It trained cadres of applied epidemiologists to be deployed in the USA and abroad. CDC scientists have helped to discover new viruses and develop accurate tests for them. CDC support was instrumental in helping WHO to eradicate smallpox. However, funding to the CDC for a long time has been subject to conservative politics that have increasingly eroded the agency’s ability to mount effective, evidence-based public health responses. In the 1980s, the Reagan administration resisted providing the sufficient budget that the CDC needed to fight the HIV/AIDS crisis. The George W Bush administration put restrictions on global and domestic HIV prevention and reproductive health programming.

The Trump administration further chipped away at the CDC’s capacity to combat infectious diseases. CDC staff in China were cut back with the last remaining CDC officer recalled home from the China CDC in July, 2019, leaving an intelligence vacuum when COVID-19 began to emerge. In a press conference on Feb 25, Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, warned US citizens to prepare for major disruptions to movement and everyday life. Messonnier subsequently no longer appeared at White House briefings on COVID-19. More recently, the Trump administration has questioned guidelines that the CDC has provided. These actions have undermined the CDC’s leadership and its work during the COVID-19 pandemic.

There is no doubt that the CDC has made mistakes, especially on testing in the early stages of the pandemic. The agency was so convinced that it had contained the virus that it retained control of all diagnostic testing for severe acute respiratory syndrome coronavirus 2, but this was followed by the admission on Feb 12 that the CDC had developed faulty test kits. The USA is still nowhere near able to provide the basic surveillance or laboratory testing infrastructure needed to combat the COVID-19 pandemic.

But punishing the agency by marginalising and hobbling it is not the solution. The Administration is obsessed with magic bullets—vaccines, new medicines, or a hope that the virus will simply disappear. But only a steadfast reliance on basic public health principles, like test, trace, and isolate, will see the emergency brought to an end, and this requires an effective national public health agency. The CDC needs a director who can provide leadership without the threat of being silenced and who has the technical capacity to lead today’s complicated effort.

The Trump administration’s further erosion of the CDC will harm global cooperation in science and public health, as it is trying to do by defunding WHO. A strong CDC is needed to respond to public health threats, both domestic and international, and to help prevent the next inevitable pandemic. Americans must put a president in the White House come January, 2021, who will understand that public health should not be guided by partisan politics.

https://www.thelancet.com…

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The Lancet blasts Trump, says voters should not reelect him

The Hill, May 15, 2020

https://thehill.com…

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Comment:

By Don McCanne, M.D.

The entire world is experiencing the severe deleterious impact of the COVID-19 pandemic. This is a time that the world would normally turn to the US Centers for Disease Control and Prevention (CDC) for assistance and guidance in dealing with this crisis. Sadly, the CDC is not currently up to the standard that they had set. The problem is political.

It is astonishing that we are in a situation wherein the editor of a highly prestigious international medical journal feels compelled to lecture the United States on the need to replace our president with one who understands the important role that the United States needs to be playing in the betterment of worldwide public health. We should be ashamed.

PNHP does not support any candidates for political office, but we do support health care justice for all. Encourage your candidates to do the same.

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By Merrill Goozner
Modern Healthcare, May 14, 2020

Call it the big disconnect. Thousands of healthcare provider groups face financial ruin. Tens of millions of Americans are losing insurance coverage. Yet private health insurers are doing just fine, thank you.

So far, Congress has responded only to the provider crisis. Social distancing has cut hospital revenue by an estimated 30% to 40%. Local physician practices, with primary care hardest hit, have seen declines of up to 90%.

It’s nearly impossible for actuaries to estimate how much of the lost healthcare spending will reappear in the second half of the year as businesses gradually reopen. Some, certainly. But with 30% of healthcare considered waste, and tens of millions of laid-off Americans returning to work slowly, most of that potential revenue is probably gone forever.

As things stand now, the government is doing everything in its power to reassure providers and payers that not much will change.

If the current crisis teaches us anything, it’s that healthcare providers need far greater flexibility to respond to emergencies like the current one. What is a “bailout” but a guaranteed budget? Isn’t this a logical direction for payment reform to take post-COVID-19?

And as for an insurance system that leaves private insurers with no responsibility for those suddenly uninsured, it’s way past time for designing a seamless system where everyone is covered, and people never fall through the cracks. This country needs mechanisms for people to switch automatically between private plans and public programs so no one ever gets left out.

https://www.modernhealthcare.com…

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Comment:

By Don McCanne, M.D.

The current pandemic certainly demonstrates the payer-provider disconnect in health care. The private insurers are doing spectacularly well whereas the players in the health care delivery system – many hospitals and especially physicians – are facing a financial crisis.

The view expressed by Merrill Goozner – the editorialist of Modern Healthcare, a publication that covers the medical-industrial complex – provides a lesson for us all. The solution for the disconnect is to have a guaranteed budget (including provisions to fund surge capacity), with him stating, “it’s way past time for designing a seamless system where everyone is covered, and people never fall through the cracks.”

He then suggests that we need mechanisms to switch automatically between private plans and public programs. Of course, this is where he veers off track. The administrative complexity and high costs of such a system are not warranted when you can have a single, seamless public program that covers everyone forever. By acknowledging that a public program must be there as the safety net that the private sector does not provide, he has presented an ironclad case for the single payer model of an improved Medicare that will always be there for all of us, no matter what crises we face.

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KFF, Press Release, May 13, 2020

Hospitals that in normal times derive most of their revenue from patients with private insurance received more than twice as much federal coronavirus relief funding per bed than the hospitals that get the smallest share of private insurance money, finds a new KFF analysis of the first $50 billion in relief grants.

Institutions representing the top 10 percent of hospitals based on share of private insurance revenue received $44,321 in coronavirus relief per hospital bed, the analysis finds. That was more than double the $20,710 per hospital bed for the hospitals in the bottom 10 percent based on private insurance revenue.

The lopsided awards are the outgrowth of a distribution formula – determined by the Department of Health and Human Services in an attempt to get relief money out quickly – that favored hospitals with the highest share of revenue from patients with private insurance. These grants were provided using funding from the Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Paycheck Protection Program and Health Care Enhancement Act, which both deferred to the HHS on how the money should be distributed.

Previous KFF analysis documented that private insurance typically reimburses at twice the rate of Medicare, with some hospitals commanding even higher reimbursement. This new study shows that the hospitals that are benefiting the most from that higher reimbursement are now getting the most taxpayer money in the form of coronavirus relief funds. Meanwhile hospitals that make most of their money treating people who are on Medicare and Medicaid, and therefore are typically paid at much lower rates, are getting relatively less help.

The analysis finds that the hospitals receiving more money are less likely to be teaching hospitals (10% vs 38%) and more likely to be for-profit (33% vs 23%). They had higher average operating margins (4.2% vs -9.0%) and provided less uncompensated care as a share of operating expenses (7.0% vs. 9.1%).

With additional relief money expected, our analysis of more than 4,500 hospitals focused on those with the highest and lowest shares of revenue from private payers to inform policy decisions regarding how to allocate any remaining grants to providers as well as any potential new funding from Congress. In its latest proposed coronavirus relief bill, the House has added details that would take steps to minimize the advantages for providers with more revenue from privately insured patients.

https://www.kff.org…

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From the full report:

Discussion

Our analysis shows that the size of the relief fund grants varies dramatically per hospital bed based on a hospital’s payor mix. Hospitals with the lowest share of private insurance revenue received less than half as much funding for each hospital bed compared to the hospitals with the greatest share of revenue from private insurance. These hospitals’ large share of private reimbursement may be due either to having more patients with private insurance or charging relatively high rates to private insurers or a combination of those two factors. All things being equal, hospitals with more market power can command higher reimbursement rates from private insurers and therefore received a larger share of the grant funds under the formula HHS used. An alternative methodology for distributing the funds based on patient volume or that increased the size of the grant for providers that are more reliant on public payors such as Medicaid would have distributed the funding more evenly and less skewed by higher revenues from private insurers.

Our analysis focused on hospitals, but all entities that receive Medicare reimbursement were eligible for the $50 billion in relief funds. Those entities include hospice providers, skilled nursing facilities and individual physicians. Importantly, providers who did not have any Medicare reimbursement in 2019 were not eligible for grants from the $50 billion allocation. Some of these providers are pediatricians and obstetricians who do not serve Medicare patients. Others are providers who specialize in serving Medicaid patients and provide crucial services such as non-emergency medical transit, substance use disorder treatment, home-and community-based services, behavioral health services and dental care. HHS has stated that Medicaid-only providers will receive a separate allocation of funding, as will skilled nursing facilities and dentists.

Our analysis shows that hospitals with the highest share of private insurance revenue received a disproportionately high share of total funds. We would expect to see similar patterns for physicians and other entities that receive private insurance reimbursement. For example, community health centers that often see a relatively small share of patients with private insurance would have received less money than a private physician’s office that sees the same total patient volume but has more patients with private insurance. With HHS expected to release additional relief fund grants and Congress considering additional stimulus, this analysis demonstrates that the formula used to distribute funding has significant consequences for how funding is allocated among providers.

https://www.kff.org…

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Comment:

By Don McCanne, M.D.

Private insurers generally pay hospitals at twice the rate that Medicare pays and at an even greater multiple than what Medicaid pays. It is no surprise that the private hospitals, especially those that are for-profit, have been very effective in concentrating their market power to enable them to siphon off the more lucrative privately insured patients. Hospitals that see a much greater proportion of Medicaid and uninsured patients obviously are faced with greater financial stresses during this COVID-19 pandemic.

Congress recognized the financial crisis that coincides with this pandemic and has authorized supplemental funds to support these institutions. So how did CMS distribute these funds? The high-income hospitals with a preponderance of privately insured patients received an average of $44,321 per bed while those struggling with predominantly uninsured and Medicaid patients received less than half that amount – an average of $20,710 per bed.

Most conservatives agree that the government does have a role in ensuring that the poorest amongst us can meet their most basic needs, and that includes health care; the private sector can meet the needs of the rest of us, in their vision. So what is our conservative government doing with our tax money in response to this crisis? They are giving much more of it to those concentrated in the private market while leaving those caring for the more needy underfunded. Outrageous.

Conservatives keep telling us that we don’t want the government involved, so why are we subsidizing private hospitals and indirectly the private insurers who pay the bills, including the private Medicare Advantage plans, while neglecting to some extent the traditional Medicare program and even more so the Medicaid program? And the uninsured? Kill the Affordable Care Act is their stated goal.

Conservatives in other nations support their universal health care programs. Why can’t conservatives and neoliberals do the same here? This is a fitting time to enact and implement single payer Medicare for All. We should all join together in achieving this noble goal.

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By Paul Shafer Nicole Huberfeld Ezra Golberstein
Health Affairs Blog, May 8, 2020

The coronavirus pandemic has led to record numbers of American workers being laid off or seeing their hours and paychecks dwindle. The economy is on the brink of a deep recession, and waves of coronavirus infections may continue for the foreseeable future. Medicaid will be a crucial piece of the puzzle that helps to ensure access to health care while protecting people from further financial ruin. Yet, one of Medicaid’s key provisions has been weakened by recently approved section 1115 “demonstration projects”, commonly referred to as waivers, that eliminate or reduce retroactive coverage. These waivers will diminish coverage for thousands of people seeking testing and treatment for COVID-19 and other medical care.

Retroactive eligibility is a long-standing feature of Medicaid that covers health care expenses for three months prior to the application date, provided that the beneficiary would have been eligible during that period. Before the Affordable Care Act (ACA), a handful of states imposed narrow restrictions on retroactive eligibility, but these limitations were paired with expansions of eligibility and had exemptions for vulnerable groups. Recently, however, many states—including Arizona, Arkansas, Florida, Indiana, Iowa, Kentucky, and New Hampshire—have gained Department of Health and Human Services (HHS) approval for 1115 waivers that drastically limit or completely eliminate retroactive eligibility, though four have been stayed by courts or halted by states as part of litigation challenging the legality of those waivers that include work requirements (Arkansas, Kentucky, Indiana, and New Hampshire).

A core purpose of Medicaid is supporting people when they need help, which is why Medicaid has continual open enrollment and retroactive eligibility to cover the cost of care when those who are eligible aren’t already enrolled before a crisis. States should restore full retroactive eligibility immediately to protect thousands of newly-unemployed workers from even greater health and economic suffering.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

In the absence of a universal health care financing program it is inevitable that many will remain uninsured because they do not qualify for whatever programs are available, or they simply cannot afford them. Thus the Medicaid program was established to provide a safety net for the uninsured who need health care but are too poor to purchase it.

When a low-income uninsured individual does develop a disorder that requires health care there is an administrative delay between the onset of the disorder and the time that enrollment can be completed. Thus the program provides for retroactive eligibility to cover care that was provided before enrollment could be completed.

Some states, for reasons of their own, have decided to create barriers that would prevent otherwise qualified individuals from receiving health care benefits under the program. For instance, the income level to qualify may be set so low that most poor people will not be able to participate. Currently there is also a fad of establishing a work requirement to determine eligibility even when such a requirement cannot reasonably be met.

The subject of this particular Health Affairs article is the effort of some states to reduce or eliminate retroactive eligibility even if the individual racked up considerable expenses because of the severity or abruptness of the disorder before the Medicaid application could be processed.

But the purpose of the Medicaid program is to cover expenses for poor individuals who are uninsured, and the program recognizes that retroactive eligibility is sometimes essential to provide that coverage. So why do some states want to defeat the program by prohibiting retroactive eligibility, or by introducing other policies that prevent individuals from receiving the benefits for which the program was designed? It seems cruel, but how could cruelty be their policy goal? Or is it just an intense ideological opposition to having government play a role in addressing such societal needs even if cruelty happens to be an unintended consequence of such a policy?

Although there is a perpetual dispute over states’ rights, this is one instance where the federal government should prevail. Avoidable cruelty cannot be tolerated in a just society.

We could end much of this nonsense by establishing a single payer national health program – an improved version of Medicare that covers everyone while eliminating financial barriers to care. It seems futile to ask them to stop being cruel; let’s just take it out of their hands instead and enact and implement Medicare for All. I can’t imagine that they would respond with demonstrations using placards that say, “WE WANT MORE CRUELTY.” But then I confess that I really don’t understand what all is going on today.

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The fragmented US hospital system, made up of private and community hospitals, has made it harder to fight coronavirus.

By Daniel Skinner
Al Jazeera, May 11, 2020

The coronavirus pandemic arrived at a pivotal moment in the US healthcare, just as scrutiny over hospital pricing and practices was gaining traction, including at the Democratic presidential debates.

The crisis has provided a closer look at US hospitals, and has done so in multiple ways. We have seen the often dangerous work performed by committed healthcare professionals, but also the precarious conditions those professionals have been forced to work in.

Though a number of different proposals for overhauling the US healthcare have been put forward by liberals and progressives, it is curious that they fail to question our dependency on a fragmented collection of private hospitals that can hardly be said to be a system.

As Elizabeth Rosenthal has argued, Americans often criticise pharmaceutical and insurance companies without noticing that hospitals are in many ways a far bigger – and more expensive – problem. Among COVID-19’s lessons is that we need a national strategy for hospitals.

While Senator Bernie Sanders based his vision of “Medicare for All” on the Canadian system, where private hospitals contract with a government “single payer”, the UK approach, where the government owns most of the hospitals and employs the healthcare professionals working in them, may be what the US needs.

The high-profile hospitalisation for COVID-19 of Prime Minister Boris Johnson put UK hospitals in the international spotlight. Americans may be confused when they hear Johnson – a conservative politician – praise the National Health Service (NHS) as “unbeatable”. After all, Americans have been falsely told by their own conservative politicians that they should fear an NHS-like system.

We have not reached the point where a UK-style nationalisation of hospitals is being widely discussed but there are a number of reasons why it should be. Consider just three reasons among many.

First, COVID-19 illustrates the difficulties of coordinating US hospitals. As the virus spread, and realising the dangers that a fragmented system posed, New York state moved to coordinate its hospitals in such a way that Governor Andrew Cuomo could declare that: “We are one healthcare system.” Specifically, Cuomo established a process by which hospitals in parts of the state that had an excess supply of ventilators and personal protective equipment (PPE), but did not face a wave of coronavirus patients, would shift those resources to high-need areas.

But it was difficult to make this happen. Those who might say that such coordination is a logical response to a pandemic but not a preferable way to organise hospitals during normal times, are missing one of COVID-19’s lessons: namely, that we could vastly improve the general quality of care by better organising our hospitals.

Second, the need for politicians to assure Americans that patients’ medical bills for COVID-19 treatment will be “taken care of” illustrates not only the poor positioning of our system to handle health crises, but deep flaws in the approach itself.

One-off, disease-specific appropriations to cover patients’ expenses during a pandemic – while cancer and heart disease patients still risk bankruptcy – is poor health policy. This, of course, is a result of the larger, more protracted design flaws in US healthcare.

With millions of Americans lacking health insurance access at all, and millions more “underinsured” because of the out-of-pocket costs required by the plans they do have, Americans often go to hospital emergency rooms without knowing whether the bills they receive will be paid by insurance companies, or whether their treatment will end up costing them thousands – or even tens of thousands – of dollars.

As physician Adam Gaffney has eloquently argued, changes in how we finance hospitals might even remove the need for hospital payments altogether by re-envisioning them as truly public goods modelled on parks, public schools or libraries.

The American dependency on private hospitals limits the role the federal government can play in setting prices and putting in place a system of care that can be understood by patients.

While a federal law, known as the Emergency Medical Treatment and Active Labor Act, requires that most hospitals must care for patients to a point of stabilisation, what hospitals charge those patients for that care, the collection practices hospitals employ, and whether any follow-up care or even referrals are provided is as variable as the number of hospitals themselves.

This is unsustainable and dangerous, especially when one considers that the chaotic current landscape of US community includes 5,198 community hospitals, 2,937 (or 56.5 percent) of which are privately owned and not-for-profit, and 1,296 (25 percent) of which are “investor owned”, for-profit facilities.

An additional 965 community hospitals (18.5 percent) are owned and administered by state and local governments. And these community hospitals are to be distinguished from the current federal system of 209 non-speciality hospitals, which include facilities run by the US Department of Veterans Affairs and Indian Health Service.

Third, on the whole, market competition has made US hospitals worse, not better.

Ranking systems that distinguish “best” hospitals from others only serve to devalue other hospitals, especially those located in rural and other under-served areas. These hospitals cannot compete with their better-funded competitors, which creates a vicious cycle of negative perceptions and disinvestment that only further hurts rural and other hospitals serving as safety nets, especially in poorer US communities.

COVID-19, which has decimated many already-hurting US hospitals, is likely to leave struggling hospitals ripe for the picking by growing hospital systems, which continue to buy up smaller hospitals as part of an ever-growing plan of increased market domination.

While consolidation might at first glance appear to offer benefits for coordination during times of national crisis, the motives that drive these institutions are still not those of the national interest. One post-COVID-19 project should be understanding the effects of consolidation, and the role of large systems, within the pandemic response.

As progressives are quick to note, Democrats have gone out of their way to save the current system from itself. For political reasons, ranging from inadequate congressional support for larger reform to a desire to minimise disruption for patients, the architects of the Affordable Care Act were not able to address the structural flaws in US healthcare. The best they could do, working under political constraints in place in 2009, was to extend the existing system – from Medicaid to private insurance – to populations that typically fell through the cracks. While the Affordable Care Act brought healthcare access to millions of Americans, and is believed to have saved thousands of lives, it only postponed the need to restructure the system itself.

To be sure, there is political wisdom in leaving US hospitals as they are. Justified or not, many Americans hold generally positive views of their local hospitals. Even more politically problematic is the fact that organisations such as the American Hospital Association have formidable lobbying operations that keep legislators from acting. The motivations of these organisations in resisting the nationalisation and even increased oversight of hospitals are rooted in maintaining the financial incentives that drive that system, not in the best interests of patients or populations.

Considering how unpopular for-profit health insurance companies are, consigning them to the dustbin of history is clearly less politically charged than a major rethinking of hospitals. But this does not mean that we should accept the status quo.

A national commission should be tasked with understanding why US hospitals were so poorly equipped to handle the pandemic. A key piece of this story is likely to be equity. While certain hospitals have fared well, many have not, but the reasons for the differences are not always clear. We are only beginning to make sense of the failures that led to equipment shortages and capacity problems.

An inquiry should also assess differences in how the US’s for-profit and non-profit hospitals have fared, with an eye towards whether the non-profit hospitals served their local communities in a way that warrants the generous tax exemptions they receive.

If Democrats and Republicans – and the pressure groups that inform them – wish to keep the nationalisation of US hospitals off the bargaining table, Congress will need to address these issues, and more.

COVID-19 has exposed the vulnerability of American hospitals. Rethinking them must be one of the pandemic’s enduring legacies.

Daniel Skinner is Associate Professor of Health Policy at Ohio University’s Heritage College of Osteopathic Medicine.

https://www.aljazeera.com…

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Comment:

By Don McCanne, M.D.

The combination of a health crisis plus an economic crisis that has disrupted the lives of everyone of us certainly lays fertile ground for reassessing our health care system and its financing. Already much has been written about how we would have been better off if we already had in place the popular single payer model of an improved Medicare that included everyone – a publicly administered and taxpayer financed social insurance program.

As long as our attention is already directed to revising our health care financing system, it seems appropriate to give more thought to another very successful model of single payer reform – a national health system in which the facilities are owned by the government and the health care professionals are employees of the government.

In this article, health policy professor Daniel Skinner calls on us to rethink the role that the fragmentation of the U.S. hospital system played in the often less than stellar performance in response to the COVID-19 pandemic.

We should give thought to issues such as the differences in the mission of a public or non-profit hospital that is dedicated to patient service versus an investor-owned hospital that has a mission to maximize returns for the investors. We should consider the rationale of a response to the pandemic that is based on a single disease when we must also ensure that the system can effectively meet the needs of patients with a multitude of other disorders that also require medical attention.

The PNHP model of single payer Medicare for All would convert for-profit hospitals to non-profit status. Is that enough? Just as many of our non-profit private insurers have adopted the egregious policies of the investor-owned insurers, would conversion of for-profit hospitals to non-profit status provide enough incentive to place patient service well above a common business ethic? But then, with government ownership and management, there can be a tendency for conservatives and austerity-minded moderates to underfund health programs that may result in impaired capacity or inadequate public health preparedness as we have seen during this pandemic. The increasing dominance of neoliberal politicians is thrusting more austerity upon us.

At any rate, it is clear that we need to dump the private insurers and establish our own universal social insurance program – a single payer improved Medicare for All. Should we also nationalize the hospitals, creating a system of socialized medicine, or should we merely convert the for-profit hospitals to non-profit status? Merely having that conversation may ease the fears of those who are worried that Medicare for All would be a move too far to the left when the alternative under consideration would be a shift all the way to socialized medicine. For some of us that would be fine, but single payer Medicare for All is not a bad position of compromise.

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By Anna Wilde Mathews and David Benoit
Morningstar, May 8, 2020

Atul Gawande is in advanced discussions to step down as chief executive and take on a less operational role as chairman of Haven, the health-care venture backed by Amazon.com Inc., Berkshire Hathaway Inc. and JPMorgan Chase & Co., according to people with knowledge of the matter.

Dr. Gawande, a prominent surgeon and professor at Harvard University, wants to move away from day-to-day management of Haven and focus more on policy and advocacy work, particularly related to the current coronavirus pandemic, the people said.

Haven has launched a search for a new CEO, but has yet to settle on a candidate, the people said. There hasn’t been a final decision on the leadership structure, the people cautioned.

His transition suggests the health-care venture’s slow start since its splashy unveiling in January 2018. The venture has shown few public signs of impact, after its announcement by the three parent companies rattled health-care investors and pushed down the shares of major insurers.

The founding companies framed the venture as an altruistic effort to overhaul health care, reining in costs and improving outcomes, and said they would start with their own employees.

Despite the initial hype, the venture’s efforts so far have been of limited scope. It has launched pilot projects testing health-benefits approaches. This included a program for around 30,000 JPMorgan employees in Ohio and Arizona, who were given a menu of flat costs for health-care services, according to people with knowledge of the matter.

Haven has been spending much of its early time building data systems on employee health-care tendencies across the three companies, these people said.

An author known for his work on health-care quality, Dr. Gawande was a high-profile choice to lead the venture. His hiring was seen as a signal that the partners’ ambitions were set higher than conventional tweaks to health coverage.

https://www.morningstar.com…

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Wiktionary

pie in the sky

1. (idiomatic) A fanciful notion; an unrealistic or ludicrous concept; the illusory promise of a desired outcome that is unlikely to happen.

Etymology

The phrase is originally from the song “The Preacher and the Slave” (1911) by Swedish-American labor activist and songwriter Joe Hill (1879–1915), which he wrote as a parody of the Salvation Army hymn “In the Sweet By-and-By” (published 1868). The song criticizes the Salvation Army for focusing on people’s salvation rather than on their material needs:

You will eat, bye and bye,
In that glorious land above the sky;
Work and pray, live on hay,
You’ll get pie in the sky when you die.

https://en.wiktionary.org…

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Comment:

By Don McCanne, M.D.

Three billionaires with great financial success in the business world – Warren Buffett, Jeff Bezos and Jamie Dimon – decided that they could buy health care reform, and they chose popular physician-writer Atul Gawande to orchestrate that reform.

It was not as if they could invent a new wheel. While totally ignoring effective reform such as a single payer national health program, they delved into some of the current, hot trends. Big data was supposed to open doors, but apparently all they got was a collection of big data on their employees, stashed away in the cloud. Price transparency – the darling of the consumer-directed movement – brought menus of prices but not much else. Because much of their activity was behind closed doors, we don’t know what else they considered or attempted, but obviously the higher quality, lower cost, replacing-volume-with-value goal remained elusive for them as they now seem to be winding down, or at least likely recognizing that their ambitious processes and goals were pie in the sky.

All is not lost. Buffett, Bezos and Dimon are not stupid. They have the intelligence to understand the vast superiority of the single payer model of an improved Medicare for All, although they may have to look past ideological preferences as they acquire greater knowledge of the topic – a task that the PNHP leadership is quite willing to assist in.

At PNHP we do not serve pie in the sky, just the design of a financing infrastructure that really does provide affordable, high quality health care for everyone. Buffett, Bezos and Dimon need to check it out.

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