PNHP national coordinator Dr. Claudia Fegan and PNHP president-elect Dr. Susan Rogers appeared on WGN News on April 1, 2020. They discussed the ways in which persistent disparities in U.S. health care could make COVID-19 even deadlier for minority and low-income communities. Drs. Fegan and Rogers cited lack of coverage and lack of community medical facilities as major concerns.
Saez and Zucman explain how we can protect our health and save our economy
Jobs Aren’t Being Destroyed This Fast Elsewhere. Why Is That?
It’s not too late to start protecting employment or to make medical care for Covid-19 free.
By Emmanuel Saez and Gabriel Zucman
The New York Times, March 30, 2020
The coronavirus pandemic is laying bare structural deficiencies in America’s social programs. The relief package passed by Congress last week provides emergency fixes for some of these issues, but it also leaves critical problems untouched. To avoid a Great Depression, Congress must quickly design a more forceful response to the crisis.
Start with the labor market. In just one week, from March 15 to March 21, 3.3 million workers filed for unemployment insurance. According to some projections, the unemployment rate might rise as high as 30 percent in the second quarter of 2020.
This dramatic spike in jobless claims is an American peculiarity. In almost no other country are jobs being destroyed so fast. Why? Because throughout the world, governments are protecting employment. Workers keep their jobs, even in industries that are shut down. The government covers most of their wage through direct payments to employers. Wages are, in effect, socialized for the duration of the crisis.
Instead of safeguarding employment, America is relying on beefed-up unemployment benefits to shield laid-off workers from economic hardship. To give just one example, in both the United States and Britain, the government is asking restaurant workers to stay home. But in Britain, workers are receiving 80 percent of their pay (up to £2,500 a month, or $3,125) and are guaranteed to get their job back once the shutdown is over. In America, the workers are laid off; they must then file for unemployment insurance and wait for the economy to start up again before they can apply for a new job, and if all goes well, sign a new contract and resume working.
Even if unemployment is generously compensated — as it is in the $2.2 trillion bill Congress passed — there is nothing efficient in letting the unemployment rate rise to double digits. Losing one’s job is anxiety inducing. Applying for unemployment benefits is burdensome. The unemployment system risks being swamped soon by tens of millions of claims. Although some businesses may rehire their workers once the shutdown is over, others will have disappeared. When social distancing ends, millions of employer-employee relationships will have been destroyed, slowing down the recovery. In Europe, people will be able to return to work, as if they had been on a long, government-paid leave.
The battle for the speediest recovery starts today. The next congressional bill needs measures to protect employment for the duration of the shutdown. This does not raise insuperable technical difficulties. The bill passed last week provides support for wages in one industry, airlines. Congress could easily extend this program to other sectors. Some countries — like Germany, with its Kurzarbeit system, a policy aimed at job retention in times of crisis — already had the government infrastructure in place to send workers home while the state replaced most of their lost earnings. But several nations with no experience in that area — like Britain, Ireland and Denmark — were able to introduce brand-new employment guarantee programs on the fly during the epidemic.
This situation for laid-off workers would be bad enough if it were not aggravated by a second American peculiarity. As they are losing their jobs, many workers are also losing their employer-provided health insurance — and now find themselves faced with the Kafkaesque task of obtaining coverage on their own.
One option involves continuing to be covered by one’s former employer, a program known as COBRA. It is prohibitively expensive: Participants have to bear the full cost of insurance, $20,500 per year on average. Another option is to go shopping for a plan on the Affordable Care Act insurance exchange, where one is faced with a bewildering choice between plans like Blue Shield’s Bronze 60 PPO (with a deductible of up to $12,600 per year) and Aetna’s Silver Copay HNOnly (with a $7,000 deductible and up to $14,000 in annual out-of-pocket expenses). The last option is to join the ranks of the uninsured, a catastrophic solution during a pandemic.
The bill passed last week does nothing to reduce co-pays, deductibles or premiums on the insurance exchanges; nor does it reduce the price of COBRA. The next bill should introduce a Covidcare for All program. This federal program would guarantee access to Covid-19 care at no cost to all U.S. residents — no matter their employment status, age or immigration status. Fighting the pandemic starts with eradicating the spread of the virus, which means that everybody must be covered.
The big battles — be they wars or pandemics — are fought and won collectively. In this period of national crisis, hatred of the government is the surest path to self-destruction.
Emmanuel Saez and Gabriel Zucman are economists at the University of California, Berkeley.
Comment:
By Don McCanne, M.D.
Much has been written about how having an equitable, efficient, comprehensive national health program (i.e., single payer Medicare for All) would have been extremely helpful combating illnesses caused by the coronavirus pandemic. We would still have other problems such as the pending permanent closure of a multitude of businesses that are not able to survive the shutdown that is occurring during this pandemic.
Emmanuel Saez and Gabriel Zucman are experts in income and wealth inequality and the adverse consequences that occur when the one entity that could remedy these problems fails to act, and that entity is the government.
In this article, they provide, as an example, an explanation of how in other nations many of the businesses will survive because of implementation of beneficial government policies. They contrast that with the dire prognosis in the United States which we can expect because of our failure to enact and implement socioeconomic programs that would help protect all of us, even during crises like the current pandemic. A recession would be understandable, but our lack of foresight could result in a prolonged depression.
The authors explain why our current health care financing system is not satisfactory. They propose an emergency financing program, but it would have been far better to have had a single payer Medicare for All system already in place. The crisis is difficult enough without adding the additional task of creating a massive new Covidcare for All program.
We are hardly into our national nightmare and yet the lesson for us is already obvious. We need greater solidarity in working together through our government, and that includes following the Willie Sutton rule (go where the money is) in establishing equitable, progressive taxes.
As Saez and Zucman state, “The big battles — be they wars or pandemics — are fought and won collectively. In this period of national crisis, hatred of the government is the surest path to self-destruction.”
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Medicare for All Explained Podcast: Episode 31
Interview with Dr. Donald Berwick
March 31, 2020
Former Centers for Medicare and Medicaid Services administrator Dr. Don Berwick outlines four principles for health system reform: cover everybody, improve quality, address the social determinants of health, and reduce total costs. He adds that a single-payer national health program would achieve all of those.
Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.
Justice Department accuses Anthem of Medicare Advantage fraud
Justice Department accuses Anthem of Medicare Advantage fraud
By Shelby Livingston
Modern Healthcare, March 27, 2020
The U.S. Justice Department has sued national health insurer Anthem for fraudulently collecting hundreds of millions of dollars from the Medicare program by exaggerating the illnesses of its members.
The lawsuit, filed Thursday by the U.S. attorney for the Southern District of New York, alleged that Anthem combed patient medical charts to find additional diagnosis codes to submit to the CMS for higher Medicare Advantage payments. But in the process, Anthem chose not to delete thousands of inaccurate diagnosis codes because that would have reduced its revenue, according to the complaint.
This practice, which generated about $100 million a year in additional revenue for Anthem, allowed Anthem to improperly obtain taxpayer funded dollars in violation of the False Claims Act.
“Ultimately, the extraordinary profits that Anthem obtained through its one-sided chart review program came at the expense of the public fisc,” the complaint said.
“This litigation is the latest in a series of investigations on Medicare Advantage plans. The government is trying to hold Anthem and other Medicare Advantage plans to payment standards that CMS does not apply to original Medicare, and those inconsistent standards violate the law,” (Anthem) said.
Payments to Medicare Advantage plans, which enroll about 24 million seniors and people with disabilities, are based in part on the medical conditions of the enrollees. Insurers ultimately are paid more for sicker members with multiple diagnoses and are paid less for healthier members because they use fewer resources. The payment methodology creates a strong incentive for health insurers to submit as many diagnosis codes as possible to drive up payments. The traditional fee-for-service Medicare program does not have the same incentive.
Diagnosis codes are supposed to be backed up by the patient’s medical record, but the federal government has in recent years accused several insurers of disregarding that rule. The Justice Department has also sued UnitedHealth Group over its Medicare Advantage billing practices but so far has been unsuccessful in court.
One Anthem executive called the program a “cash cow,” the complaint states. The insurer’s retrospective chart review program produced a return-on-investment of up to 7 to 1.
According to the lawsuit, one Anthem finance vice president estimated in 2017 that switching from a one-sided chart review to a program that deleted inaccurate codes would reduce the value of chart review for Anthem by 72% or $86 million that year.
“As Anthem knew, identifying and deleting such inaccuracies in its diagnosis code submissions could lead CMS to calculate lower risk adjustment payments to Anthem. So it did not make an effort to do so,” the complaint said.
https://www.modernhealthcare.com…
Comment:
By Don McCanne, M.D.
Many readers are aware that the private Medicare Advantage plans (previously Medicare + Choice) that were offered as a supposedly higher quality and lower cost option to traditional Medicare successfully engaged in deceptive favorable selection through cherry picking (e.g., marketing their plans to healthier beneficiaries in upstairs restaurant banquet rooms with no elevator) and lemon dropping (e.g., pulling out of markets with a disproportionately high percentage of beneficiaries with major health problems).
Because the insurers were enrolling healthier patients while being paid at rates appropriate for a population that included a greater mix of chronically ill patients, it was recognized that their payment rates needed to be adjusted based on risk. Insurers would be paid more for those patients with greater health problems.
We all know what happened next. Insurers began padding the diagnoses (upcoding) through chart reviews and home visits to make the patients appear more ill than they really were, and at the same time failing to remove diagnoses that were not adequately substantiated. As one Anthem executive said, this proved to be a “cash cow.”
A similar Justice Department lawsuit against UnitedHealth did not get very far basically because adding additional diagnoses supposedly did not constitute a false claim even if the care rendered was not for the specific diagnoses added. That was just a good business practice on the part of the insurer, but that did not refute the fact that they were being paid for healthier patients at rates more appropriate for patients with multiple significant disorders.
Try this experiment: list every disorder you have or have had, no matter how minor – headaches, allergic rhinitis, lumbar myalgia, refractive error, tinnitus, sunburn, pyrosis, URI, Trump disaffection syndrome, contusion, arthralgia, urinary urgency, white coat hypertension, and so on until you’ve listed 50 items. Then look at that list. Wow! Better call the paramedics… Of course, that’s silly, but it simply shows how easy it is to play games with taxpayer funds when you compare the business model of the private insurers with the service model of the public Medicare program.
Look, it’s this private insurance industry that has really screwed up health care financing, wasting tremendous resources while setting up barriers to care, all to benefit their executives and passive shareholders. Why are we giving them a most-favored-status with our Medicare funds, or, for that matter, with funds for employer-sponsored plans, ACA exchange plans, and Medicaid managed care plans? It’s time to dump them and establish our own public single payer Medicare for All program that takes care of all of us equitably and efficiently.
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You don’t need a pandemic to lose your health plan at work
Millions of Americans are about to lose their health insurance in a pandemic
Americans are about to learn something horrifying: how irrational it is for health insurance to be linked to your employment status
By Wendell Potter
The Guardian, March 27, 2020
The tragic effects of our battle with the novel coronavirus are seemingly endless. But arguably the most mind-blowing is this: the very pandemic that threatens to infect and kill millions is simultaneously causing many to also lose their health coverage at their gravest time of need.
Here’s how: the virus has caused a public health crisis so severe that people have been forced to stay home, causing businesses to shutter and lay off workers. And with roughly half of Americans getting their health insurance from their employer, these layoffs mean not only losing their income but also their medical coverage. In other words, just as our need for medical care skyrockets in the face of a global pandemic, fewer will have health insurance or be able to afford it.
America needs to finally get out of the business of linking health coverage to job status. Even in better times, this arrangement was a bad idea from a health perspective. Most Americans whose families depend on their employers for coverage are just a layoff away from being uninsured. And now, when many businesses are shutting down and considering layoffs, it’s a public health disaster.
It’s worth noting that even in good times, the employer-based model fails to cover enough of us, with the number of Americans covered through an employer steadily dropping in general. Since 1999, the percentage of those with job-based coverage has declined by nine points. And it most certainly will drop like a rock in the coming weeks and months.
Comment:
By Don McCanne, M.D.
A well designed single payer model of an improved Medicare for All would meet the health care financing needs of everyone forever while being affordable for each of us based on our ability to pay. Yet some politicians and pundits keep telling us that we want to protect our choice of continuing to be covered through private insurance, which for about half of us means keeping the insurance we receive through our employment.
But that’s a fallacy. Think back twenty years ago. Do you have the same insurance now that you had then? Likely not, unless you are over 85 and on Medicare or perhaps if your long-term employer has provided benefits under Kaiser Permanente. But most of you have not had the opportunity to continue on the plan you had twenty years ago.
Coverage under employer-sponsored plans is highly unstable. The most common reason is that, each year, over 60 million people leave their jobs and thus lose the coverage they had, if any. Though many will find other coverage through a new employer, through ACA exchanges, through Medicaid if income eligible, or through Medicare if age eligible, virtually none will be able to keep their previous plan once COBRA runs out. Also employers frequently change the plans they offer which often means changing the network of physicians and hospitals that are covered or changing the benefits and cost sharing, especially the deductibles.
Right now, job instability due to the coronavirus pandemic demonstrates how fragile coverage under employer-sponsored plans can be, as Wendell Potter describes in his article. Many of those being laid off will find that their options for health care coverage may be very limited if for no other reason than that the options may be unaffordable if the individual does not qualify for a government subsidized program.
If there ever was an opportune time to talk up single payer improved Medicare for All, that time is now. With the tremendous insecurity that so many of us are facing, it would be a relief if at least we had in place a system that would ensure health security forever, no matter what crises we may or may not face. If the people demand it, we can have it.
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Arno and Caper: What is left out in the discussion of Medicare for All
Medicare For All: The Social Transformation Of US Health Care
By Peter S. Arno and Philip Caper
Health Affairs Blog, March 25, 2020
There is a large elephant in the room in the national discussion of Medicare for All: the transformation of the US health care system’s core mission from the prevention, diagnosis, and treatment of illness—and the promotion of healing—to an approach dominated by large, publicly traded corporate entities dedicated to growing profitability and share price, that is, the business of medicine.
The problem is not that these corporate entities are doing something they shouldn’t. They are simply doing too much of what they were created to do—generate wealth for their owners. And, unlike any other wealthy country, we let them do it. The dilemma of the US health care system is due not to a failure of capitalism or corporatism per se, but a failure to implement a public policy that adequately constrains their excesses.
Since the late 1970s, US public policy regarding health care has trended toward an increasing dependence on for-profit corporations and their accompanying reliance on the tools of the marketplace—such as competition, consolidation, marketing, and consumer choice—to expand access and assure quality in the provision of medical care.
This commercialized, commodified, and corporatized model is driving the US public’s demand for fundamental reform and has elevated the issue of health care to the top of the political agenda in the current presidential election campaign.
We must therefore ask: How is it that we spend more on health care than any other nation, yet have arrived at such a sorry state of affairs?
The answer is that only in the United States has corporatism engulfed so much of medical care and come so close to dominating the doctor-patient relationship. Publicly traded, profit-driven entities—under constant pressure from Wall Street—control the financing and delivery of medical care in the US to an extent seen nowhere else in the world. For instance, seven investor-owned publicly traded health insurers now control almost a trillion dollars ($913 billion) of total national health care spending and covers half the US population. In 2019, their revenue increased by 31 percent, while their profits grew by 66 percent.
The corporatization of medical care may be the single most distinguishing characteristic of the modern US health care system and the one that has had the most profound impact on it since the early 1980s. The theology of the market and the strongly held—but mistaken—belief that the problems of US health care can be solved if only the market could be perfected have effectively obstructed the development of a rational, efficient, and humane national health care policy.
What Is The Best Approach To Reform?
It is not an exaggeration to say that no reforms except publicly financed, single-payer universal health care will solve the problems of our health care system. This is true whether we are talking about a public option, a Medicare option, Medicare buy-in, Medicare extra, or any other half-measure. The main reason is because of the savings that are inherent only in a truly universal single-payer plan. Specifically, the administrative and bureaucratic savings gained by eliminating private insurers are the largest potential source of savings in a universal single-payer framework, yet all the “option” reforms listed above leave largely intact the tangle of wasteful, inefficient, and costly private commercial health insurers. The second largest source of savings comes through reducing the cost of prescription drugs by using the negotiating leverage of the federal government to bring down prices, as is done in most other developed countries. The ability, will, and policy tools (such as global budgeting) to restrain these and other costs in a single-payer framework are the key to reining in the relentless rise in health care expenditures and providing universal coverage.
The various “option” reform proposals will not simplify our confusing health care system nor will they lead to universal coverage. None have adequate means to restrain health care costs. So why go down this road?
Conclusion
The real struggle for a universal single-payer system in the US is not technical or economic but almost entirely political. Retaining the status quo (for example, the Affordable Care Act) is the least disruptive course for the existing medical-industrial complex, and therefore the politically easiest route. Unfortunately, the status quo is disruptive to the lives of most Americans and the least effective route in attacking the underlying pathology of the US health care system—corporatism run amok. Following that route will do little more than kick the can down the road, which will require repeatedly revisiting the deficiencies in our health care system outlined above (see full article at link) until we get it right.
The US public and increasingly the business community are becoming acutely aware of the rising costs and inadequacies of our current system. It is the growing social movement, which rejects the false and misleading narratives, that will lead us to a universal single-payer system—truly the most effective way to reform our health care system for the benefit of the US people.
Peter S. Arno, PhD, is an economist and senior fellow and director of health policy research at the Political Economy Research Institute at the University of Massachusetts–Amherst and a senior fellow at the National Academy of Social Insurance.
Philip Caper, MD, is a physician and founding member of the National Academy of Social Insurance and currently serves on the Board of Maine AllCare.
https://www.healthaffairs.org…
Comment:
By Don McCanne, M.D.
Earlier this month, the National Academy of Social Insurance released a report on expanding Medicare eligibility through three options: lowering the eligibility age for Medicare, establishing a Medicare buy-in or a Medicare-like public option, or extending Medicare to cover everyone (Quote of the Day, 3/4/20). Peter Arno and Philip Caper were members of the study panel that wrote the report, but they felt that the final report missed the elephant in the room: “the transformation of the US health care system’s core mission from the prevention, diagnosis, and treatment of illness—and the promotion of healing—to an approach dominated by large, publicly traded corporate entities dedicated to growing profitability and share price, that is, the business of medicine.”
They decided that it was important to issue a “minority view” in response to the NASI report that would raise alarms over the business transformation of US health care. Excerpts of their response appear above though it is highly recommended that the full article be accessed at the Health Affairs website, not only for the sake of completeness but also because the article should be distributed widely to inform the public on why our health care system requires much more than a Medicare option to fix its problems.
Perhaps if enough of you recommend the article to Joe Biden, he might actually read it. He needs to. For that matter, so does Donald Trump.
PNHP does not support any political candidates for office, but we do encourage all candidates to be thoroughly and accurately informed on health policy so that they will support health care measures that are truly in the best interests of all of us.
Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.
Medicare For All: The Social Transformation Of US Health Care
By Peter S. Arno, Ph.D. and Philip Caper, M.D.
Health Affairs Blog, March 25, 2020
There is a large elephant in the room in the national discussion of Medicare for All: the transformation of the US health care system’s core mission from the prevention, diagnosis, and treatment of illness—and the promotion of healing—to an approach dominated by large, publicly traded corporate entities dedicated to growing profitability and share price, that is, the business of medicine.
The problem is not that these corporate entities are doing something they shouldn’t. They are simply doing too much of what they were created to do—generate wealth for their owners. And, unlike any other wealthy country, we let them do it. The dilemma of the US health care system is due not to a failure of capitalism or corporatism per se, but a failure to implement a public policy that adequately constrains their excesses.
Since the late 1970s, US public policy regarding health care has trended toward an increasing dependence on for-profit corporations and their accompanying reliance on the tools of the marketplace—such as competition, consolidation, marketing, and consumer choice—to expand access and assure quality in the provision of medical care.
This commercialized, commodified, and corporatized model is driving the US public’s demand for fundamental reform and has elevated the issue of health care to the top of the political agenda in the current presidential election campaign.
Costs have risen relentlessly, and the quality of and access to care for many Americans has deteriorated. The cultural changes accompanying these trends have affected every segment of the US health care system, including those that remain nominally not-for-profit. Excessive focus on health care as a business has had a destructive effect on both patients and caregivers, leading to increasing difficulties for many patients in accessing care and to anger, frustration, and burnout for many caregivers, especially those attempting to provide critical primary care.
As a result, the ranks of primary care providers have eroded, and that erosion continues. One of the major reasons for burnout in this group is the clash between its members’ professional ethics (put the patient first and “first do no harm”) and the profit-oriented demands of their corporate employers. Applying Band-Aids can’t cure the underlying causes of disease in medicine or public policy. Ignoring the underlying pathology in public policy, as in clinical medicine, is destined to fail.
Many of the symptoms of our dysfunctional health care system are not in dispute:
- We pay more than twice as much per person on total health care spending and on prescription drugs in comparison to other developed countries. This spending totals nearly 18 percent of our economy.
- Between 2008 and 2018, premiums for employer-sponsored insurance plans increased 55 percent, twice as fast as workers’ earnings (26 percent). Over the same time period, the average health insurance deductible for covered workers increased by 212 percent.
- An average employer-sponsored family health insurance policy now exceeds $28,000 per year, with employers paying about $16,000 and employees paying about $12,000.
- Almost half (45 percent) of US adults ages 19 to 64, or more than 88 million people, were inadequately insured over the past year (either they were uninsured, had a gap in coverage, or were underinsured; that is, they had insurance all year but their out-of-pocket costs were so high that they frequently did not receive the care they needed).
- Compared to other developed countries, the US ranks near the bottom on a variety of health indicators including infant mortality, life expectancy, and preventable mortality.
We must therefore ask: How is it that we spend more on health care than any other nation, yet have arrived at such a sorry state of affairs?
The answer is that only in the United States has corporatism engulfed so much of medical care and come so close to dominating the doctor-patient relationship. Publicly traded, profit-driven entities—under constant pressure from Wall Street—control the financing and delivery of medical care in the US to an extent seen nowhere else in the world. For instance, seven investor-owned publicly traded health insurers now control almost a trillion dollars ($913 billion) of total national health care spending and covers half the US population. In 2019, their revenue increased by 31 percent, while their profits grew by 66 percent.
The corporatization of medical care may be the single most distinguishing characteristic of the modern US health care system and the one that has had the most profound impact on it since the early 1980s. The theology of the market and the strongly held—but mistaken—belief that the problems of US health care can be solved if only the market could be perfected have effectively obstructed the development of a rational, efficient, and humane national health care policy.
There are three main reasons to pursue a public policy that embraces genuine health care reform:
- Saving lives: To simplify our complex and confusing health care system while providing universal affordable health care coverage;
- Affordability: To rein in the relentless rise in health care costs that are cannibalizing private and public budgets; and
- Improving quality: To eliminate profitability and share price as the dominant and all-consuming mission of the entities that provide health care services and products when that mission influences clinical decision making. Profitability should be the servant of any health care system’s mission, not its master as seems to be increasingly the case in the US.
What Is The Best Approach To Reform?
It is not an exaggeration to say that no reforms except publicly financed, single-payer universal health care will solve the problems of our health care system. This is true whether we are talking about a public option, a Medicare option, Medicare buy-in, Medicare extra, or any other half-measure. The main reason is because of the savings that are inherent only in a truly universal single-payer plan. Specifically, the administrative and bureaucratic savings gained by eliminating private insurers are the largest potential source of savings in a universal single-payer framework, yet all the “option” reforms listed above leave largely intact the tangle of wasteful, inefficient, and costly private commercial health insurers. The second largest source of savings comes through reducing the cost of prescription drugs by using the negotiating leverage of the federal government to bring down prices, as is done in most other developed countries. The ability, will, and policy tools (such as global budgeting) to restrain these and other costs in a single-payer framework are the key to reining in the relentless rise in health care expenditures and providing universal coverage.
The various “option” reform proposals will not simplify our confusing health care system nor will they lead to universal coverage. None have adequate means to restrain health care costs. So why go down this road? Is it too difficult for the US to guarantee everyone access to affordable care when every other developed country in the world has done so?
The stated reason put forth in favor of these mixed option approaches is that Americans want “choice.” But choice of what? We know with certainty from former insurance company executives such as Wendell Potter that the false “choice” meme polls well with the US public and was used to undermine the Clinton reform efforts more than 25 years ago. It is being widely used today to manipulate public opinion.
But choice in our current system is largely an illusion. In 2019, 67.8 million workers across the country separated from their job at some point during the year—either through layoffs, terminations, or switching jobs. This labor turnover data leaves little doubt that people with employer-sponsored insurance are losing their insurance constantly, as are their spouses and children. And even for those who stay at the same job, insurance coverage often changes. In 2019, more than half of all firms offering health benefits reported shopping for a new health plan and, among those, nearly 20 percent actually changed insurance carriers. Trading off choice of doctors or hospitals for choice of insurance companies is a bad bargain.
The other major objection to a universal single-payer program is cost. Yet, public financing for health care is not a matter of raising new money for health care but of reducing total health care outlays and distributing payments more equitably and efficiently. Nearly every credible study concludes that a single-payer universal framework, with all its increased benefits, would be less costly than the status quo, more effective in restraining future cost increases, and more popular with the public—as 50 years of experience with Medicare has demonstrated.
The status quo generates hundreds of billions of dollars in surplus and profits to private stakeholders, who need only spend a small portion (millions of dollars) to influence legislators, manipulate public opinion, distort the facts, and obfuscate the issues with multiple competing reform efforts.
Conclusion
The real struggle for a universal single-payer system in the US is not technical or economic but almost entirely political. Retaining the status quo (for example, the Affordable Care Act) is the least disruptive course for the existing medical-industrial complex, and therefore the politically easiest route. Unfortunately, the status quo is disruptive to the lives of most Americans and the least effective route in attacking the underlying pathology of the US health care system—corporatism run amok. Following that route will do little more than kick the can down the road, which will require repeatedly revisiting the deficiencies in our health care system outlined above until we get it right.
The US public and increasingly the business community are becoming acutely aware of the rising costs and inadequacies of our current system. It is the growing social movement, which rejects the false and misleading narratives, that will lead us to a universal single-payer system—truly the most effective way to reform our health care system for the benefit of the US people.
Health spending for the next decade
National Health Expenditure Projections, 2019–28: Expected Rebound In Prices Drives Rising Spending Growth
By Sean P. Keehan, et al, CMS Office of the Actuary
Health Affairs, March 24, 2020
Abstract
National health expenditures are projected to grow at an average annual rate of 5.4 percent for 2019–28 and to represent 19.7 percent of gross domestic product by the end of the period. Price growth for medical goods and services is projected to accelerate, averaging 2.4 percent per year for 2019–28, which partly reflects faster expected growth in health-sector wages. Among all major payers, Medicare is expected to experience the fastest spending growth (7.6 percent per year), largely as a result of having the highest projected enrollment growth. The insured share of the population is expected to fall from 90.6 percent in 2018 to 89.4 percent by 2028.
- $4,014.2 billion – National health expenditures 2020
- $6,192.5 billion – National health expenditures, projected 2028
National health spending is projected to increase 5.4 percent per year, on average, for 2019–28, compared to a growth rate of 4.5 percent over the past three years (2016–18). The acceleration is largely due to expected faster growth in prices for medical goods and services (2.4 percent for 2019–28, compared to 1.3 percent for 2016–18). Growth in gross domestic product (GDP) during the projection period is expected to average 4.3 percent. Because national health spending growth is expected to increase 1.1 percentage points faster, on average, than growth in GDP over the projection period, the health share of GDP is expected to rise from 17.7 percent in 2018 to 19.7 percent in 2028.
Although growth in economywide prices is projected to accelerate during 2019–28, growth in personal health care prices is expected to increase more quickly, partly reflecting faster expected growth in the wages paid to health care workers.
Over the projection period, Medicare is expected to have the highest spending growth among the major payers of health care each year and on average (7.6 percent), largely reflecting the continued shift of the baby-boom generation out of private health insurance and into Medicare.
The modest rate of growth in private health insurance enrollment is influenced both by the impact of the repeal of the Affordable Care Act (ACA) individual mandate in the early part of the projection period and by the expectation that the working-age population will continue the recent trend of enrolling in private health insurance (primarily employer-sponsored insurance) at lower rates. As a result, by 2028 the insured share of the population is expected to fall to 89.4 percent (from 90.6 percent in 2018).
The share of health care spending financed by federal, state, and local governments is expected to increase by 2 percentage points during 2019–28, reaching 47 percent in 2028. The increase is primarily due to the federal government’s share, which is projected to grow from 28 percent in 2018 to 31 percent by 2028, driven by faster growth in Medicare spending related to increasingly higher enrollment. The projected business and household share is expected to fall from 55 percent in 2018 to 53 percent in 2028.
Conclusion
As it has over the past several decades, health spending is expected to grow, on average, more rapidly than the rest of the economy in each year of the projection period through 2028 and to consume an increasingly larger share of GDP. Thus, health spending is projected to reach 19.7 percent of GDP in 2028, even with a modest projected decline in the insured share of the US population. Anticipated increases in inflation for medical goods and services are key drivers of accelerating national health spending growth, since the use and intensity of services are expected to grow more slowly than in recent years—in part because the share of the population with insurance coverage is projected to decline slightly. The government is projected to pay a larger share (nearly half) of the nation’s total health bill by 2028, as the baby boomers continue aging into Medicare and the program’s beneficiaries consume $1 out of every $4 spent on health care. Policy makers and other stakeholders will undoubtedly continue to monitor these trends and their implications for the health sector, federal and state budgets, and the economy as a whole.
(Given the timing of publication and the uncertainty associated with the impacts of the COVID-19 pandemic, those impacts are not reflected in the estimates.)
https://www.healthaffairs.org…
Comment:
By Don McCanne, M.D.
Two important take-home points from this annual report from CMS Office of the Actuary: 1) Health care spending will continue to increase at a rate greater than the growth of the GDP, comprising 19.7% in 2028, and 2) The percentage uninsured will increase from 9.4% in 2018 to 10.6% in 2028.
Thus the Affordable Care Act has fallen short of the goals of reform, especially when you consider all of the other deficiencies of our health care financing system that will remain in place (profound administrative waste, rampant underinsurance, restrictive provider networks, job lock with employer-sponsored plans, etc., etc.).
Of course, the system could be changed in the next decade. Since the Republicans have been unable to come up with a replacement plan for the Affordable Care Act, it is likely that not much would happen under their control. It now appears that, if the Democrats were to gain control, a public option might be added, but that would have very little impact on the financing system at large. The public option would be only one more administratively-complex player added to our fragmented, dysfunctional system of financing health care.
Of course we don’t know yet what COVID-19 will do, but it may well have a major impact on the health care delivery system and its financing. The health and economic consequences could jar the minds of the political and policy communities such that it is possible that they may regret that we did not have in place a well designed, single payer improved Medicare for All program. Imagine if we enacted and implemented such a system what the following 10 year projection by the Office of the Actuary would be. Pretty good, I’d say.
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Vets Say We Need a Strong VA to Combat Coronavirus and Win Medicare for All
Spend a life-changing hour with Frances Perkins
Summoned: Frances Perkins and the General Welfare
By Mick Caouette, Filmmaker
South Hill Films
About the Film:
In the depths of the Great Depression, Franklin Roosevelt appointed Frances Perkins as the first woman on a presidential cabinet. Against overwhelming odds, she became the driving force behind Social Security, the 40-hour work week, the eight-hour day, minimum wage and unemployment compensation. “Summoned: Frances Perkins and the General Welfare” features compelling interviews with David Brooks, Nancy Pelosi, Amy Klobuchar, Lawrence O’Donnell and others while telling Perkin’s heroic story which explores the history of women in politics, Social Security, our attitudes toward immigration, poverty, Socialism, and the role of government. Without this context our current dialogue is ill-informed and diminished.
“Some of us decided that the purpose and the reason for government should be the improvement of life for all of its people.” – Frances Perkins
This link includes a six minute preview of the film:
https://www.southhillfilms.com…
“Summoned: Frances Perkins and the General Welfare” (full video – 57 minutes):
https://www.kcet.org…
Also a DVD can be purchased through PBS:
https://shop.pbs.org…
Comment:
By Don McCanne, M.D.
These are difficult times. The highly contagious nature and the lethality of Covid-19 has caused many of us to accept the advice and direction of experts in epidemics of infectious diseases to retreat and practice “social distancing.” This should give us time for contemplation and values clarification.
Somewhere in your schedule, or what’s left of it, you should be able to find an hour to sit down and watch this video. I would say that it is an imperative in that it shows how a nation, with the inspiration provided by leaders like Frances Perkins, can address the problems of our times. Although the specific issues are not all the same now as they were then, the general concept is the same: society is not functioning well even though the nation has the ability and resources to do something about it.
How are we not functioning well now? We are facing a pandemic at a time that our government stewards had elected to diminish our public health resources so that we were not adequately prepared for this. We have diverted too much of our very high national health expenditures away from patients and to administrators and passive investors, while leaving too many without access to the health care they need. We have shifted decades of the gains in productivity to the wealthy at the top while leaving workers and their families struggling just to try to make ends meet. We have continued to engage in endless, meaningless wars. We have allowed democracy to deteriorate to the point that our elections all too often no longer represent the will of the people. And the list goes on.
Viewing this will be an hour well spent, but much more important will be the contemplation that follows. That can lead to an epiphany for each of us. Dammit, we can do something about this!
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Why are we waiting for Medicare for All?
By F. Douglas Stephenson
The Gainesville (Fla.) Sun, March 23, 2020
An old social justice chant, “Why are We Waiting,” is sung to the tune of the beautiful and inspiring Christmas carol, “O Come All Ye Faithful.” The lyrics apply to the situation today: Even with the dangerous coronavirus pandemic, big insurance and big pharma continue opposing legislation for the new Medicare for All.
We still wait because these resistant, self-serving industries have the most to lose if their huge profits are redirected to direct patient care for all. Individual and corporate predators regard democracy, government and community as obstacles to their greed and avarice, always placing profits over individual patients, families and public health. It’s no wonder so many beholden members of Congress want to protect the interests of big insurance and big pharma, industries that spent $371 million on lobbying in 2017 alone.
Dealing with the COVID-19 virus would be more life-saving if Medicare for All was in place today. A recent New York Times editorial, “With Coronavirus, ‘Health Care for Some’ Is a Recipe for Disaster,” stresses the importance of covering everyone.
Even before COVID-19 was known to humans, Northeastern University professor of public health Wendy Parmet presciently warned that the push to exclude immigrants from access to health-care services would be both dangerous and quixotic.
“None of us can be self-sufficient in the face of a widespread epidemic,” she wrote in 2018. “That is just as true for noncitizen immigrants as everyone.” In any pandemic, self-sufficiency can be self-deluding; everyone’s health, citizens, immigrants, etc. alike is only as good as our most vulnerable neighbors.
In what is truly a recipe for disaster, vested interests reject the science of public health epidemiology by asserting that only an incremental approach to health insurance reform is possible or acceptable. So, what are we willing to settle for, and should we just settle for what we can get? Should we lower the expectations, turn down the public heat and keep waiting?
Gradualism, baby steps and extending health insurance coverage to some, but not all, are the mantra of the day. “Medicare for some,” but not Medicare for All, is fawned over by politicians, profiteers and advocacy groups alike while reducing communities resources to deal with dangerous epidemics.
Virtually all the risky gradual reforms being touted would reinforce a dysfunctional health insurance system with as many standards of insurance as there are dollars to purchase them. It would further lock us into an obsolete private insurance-based model that holds everyone’s health hostage to profiteering HMOs and unaccountable big insurance companies for years to come.
For these proponents of political expediency, the question remains, who will be left behind while we wait? Every year, well over 18,000 unnecessary deaths, the equivalent of six times the number who died in the Sept. 11 attacks, are linked to lack of health insurance coverage. Pandemics can quickly increase these numbers.
Our most successful national health insurance program, Medicare, provides one of the best arguments against incremental steps. When Medicare was enacted 55 years ago, following a broad grassroots campaign, many believed the dream of a full national health insurance system was right around the corner.
Five decades later, Medicare still has not been expanded. Most of the changes have been contractions with higher out-of-pocket costs for beneficiaries and repeated attempts at privatization by big pharma, the health insurance industry and its champions in the White House and Congress.
It’s time to end inadequate and dangerous health insurance programs. Insist on real health insurance reform essential for individuals and families.
American history is filled with examples of fundamental, democratic change brought about by successful mass action and public pressure against the counseling of the go slow, vested interest crowd. No more waiting! Ask your legislators to fully support Medicare For All now: HR-1384/S-1129.
F. Douglas Stephenson, LCSW, BCD, is a retired clinical social work psychotherapist. Formerly on the faculty of the University of Florida Department of Psychiatry, he is a health professional member of Physicians for a National Health Program.
Marcia Angell: Coronavirus reinforces moral basis for Medicare for All
Why the U.S. failed the coronavirus test
By Marcia Angell
Santa Fe New Mexican, March 21, 2020
The coronavirus pandemic is the best argument for “Medicare for All.” As it stands, most Americans get health care only if we have insurance that will pay for it. If we don’t or we can’t afford the deductibles and copayments, too bad. Every other advanced country provides universal health care in a predominately nonprofit system.
What happens, then, when Americans develop a fever and cough? Are they likely to seek medical help, despite the hefty bills they are sure to receive, particularly if, say, the radiologist is out of network or the insurance company refuses to pay for some other reason? The new coronavirus, while highly contagious, is usually mild, so people with minimal symptoms might simply take their usual cold remedies while they go about their business and spread the infection widely.
The problem is that we treat health care like a market commodity distributed according to the ability to pay in an uncoordinated system with hundreds of commercial insurers and profit-oriented providers. Some 30 million people have no access to health care because they are uninsured, and millions more don’t use their insurance because the deductibles and copayments are unaffordable. In addition, insurers usually require patients to get their care within a narrow network of providers and exclude certain services.
The shortage of test kits for coronavirus stems from a related problem. Since there was no commercial market for them, they didn’t get made immediately. While we’ve converted health care into a market commodity, we’ve hollowed out our public health system, so it couldn’t do the job.
For all we know, the coronavirus may already have spread widely within the United States. Although it has been in other countries for more than two months, we have not really looked for it here. Until the last week in February, our premier public health agency, the Centers for Disease Control and Prevention, limited its diagnostic testing to symptomatic patients who had traveled to China or had contact with someone known to be infected. This is akin to looking for lost keys only under a lamppost.
The CDC probably could not have done better, given its lack of funding and governmental support. But ignorance is hardly a good public health strategy. Right from the beginning, we should have made test kits available to state and local public health agencies (as was done in Italy and South Korea). The only way to deal with an epidemic of this scope is with a universal health care system like “Medicare for All” and a strong, well-funded public health network.
The political opposition to “Medicare for All” is puzzling, since Medicare is the most popular part of our current fragmented system. In fact, many 64-year-olds can hardly wait to be 65, so they will be eligible. Why, then, do opponents of “Medicare for All” seem to believe that extending this popular program to everyone would be a sacrifice? Would a 64-year-old really prefer private insurance, with its networks and variable benefits, to Medicare, with its free choice of doctors and guaranteed benefits?
It’s true that taxes would have to increase to pay for “Medicare for All,” but the taxes could be as progressive as we wanted. For most Americans, they would probably be completely offset by the elimination of premiums, deductibles and copayments. In addition, the system as a whole would be far more efficient, because of the reduction in our gigantic overhead costs and the elimination of most profits. Most important, cost inflation would slow greatly, so that in a few years we would come out well ahead.
But as important as cost control is, my reason for favoring “Medicare for All” is primarily moral. Health care is not like ordinary consumer goods that people can choose to purchase. Illness is not a choice; it’s a misfortune. So why should people have to pay for it, as if they wanted it? Providing health care, just like providing clean water or police protection or basic education, is simply what decent societies should do. And during an epidemic, it protects all of us. The coronavirus pandemic powerfully underscores the need for a coherent national health system, in which we all pull together.
Marcia Angell is a member of Harvard Medical School’s Department of Global Health and Social Medicine, and a former editor-in-chief of the New England Journal of Medicine. She will soon be a resident of Santa Fe.
https://www.santafenewmexican.com…
Comment:
By Don McCanne, M.D.
Certainly we have all had more than enough reason recently to give considerable thought to factors potentially influencing the health of all of us. As Marcia Angell makes clear, we most emphatically need a coherent national health system like “Medicare for All” with a strong, well-funded public health network. Most of us can cite many reasons for this, but, above all, the reason is primarily moral. How can we not do it?
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