PNHP

Americans now more likely to have unmet health needs than twenty years ago: Harvard study

Americans now more likely to have unmet health needs than twenty years ago: Harvard study

Many skipping needed healthcare because of cost, likely due to deteriorating private insurance coverage

Contact: Dr. Laura Hawks, primary care physician and research fellow at Harvard Medical School and Cambridge Health Alliance, lhawks@challiance.org

Jan., 27, 2020 — More Americans have unmet health needs today than two decades ago, according to a new study from Harvard Medical School and the City University of New York at Hunter College. The study, published today in JAMA Internal Medicine, found that despite an increase in insurance coverage from the Affordable Care Act (ACA), the percentage of people who are unable to afford to see a doctor when needed has risen. This was especially true of people with serious medical conditions like heart disease, for whom physician care is essential. The largest relative increases in unmet health needs occurred among people who had had insurance, suggesting that deterioration in quality of private health insurance, not lack of insurance, caused most of the increase in unmet health needs over the last 20 years.

Using survey data from over 400,000 working age adults, the researchers compared responses in 1998 to responses to the same questions in 2017. Over the two decades, the share of non-elderly adults who were unable to afford to see a doctor has increased by nearly a third – from 11% to 16%. However, among those with health insurance coverage, the study found a 60% increase — from 7% to 12%. Overall, adults with a chronic disease had nearly a 20% chance of skipping a doctor visit due to cost in 2017 — 63% worse than 1998. The study also found no improvements in the likelihood of having a routine check-up among high-risk patients in 2017 as compared to 1998.

The study’s authors noted that private insurance has become less comprehensive as insurers have increased deductibles, coinsurance and copays. Meanwhile, many private insurers’ provider networks have narrowed, leading to the recently publicized phenomenon of “surprise medical bills” which may deter patients from seeking future care. While the study could not separate private insurance from public insurance programs such as Medicaid, Medicaid typically does not require cost sharing.

“Our findings call into question the value of private health insurance today,” said the study’s lead author, Dr. Laura Hawks, a Harvard research fellow and primary care physician. “When so many people can’t get the care they need even when they have insurance coverage, it says that insurance is not doing what it is supposed to do: ensure that health care is affordable when you need it.”

The new study also provides new insights into both the achievements and limitations of the ACA’s coverage expansions. Previous studies have established that these expansions improved both insurance coverage and the affordability of care for previously uninsured Americans. The new Harvard/Hunter College study suggests, however, that these gains didn’t counterbalance the long-term trend toward deteriorating access to needed medical care.

“The ACA was crucial for expanding coverage to low-income Americans, particularly the Medicaid expansion in states that allowed it,” said senior study author Dr. Danny McCormick, an associate professor of medicine at Harvard Medical School and primary care physician at the Cambridge Health Alliance. “However, because it did little to fix the biggest problems with private insurance — such as high copays and deductibles and narrow networks — the ACA didn’t reverse the long-term downward trend towards decreasing health care affordability.”

“Health coverage needs to be both universal and comprehensive, meaning that it covers everyone and that it pays in full for all medically necessary care,” commented study co-author, Dr. Steffie Woolhandler, a distinguished professor of public health at CUNY’s Hunter College and lecturer in medicine at Harvard Medical School. “Our private insurance-based system simply isn’t doing that.”

The study found improvement in a few types of preventive care since 1998; more Americans are receiving cholesterol checks and flu shots. However, fewer women are now receiving mammograms.

“Some aspects of health care are improving, but death rates are rising and we are mostly moving backwards on the health and health care of working-age adults, ” said study co-author Dr. David Himmelstein, a distinguished professor of public health at CUNY’s Hunter College and lecturer in medicine at Harvard Medical School. “A single-payer reform like Medicare-for-All that eliminates financial barriers to care is what patients need.”

* * * * * *

“Trends in Unmet Need for Physician and Preventive Services in the United States, 1998 to 2017,” Laura Hawks, MD; David U. Himmelstein, MD; Steffie Woolhandler, MD, MPH; David H. Bor, MD; Adam Gaffney, MD, MPH; and Danny McCormick, M.D., M.P.H. JAMA Internal Medicine. Published online first, January 27th, 2020. doi:10.1001/jamainternmed.2019.6538

16 minutes EHR time per ambulatory patient? Get real!

Physician Time Spent Using the Electronic Health Record During Outpatient Encounters: A Descriptive Study

By J. Marc Overhage, M.D., Ph.D. and David McCallie Jr., M.D.
Annals of Internal Medicine, January 14, 2020

Abstract

Background: The amount of time that providers spend using electronic health records (EHRs) to support the care delivery process is a concern for the U.S. health care system. Given the potential effect on patient care and the high costs related to this time, particularly for medical specialists whose work is largely cognitive, these findings warrant more precise documentation of the time physicians invest in these clinically focused EHR functions.

Objective: To describe how much time ambulatory medical subspecialists and primary care physicians across several U.S. care delivery systems spend on various EHR functions.

Design: Descriptive study.

Setting: U.S.-based, adult, nonsurgical, ambulatory practices using the Cerner Millennium EHR.

Participants: 155,000 U.S. physicians.

Measurements: Data were extracted from software log files in the Lights On Network (Cerner) during 2018 that totaled the time spent on each of the 13 clinically focused EHR functions. Averages per encounter by specialty were computed.

Results: This study included data from approximately 100 million patient encounters with about 155 000 physicians from 417 health systems. Physicians spent an average of 16 minutes and 14 seconds per encounter using EHRs, with chart review (33%), documentation (24%), and ordering (17%) functions accounting for most of the time. The distribution of time spent by providers using EHRs varies greatly within specialty. The proportion of time spent on various clinically focused functions was similar across specialties.

Limitations: Variation by health system could not be examined, and all providers used the same software.

Conclusion: The time spent using EHRs to support care delivery constitutes a large portion of the physicians’ day, and wide variation suggests opportunities to optimize systems and processes.

https://annals.org…

Epic’s CEO is urging hospital customers to oppose rules that would make it easier to share medical info

By Christina Farr
CNBC, January 22, 2020

Key Points

  • Epic Systems is urging its health system customers to take a stand against the U.S. Department of Health and Human Services’ proposed rules to make it easier to share patient data.
  • Epic’s CEO Judy Faulkner says that patient privacy will be negatively impacted.
  • Privately held Epic is one of the leading providers of electronic medical records in the U.S.

https://www.cnbc.com…

Comment:

By Don McCanne, M.D.

Ambulatory primary care physicians and medical subspecialists spent an average of 16 minutes and 14 seconds per encounter using EHRs, with chart review (33%), documentation (24%), and ordering (17%) functions accounting for most of the time. Those physicians who try to see four patients an hour understand that this does not compute.

In my earlier years of general practice (before I became a charter diplomat in the new field of family practice), only one of our four hospitals existed, and the emergency room was not staffed (we rotated call to cover it from our individual practices). My brother and I each scheduled four patients and averaged about two walk-ins per hour (unavoidable because of the acute nature of our practice – problems that are now usually seen in the emergency room or urgent care centers).

Obviously medical records were a problem. We had to record notes quickly yet adequately. How did we do that? A few years later Lawrence Weed developed the problem oriented medical record. He proselytized on SOAPing the records – recording the organized elements of subjective, objective, assessment, and plans. Intuitively I was already doing that, but without the S,O,A,P designations. It worked very well. It took maybe a minute to record the note, and there was always enough recorded for continuity of care. Also my records were never questioned for lack of adequacy.

So why do we need electronic health records? To make it easier for insurers to deny claims? For entrepreneurial entities to collect and sell data to other enterprises to profit off of patient and provider information? To violate the patients’ privacy? And for what reason?

Even EPIC’s Judy Faulkner says that under HHS rules making it easier to share patient data patient privacy will be negatively impacted. Do we really want to go there?

Surely we can find things to do with 15 of those 16 minutes that will better serve the interests of our patients.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Stagnant incomes and health care subsidies

Middle class income growth is lagging the rich and the poor - how much is due to healthcare subsidies?

By Isabel V. Sawhill and Christopher Pulliam
Brookings, January 21, 2020

The state of the American middle class is a hot topic on the campaign trail and in the policy community. As we have shown before, income growth for the middle class, defined as the middle 60 percent of the income distribution, is falling behind both the bottom and the top. Using the Congressional Budget Office’s measure of income after taxes and transfers, which takes into account market income, social insurance, federal taxes, and means-tested transfers, middle-class incomes have grown 47 percent from 1979 to 2016.

That growth pales in comparison to the top and the bottom. The top 20 percent has seen their incomes double. But much more surprisingly, the bottom 20 percent has seen income growth of 84 percent, far outpacing the middle class. Plus, these trends are predicted to continue.

Measuring income is a tricky business. A reasonable critique of this approach is the inclusion of the value of health insurance subsidies, especially for those at the bottom of the income distribution. The value of these insurance subsidies, and therefore the value added to a poor family’s income, has grown faster than other components of income over the past several decades. Some of that additional income bought better healthcare but some did not. More importantly, health insurance can’t be used to pay the rent or buy food, and many if not most of these low-income families would likely value this coverage at less than its high cost. Recognizing the problem, previously, CBO used the “fungible” value of Medicare, Medicaid, and CHIP, which values government insurance to the extent it frees up other income to spend outside of necessities. Then, starting in 2012, CBO began counting the full per capita cost to the government of providing that insurance as income.

This debate about how to count government subsidized health insurance in measures of income has not been fully resolved. Does giving low-income families access to healthcare really increase their income? Some argue yes. If the cost of that access is $7,000, and the family would otherwise have had to buy an insurance policy costing that much, then government provision is worth a lot. Moreover, those are real federal dollars funded by taxpayers and should be counted. Others argue that, in the absence of government provision, most of these families would never buy such an expensive insurance policy for the simple reason that they can’t afford it. They likely value other goods and services more, especially if they are relatively healthy and do not utilize the full value of government insurance.

While we will not solve that debate here, we do want to make a point about the role of healthcare in the CBO numbers. CBO includes three measures of healthcare income: Medicaid and CHIP, Medicare, and employer’s contributions to health insurance. Government subsidies for health insurance make up a large portion of the bottom quintile’s income growth over the past 40 years, largely due to Medicaid and CHIP as mentioned above. Excluding all government and employer health insurance subsidies, the bottom quintile’s income growth drops from 84 percent to 40 percent—a huge decrease.

However, excluding healthcare affects income growth throughout the income distribution. Without healthcare, middle class income growth decreases from 47 percent to 32 percent, a sizable decrease.

Regardless of your view on the healthcare question, income growth for the middle class is still falling behind both the rich and the poor. To be sure, the bottom quintile started from a much lower base in 1979. We are not suggesting that those at the bottom are doing just fine. However, we are arguing that the middle class has not seen strong income growth relative to other groups.

https://www.brookings.edu…

Comment:

By Don McCanne, M.D.

In the past several decades, the increase in income and wealth due to gains in productivity have accrued primarily to the wealthy, leaving incomes relatively stagnant for four-fifths of our population, even though, as this article indicates, strictly as a percentage the income for the lowest quintile has increased significantly (keeping in mind that a large percentage of a small number is still a very modest amount).

Since health care has become very expensive, and since the government and employer increase in health care subsidies constitutes a form of income, what impact has this had on the inequities of income inequality? If health care subsidies were not included as income, the bottom quintile’s income growth over the past four decades drops from 84 percent to 40 percent, whereas middle class income growth decreases from 47 percent to 32 percent. This suggests that our current health care financing is somewhat progressive, though for the very wealthy, income gains have far more than offset increases health care costs – certainly a regressive trend. Because of the increase in health care costs and the stagnation of incomes for all but the top quintile, the current progressively of health care financing is still inadequate, not to mention that too many are left uninsured or underinsured.

The fact is that America’s working families are stressed because of flat wages and high health care costs. There are many remedies for this that should be implemented, but perhaps the most effective would be to enact single payer Medicare for All in which the universal risk pool is funded through equitable, progressive tax policies. All of us would receive the health care we need and each of us could afford it. In contrast, merely allowing uninsured individuals to purchase Medicare, even if partially subsidized, will have very little overall impact on health care justice. Even worse is to pretend that the market will work for people whose pockets are empty.

Setting aside the problem of financing health care for all of us would allow us to direct our attention to evaluating and implementing other beneficial policies that would bring us closer to the more egalitarian society that we all would like to be a part of (wouldn’t we?).

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

‘Complete’ health insurance improves access and prevents financial hardship

Does ‘no more copays, no more deductibles’ really represent radical health care reform?

By Christopher T. Robertson
STAT, January 20, 2020

Lost in the shuffle of competing plans for saving health care is the radical call by Democratic presidential candidates Bernie Sanders and Elizabeth Warren for “no more copays, no more deductibles” as part of their “Medicare for All” plans.

Doing away with copays and deductibles would represent a complete reversal of U.S. health care policy. In the last decade alone, deductibles have risen 212%, which is about 10 times the rate of inflation or wages. And that’s exactly what federal law has encouraged. The Affordable Care Act capped annual out-of-pocket payments at $16,300 per year, but that is one-quarter of median family income — more than enough to bankrupt a family if illness strikes. When insurance leaves people unprotected against such large costs, it defeats the purpose of having insurance in the first place.

In this way, the Affordable Care Act reinforced this peculiar American policy of making health insurance incomplete — leaving insured individuals to pay substantial costs. This policy reflects a long-ingrained notion of personal responsibility: Nothing is supposed to come for free. This point has seemed about as controversial as the idea that banks should have locks on their doors. To do otherwise, to have a system of altogether “free” (fully insured) health care, would seem imprudent, irresponsible, and wasteful.

There is now a wealth of evidence about how copays and deductibles actually work. And it isn’t pretty.

In the 1970s, scientists fielded a remarkable experiment in which families were actually randomized to have large copays, smaller copays, or no copays. As predicted, those who had to pay some of the costs out of pocket spent less money on health care than those who got “free” care. Yet they seemed to cut back on care indiscriminately, avoiding both low-value care (like antibiotics for a viral infection) and high-value care (like insulin for diabetes). More recent research shows that patients primarily do what their physicians suggest.

Even with copays, patients are rarely able to effectively price shop for health care.

Ultimately, policies with large copays and deductibles do not target wasteful spending with any precision. They just smite those who are unlucky enough to get sick. And they deny access to care for those who cannot afford the payments.

To get real and enduring change, we may have to turn away from substantial copays and deductibles and join the rest of the civilized world with complete health insurance. Rather than trying to get patients to second-guess their own doctors, the law should target the real drivers of wasteful spending — physicians’ conflicting interests, monopolies and market concentration of health care providers, and the lack of investment in rigorous science about what health care is truly valuable.

In this light, it is striking that moderates like Pete Buttigieg and Joe Biden are failing to really grapple with the problem of patient exposure to costs, which polls show is the single most important issue to voters, when they think about health care reform. After all, that is the issue that most directly affects their pocketbooks, at a time when they are most vulnerable and desperate. Nonetheless, the Buttigieg and Biden plans do nothing to address the growing copays and deductibles in employer-sponsored health insurance — the main source of coverage in America.

Sure, Americans may get to keep their insurance under a moderate’s reform plan. But that is the very same insurance that is failing to really secure our access to care and failing to protect us from financial catastrophe when devastating illness strikes.

Christopher T. Robertson, J.D., is professor of law and associate dean for research and innovation at the University of Arizona and author of “Exposed: Why Our Health Insurance is Incomplete and What Can Be Done About It” (Harvard University Press, 2019).

https://www.statnews.com…

Comment:

By Don McCanne, M.D.

Should a person be automatically exposed to financial penalties merely because of having to face the misfortune of suffering illness or injury, especially when those penalties may impair access to the health care needed, in addition to suffering the insult of financial hardship? Of course not, yet that is precisely what deductibles, copays and other cost sharing of health insurance does.

Yet some say that we need cost sharing to reduce moral hazard – the tendency of individuals to take more risks exposing them to illness or injury if they know that the consequent medical expenses will be covered by others. Really? It’s okay to break a leg as long as the medical costs are covered by insurance? It’s okay to acquire AIDS as long as insurance covers it? It’s okay to suffer the grief and infirmities of obesity (as if that were preventable) as long as mental and physical consequences are covered by insurance? Is threatening a person with cost-sharing financial penalties really a means of ensuring personal responsibility that would prevent behavior that could have medical consequences? Further, is it just to penalize the majority of individuals with illness or injury when their medical misfortunes were not due to a failure of personal responsibility? This last point is the most compelling reason of all to eliminate deductibles, copays, and coinsurance. It’s just not fair.

Professor Robertson refers to “complete” health insurance as that which eliminates substantial copays and deductibles – complete because it replaces today’s incomplete insurance “that is failing to really secure our access to care and failing to protect us from financial catastrophe when devastating illness strikes.”

Time to make our health insurance complete while we bring in everyone and make it affordable for each of us through progressive financing.

PNHP supports policies that improve our health care system for the benefit of all of us, with special attention as to how health care is financed. PNHP, as an organization, does not support any candidates for political office. We advocate for optimal policy, and it is the candidates themselves who select the policies they support.

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The American College of Physicians’ endorsement of single payer

Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians

By Robert Doherty, B.A.; Thomas G. Cooney, M.D.; Ryan D. Mire, M.D.; Lee S. Engel, M.D.; Jason M. Goldman, M.D.; for the Health and Public Policy Committee and Medical Practice and Quality Committee of the American College of Physicians
Annals of Internal Medicine, January 21, 2020

U.S. health care costs too much; leaves too many behind without affordable coverage; creates incentives that are misaligned with patients’ interests; undervalues primary care and public health; spends too much on administration at the expense of patient care; fails to invest and support public health approaches to reduce preventable injuries, deaths, diseases, and suffering; and fosters barriers to care for and discrimination against vulnerable individuals.

The ACP’s Vision of a Better Health Care System for All

The ACP believes the United States can, and must, do better and offers the following 10 vision statements for a better health care system for all.

  1. The American College of Physicians envisions a health care system where everyone has coverage for and access to the care they need, at a cost they and the country can afford.

(Nine more vision statements listed.)

The accompanying policy papers offer specific recommendations, supporting rationales, and evidence on ways the United States can move to achieve ACP’s vision.

In “Envisioning a Better Health Care System for All: Coverage and Cost of Care” (1), ACP recommends transitioning to a system of universal coverage through either a single payer system, or a public choice to be offered along with regulated private insurance. Although each approach has advantages and disadvantages, either can achieve ACP’s vision of a health care system where everyone has coverage for and access to the care they need, at a cost they and the country can afford. The evidence suggests that publicly financed and administered plans have the potential to reduce administrative spending and associated burdens on patients and clinicians compared with private insurers. Other approaches were considered by ACP, including market-based approaches, yet ACP found they would fall short of achieving our vision of affordable coverage and access to care for all. The ACP asserts that under a single payer or public option model, payments to physicians and other health professionals, hospitals, and others delivering health care services must be sufficient to ensure access and not perpetuate existing inequities, including the undervaluation of primary and cognitive care.

The ACP proposes that costs be controlled by lowering excessive prices, increasing adoption of global budgets and all-payer rate setting, prioritizing spending and resources, increasing investment in primary care, reducing administrative costs, promoting high-value care, and incorporating comparative effectiveness and cost into clinical guidelines and coverage decisions.

In “Envisioning a Better Health Care System for All: Health Care Delivery and Payment Systems” (2), ACP calls for increasing payments for primary and cognitive care services, redefining the role of performance measures to focus on value to patients, eliminating “check-the-box” reporting of measures, and aligning payment incentives with better outcomes and lower costs. The position paper calls for eliminating unnecessary or inefficient administrative requirements, and redesigning health information technology to better meet the needs of clinicians and patients. The ACP concludes there is no one-size-fits-all approach to reforming delivery and payment systems, and a variety of innovative payment and delivery models should be considered, evaluated, and expanded.

In “Envisioning a Better Health Care System for All: Reducing Barriers to Care and Addressing Social Determinants of Health” (3), ACP calls for ending discrimination and disparities in access and care based on personal characteristics; correcting workforce shortages, including the undersupply of primary care physicians; and understanding and ameliorating social determinants of health. This position paper calls for increased efforts to address urgent public health threats, including injuries and deaths from firearms; environmental hazards; climate change; maternal mortality; substance use disorders; and the health risks associated with nicotine, tobacco use, and electronic nicotine delivery systems.

These are just a partial summary of the recommendations in the 3 position papers; considered together, they offer a comprehensive and interconnected set of policies to guide the way to a better a health care system for all. We urge readers of this call to action to review the 3 papers for a complete understanding of ACP’s recommendations and the evidence in support of them.

The ACP rejects the view that the status quo is acceptable, or that it is too politically difficult to achieve needed change. By articulating a new vision for health care, ACP is showing a willingness to try to achieve a better U.S. health care system for all. We urge others to join us.

https://annals.org…

Better Is Possible: The American College of Physicians’ Vision for the U.S. Health Care System

Vol: 172, Issue 2 Supplement, January 21 2020

The following link provides full free access to nine papers in this special Annals of Internal Medicine/American College of Physicians Supplement on a bold new prescription for the U.S. health care system:

https://annals.org/aim/issue

The American College of Physicians’ Endorsement of Single-Payer Reform: A Sea Change for the Medical Profession

By Steffie Woolhandler, M.D., M.P.H.; David U. Himmelstein, M.D.
Annals of Internal Medicine, January 21, 2020

For a century, most U.S. medical organizations opposed national health insurance. The endorsement by the American College of Physicians (ACP) of single-payer reform marks a sea change from this unfortunate tradition.

Canada’s generally positive experience is among the strands of evidence underpinning the ACP’s endorsement. A single-payer reform that reduced insurance overhead to 2% (the level for Canada and traditional Medicare) could save more than $200 billion annually. In addition, our multipayer system imposes complexity and expense on providers; the Cleveland Clinic has 210 000 000 different prices. Single-source payment could streamline reimbursement—for example, by replacing per patient hospital payment with global budgets and establishing uniform billing and documentation requirements. Hospitals and doctors could save billions on billing-related costs and repurpose those savings to expand care, making universal, first-dollar coverage affordable.

Achieving universal coverage would be costlier under the “public choice” model the ACP co-endorses along with single payer. Multipayer systems incorporating for-profit insurers have not gleaned large administrative savings. For-profit insurers’ overhead is high everywhere, and the persistence of multiple payers would hinder efforts to streamline providers’ billing-related work.

Moreover, real-world experience with 2 public choice models—Medicare’s Advantage program and the Consumer Oriented and Operated Plans (CO-OPs) under the Patient Protection and Affordable Care Act (ACA)—warns that in health insurance competition, public option good guys finish last.

Although no reform achieves perfection, evidence indicates that a well-structured single-payer reform might resolve our nation’s coverage and affordability problems, preserve the choices patients value, and allow doctors to focus on what matters most: caring for our patients.

https://annals.org…

PNHP release:
https://pnhp.org…

Comment:

By Don McCanne, M.D.

Welcome to a bright new day in health care reform.

The American College of Physicians (ACP) is the largest physicians’ organization dedicated to patient care (the AMA has traditionally functioned primarily as a physicians’ guild). “ACP recommends transitioning to a system of universal coverage through either a single payer system, or a public choice to be offered along with regulated private insurance.”

ACP has proffered a large volume of material that presents a multitude of problems with our current expensive but underperforming health care system. They present many options for reform that have been under consideration, but, as mentioned, they single out two for their vision of a better U.S. health care system for all: 1) single payer, or 2) a “public choice” with regulated private insurance.

Included in the AIM supplement is an important paper by Steffie Woolhandler and David Himmelstein. They discuss the clear advantages of a Canadian-style single payer model, but they caution us about the deficiencies of the for-profit insurers that we have in the United States, and the failures of our experimentation with public choice models – CO-OPs and Medicare Advantage. (To understand better the problems with a private plan and public choice approach, you should read not only the full Woolhandler/Himmelstein paper at the link above, but also the voluminous material on this topic at pnhp.org.)

There is much more material in this AIM supplement, especially on delivery reform and addressing social determinants of health, but it is important to not get buried under the reams of material such that you might be distracted from the overriding imperative of ACP’s vision for reform – the pressing need to enact and implement the essential infrastructure on which we can build the rest of reform – a single payer national health program.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

The American College of Physicians’ Endorsement of Single-Payer Reform: A Sea Change for the Medical Profession

By Steffie Woolhandler, M.D., M.P.H. and David U. Himmelstein, M.D.
Annals of Internal Medicine, January 21, 2020

For a century, most U.S. medical organizations opposed national health insurance. The endorsement by the American College of Physicians (ACP) of single-payer reform marks a sea change from this unfortunate tradition (1, 2).

Like their U.S. counterparts in an earlier era, many Canadian physicians feared, and fiercely opposed, single-payer reform. “We were afraid it would destroy the profession . . . that our integrity would be destroyed . . . that the government would intrude on the private doctor–patient relationship,” said E.W. Barootes, who as President of Saskatchewan’s medical association led a 3-week doctors’ strike in 1962 against that province’s new single-payer program (3).

Yet despite a rocky start, most Canadians now embrace their single-payer system. Everyone is covered, and all doctors and hospitals are “in-network.” Health costs, almost identical to U.S. levels in the 1960s, are now about 40% lower, with savings on administration accounting for half the difference (4). Although funding for some aspects of care has, in our view, been squeezed too tightly in Canada, physicians’ incomes have not; Canadian internists’ take-home pay averages about CAD$300 000. Canada’s health outcomes surpass those of the United States, including for such conditions as cystic fibrosis, end-stage renal disease, and type 1 diabetes, whose outcomes reflect quality of care (5–7).

Canada’s generally positive experience is among the strands of evidence underpinning the ACP’s endorsement. A single-payer reform that reduced insurance overhead to 2% (the level for Canada and traditional Medicare) could save more than $200 billion annually. In addition, our multipayer system imposes complexity and expense on providers; the Cleveland Clinic has 210 000 000 different prices (8). Single-source payment could streamline reimbursement—for example, by replacing per patient hospital payment with global budgets and establishing uniform billing and documentation requirements. Hospitals and doctors could save billions on billing-related costs and repurpose those savings to expand care, making universal, first-dollar coverage affordable.

Achieving universal coverage would be costlier under the “public choice” model the ACP co-endorses along with single payer. Multipayer systems incorporating for-profit insurers have not gleaned large administrative savings. For-profit insurers’ overhead is high everywhere (9), and the persistence of multiple payers would hinder efforts to streamline providers’ billing-related work.

Moreover, real-world experience with 2 public choice models—Medicare’s Advantage program and the Consumer Oriented and Operated Plans (CO-OPs) under the Patient Protection and Affordable Care Act (ACA)—warns that in health insurance competition, public option good guys finish last.

Twenty-three CO-OPs offering plans on the ACA exchanges received $2.4 billion in federal start-up loans. Only 4, covering 150 000 enrollees, survive. New York’s defunct CO-OP, like many others, attracted many expensively ill patients, in part because its network—unlike that of other exchange plans—included Memorial Sloan Kettering Cancer Center. Iowa’s CO-OP, which offered lower cost sharing for antiretrovirals than its competitors, reportedly enrolled 98% of all patients with HIV covered by Iowa’s exchange plans. Although the ACA included special funding to compensate CO-OPs for high-risk enrollees, the losses far exceeded what Congress was willing to appropriate.

Small start-ups, such as the CO-OPs, often succumb to deep-pocketed competitors. However, the traditional Medicare program—a large, well-established public option—also is losing out in competition with private (Medicare Advantage) plans, despite their 6-fold higher overhead and 6% higher total costs (after accounting for “cherry picking” and upcoding) (10).

Medicare Advantage plans have flourished, because chicanery trumps efficiency. The Centers for Medicare & Medicaid Services uses patients’ diagnoses to risk adjust its payments to Medicare Advantage plans and minimize incentives for cherry picking. However, insurers game the risk-adjustment formulas by labeling enrollees with new (often clinically insignificant) diagnoses and recruiting lower-cost patients within a diagnostic category, such as minimally symptomatic patients carrying such diagnoses as osteoarthritis, asthma, or congestive heart failure.

Plans also profit by “lemon dropping”—pushing out unprofitably ill enrollees. Imposing high copayments for chemotherapy agents and excluding specialized cancer providers from networks encourages oncology patients to disenroll. Seniors requiring nursing home stays or treatment for new-onset end-stage renal disease have transferred in droves from Medicare Advantage to traditional Medicare (11, 12). Moreover, Medicare Advantage plans that accumulate unprofitably ill seniors can, and do, pull out of entire counties, an option unavailable to their public option competitor.

Private insurers have turned traditional Medicare (like the ACA’s CO-OPs) into a de facto high-risk pool, despite regulations banning cherry picking and lemon dropping. Enforcement of those regulations, already overmatched by insurers’ stratagems, will surely become harder. Google, part owner of Oscar, an insurance start-up, knows who’s playing tennis and who’s buying plus-size dresses and can micro-target marketing accordingly. As some suggest, insurers, like casinos, are profitable because they know the odds of every bet they place and can eject people who are beating the house (13).

Despite drawbacks, public choice reform offers 2 apparent advantages: It avoids confrontation with private insurers and allows individuals to retain their current coverage.

Unfortunately, achieving universal, affordable coverage through public choice would, like single payer, impose painful sacrifices on private insurers. In Germany, an oft-cited example of a universal multipayer system, insurers offering the mandatory coverage are nothing like ours. By law, Germany’s “statutory” insurers must be nonprofit, pay the same fees, charge the same premiums, and contract with every hospital and every doctor. Insurers with low-risk patients must cross-subsidize others, effectively creating a single risk pool. In sum, Germany’s statutory insurers (like Switzerland’s and Holland’s) “are not as a matter of public policy conceived of . . . [or] allowed to function as private businesses” (14); they are more akin to the fiscal intermediaries that process traditional Medicare claims. U.S. insurers would surely fight tooth and nail against such transformation.

Public choice’s second purported advantage may also be illusory. Although surveys indicate that voters value choice, it’s choice of doctor and hospital—not insurer—that they care about.

Although no reform achieves perfection, evidence indicates that a well-structured single-payer reform might resolve our nation’s coverage and affordability problems, preserve the choices patients value, and allow doctors to focus on what matters most: caring for our patients.

Three decades after leading the Saskatchewan strike, Dr. Barootes had changed his view: “Today I support the universal healthcare program…There has been no interference in the decision making between a doctor and his [sic] patient…A politician is more likely to get away with canceling Christmas than he is with canceling Canada’s health insurance program” (15).

References

1. Doherty R, Cooney TG, Mire RD, et al; Health and Public Policy Committee and Medical Practice and Quality Committee of the American College of Physicians. Envisioning a better U.S. health care system for all: a call to action by the American College of Physicians. Ann Intern Med. 2020;172:S3-S6.

2. Crowley R, Daniel H, Cooney TG, et al; Health and Public Policy Committee of the American College of Physicians. Envisioning a better U.S. health care system for all: coverage and cost of care. Ann Intern Med. 2020;172:S7-S32.

3. Nagle P. Tragedy marked Medicare’s first day. Toronto Star. 19 June 1992:A1 and A24.

4. Himmelstein DU, Campbell T, Woolhandler S. Health care administrative costs in the US and Canada, 2017. Ann Intern Med. 2020;172:134-42.

5. Stephenson AL, Sykes J, Stanojevic S, et al. Survival comparison of patients with cystic fibrosis in Canada and the United States: a population-based cohort study. Ann Intern Med. 2017; 166:537-546. CrossRef. PubMed.

6. Guyatt GH, Devereaux P, Lexchin J, et al. A systematic review of studies comparing health outcomes in Canada and the United States. Open Med. 2007;1:e27-36. PubMed.

7. Gaffney A, Christopher A, Katz A, et al. The incidence of diabetic ketoacidosis during “emerging adulthood” in the USA and Canada: a population-based study. J Gen Intern Med. 2019;34:1244-50. CrossRef. PubMed.

8. Cleveland Clinic letter to CMS. Quoted in: Livingston S. Hospitals, insurers urge CMS to abandon plan to force negotiated price disclosure. Modern Healthcare. 30 September 2019. Accessed at www.modernhealthcare.com… on 26 November 2019.

9. Hagenaars LL, Klazinga NS, Mueller M, et al. How and why do countries differ in their governance and financing-related administrative expenditure in health care? An analysis of OECD countries by health care system typology. Int J Health Plann Manage. 2018;33:e263-e278. CrossRef. PubMed.

10. Curto V, Einav L, Finkelstein A, et al. Health care spending and utilization in public and private Medicare. Am Econ J Appl Econ. 2019;11:302-32. CrossRef. PubMed.

11. Rahman M, Keohane L, Trivedi AN, et al. High-cost patients had substantial rates of leaving Medicare Advantage and joining traditional Medicare. Health Aff (Millwood). 2015;34:1675-81. CrossRef. PubMed.

12. Li Q, Trivedi AN, Galarraga O, et al. Medicare Advantage ratings and voluntary disenrollment among patients with end-stage renal disease. Health Aff (Millwood). 2018;37:70-7. CrossRef. PubMed.

13. Ames S. Letter to the editor. New York Times. 1 August 2019:A26

14. Jost TS. The experience of Switzerland and the Netherlands with individual health insurance mandates: a model for the United States? Accessed at http://law2.wlu.edu… on 22 November 2019.

15. Lyons SA. The 1962 battle over Canadian health care: Labor pains. Whole Earth Rev. 1995(Winter):74-81.

https://annals.org…

Doctors prescribe Medicare-for-All: Single payer reform endorsed by America’s largest medical specialty society and recommended in open letter from thousands of physicians

Advocates call the endorsement a “sea change” for the medical profession

Contact: Steffie Woolhandler, M.D., M.P.H., steffie_woolhandler@hms.harvard.edu
Adam Gaffney, M.D., M.P.H., agaffney@cha.harvard.edu
Clare Fauke, Physicians for a National Health Program, clare@pnhp.org

Physicians for a National Health Program (PNHP) today welcomed the American College of Physicians’ (ACP) endorsement of single-payer Medicare for All. The ACP, a national organization of 159,000 internists, is the largest medical specialty society and second-largest physician group in the U.S. after the American Medical Association (AMA). 

The ACP announced its endorsement of Medicare for All in a special supplement to its official journal, the Annals of Internal Medicine, where the group also endorsed a “universal public choice” reform model. 

The ACP endorsement coincides with the publication of an open letter signed by more than 2,000 physicians “prescribing” Medicare for All, an effort organized by advocates separately from the ACP. Among the “prescribers” are towering figures in American medicine, including Dr. Marcia Angell, former editor-in-chief of the New England Journal of Medicine; Dr. Bernard Lown, developer of the defibrillator; Dr. Paul Farmer, infectious disease expert and founder of Partners in Health; and Dr. Mary Bassett, former New York City Health Commissioner. The letter will appear as an advertisement in the New York Times on January 21. 

Along with the ACP’s position paper, the Annals of Internal Medicine published an editorial by PNHP co-founders Drs. Steffie Woolhandler and David Himmelstein. Drs. Woolhandler and Himmelstein, noting that organized medicine had opposed national health insurance for a century, called the ACP’s new position “a sea change for the medical profession.”

The ACP’s endorsement of Medicare for All and the publication of the open letter reflects growing support for single-payer reform among physicians. Recent surveys have found that half of all doctors now favor national health insurance. Last June, the AMA’s House of Delegates only narrowly defeated a resolution that would have rescinded its long-standing opposition to Medicare for All. Under pressure from Medicare for All supporters, the AMA then resigned from the dark money group Partnership for America’s Health Care Future, which opposes single-payer reform. 

“As physicians, we see daily the harm that our fragmented, private-insurance based system does to our patients,” noted Dr. Adam Gaffney, President of PNHP and a pulmonary and critical care physician at Harvard Medical School and the Cambridge Health Alliance. “Patients go without the care they need, and physicians squander time and resources on wasteful billing and clerical tasks. Medicare for All would be a much better way — for patients and doctors both.”  

According to Dr. Woolhandler, a Distinguished Professor at the City University of New York at Hunter College and Lecturer in Medicine at Harvard Medical School, “When we started PNHP, doctors who supported single-payer reform were considered radicals, and reporters likened us to ‘furriers for animal rights’.  Now we’re squarely in the mainstream of the medical profession. More and more doctors have realized – often from talking to our Canadian colleagues – that single payer is the only way to cut insurers’ paperwork and profits that siphon hundreds of billions annually from care in the U.S.” Dr. Woolhandler is a Fellow of the ACP, but not an official spokesperson for that organization.

PNHP is a nonprofit research and education organization whose more than 23,000 members support single-payer Medicare for All reform. PNHP’s physician members have been working for single payer since publication of its policy proposal in the New England Journal of Medicine in 1989.

The following documents are available to credentialed media professionals upon request:

Second-Largest Doctor Group Endorses National Health Insurance (Of Some Kind)

Internal medicine association signals it would support either “Medicare for All” or a strong public option.

By Jonathan Cohn
HuffPost, January 20, 2020

The campaign to create a government-managed, truly universal health care system may have just picked up an important new ally: the nation’s second-largest physician organization.

The American College of Physicians, which represents 159,000 doctors with training in internal medicine, on Monday said the federal government should assert more control over national health spending and guarantee insurance for all Americans, either by covering everybody directly (through what advocates call “Medicare for All”) or by creating a new public program that can compete with private plans (through what’s come to be known as a “public option”).

ACP’s announcement could prove to be a milestone in the century-long quest to make health care a universal right, considering how frequently and effectively physicians have resisted ambitious reforms. And it comes at a time when such reforms are once again a focus of national debate, because so many Americans are still struggling with the cost of medical care and because the two political parties are calling for such radically different responses.

Republicans, led by President Donald Trump, are still trying to repeal or roll back the Affordable Care Act, which dramatically reduced the number of uninsured people and established key principles of universal coverage such as guaranteed insurance for people with preexisting conditions. Insofar as Republicans support new initiatives, they have in mind reforms that would relax or eliminate these regulations on insurance companies and shrink government insurance programs on which tens of millions rely.

Democrats want government to do more than it does today ― by reaching the remaining uninsured, providing everybody with more protection from medical bills, and addressing health care spending more aggressively. Inside the party, the debate is all about whether Medicare for All or the public option is the best way to achieve those goals.

What They Are Saying About Government And Health Care

After more than a year of study and internal deliberations, ACP’s governing boards and policy committees have concluded that either Medicare for All or a strong public option could work, though it doesn’t use those terms. The overriding goal, the organization says, should be to give the government much more sway over health care, like other developed countries have long done, rather than to rely on some combination of patchwork reforms and the free market.

And in a series of articles that appear in the new Annals of Internal Medicine, ACP officials and affiliates make a detailed case for why. The package includes a thorough review of national health systems abroad, along with summaries of what American politicians are now proposing.

“The U.S. health care system is like a chronically ill patient, and ACP is proposing a new prescription,” three of the group’s officials say in the lead essay. “Simple market solutions have been unsuccessful elsewhere, and we do not believe that health care is a commodity.”

ACP, which supported the Affordable Care Act and has fought efforts to repeal it, has always been among the most liberal physician organizations. But this is the first time the organization has formally called for the government to create a new insurance program, be it mandatory or optional, and to exert so much more power over health care spending, according to Robert McLean, an internist and the group’s president.

“We have said in the past, ‘Hey, maybe we need to consider or look at single-payer financing as an option,’ but we didn’t fully come out and boldly endorse it,” McLean told HuffPost. “We are doing that now. This is a really assertive endorsement with much more detail on how this approach has been shown to be effective for these various reasons. … That is new for us.”

What It Means For The 2020 Election

The ACP articles assiduously avoid endorsing any politician or party. But ACP’s positions line up with some well-known advocates.

Sen. Bernie Sanders (I-Vt.) is Medicare for All’s most visible champion, having written the damn bill, as he likes to say, and endorsed it for nearly his entire life in politics. Sen. Elizabeth Warren (D-Mass.) has also endorsed Medicare for All, though she has said she would seek to get there through a two-step process, starting with a law to create a public option.

Other 2020 Democratic presidential candidates ― including former Vice President Joe Biden; former South Bend, Indiana, Mayor Pete Buttigieg; and Sen. Amy Klobuchar (D-Minn.) ― have warned that Medicare for All represents too dramatic a change. They have said they would prefer simply to pass public option reforms, at least for now, although the specific initiatives those candidates have put forward would appear to be less ambitious than what ACP has in mind.

In its review of public option proposals, ACP cited plans from the Center for American Progress and Yale political scientist Jacob Hacker. The closest analogue to those plans is proposed ”Medicare for America” legislation from Reps. Rosa DeLauro (D-Conn.) and Jan Schakowsky (D-Ill.) that would envision, among other things, more federal intervention to control prices.

And that element of the ACP endorsement, the interest in letting government get more involved with the price of health care through either Medicare for All or a public option, may ultimately be the most important part of its endorsement.

How And Why Physician Opinion May Be Shifting

Physicians, like most providers of health care, have a long history of fighting ambitious reforms, going back to the Progressive Era when state medical societies fought the first, embryonic efforts at “compulsory health insurance.” Thirty years later, the American Medical Association, which was and remains the largest U.S. organization representing doctors, led the fight to defeat Harry Truman’s universal coverage plan.

Since that time, however, physician opposition to sweeping health reforms has softened.

The AMA, like the ACP, supported the Affordable Care Act and has opposed efforts to repeal it. Last year, the AMA’s House of Delegates came within a few percentage points of voting to rescind its historic opposition to single-payer schemes like Medicare for All. It also withdrew from the Partnership for America’s Health Care Future, a health industry group that has fought both Medicare for All and the public option.

The evolution of physician sentiment likely reflects a variety of factors, including a generational shift. Older physicians came into the profession with expectations of operating in solo practices or as small groups, with minimal outside interference.

Younger doctors are more accustomed to working in large organizations and in many cases see government as a necessary, even welcome force to counter the influence of insurance companies and guarantee access in a way that private plans do not.

“First, there is widespread recognition of the harm that our health care financing system inflicts on our patients’ health,” said Adam Gaffney, a pulmonology specialist who is president of Physicians for a National Health Program. “But second, there’s also growing recognition of the ways that the system fails physicians too — endless hours glued to the electronic medical record, enormous amounts of time, energy, and resources expended on billing, documentation, and other onerous clerical tasks. We’re recognizing more and more that patients and doctors are in this together.”

What The Endorsement Doesn’t Say

PNHP is a longtime champion of Medicare for All and recruited more than 2,000 doctors to sign an open letter, set to run as an advertisement in The New York Times on Tuesday, endorsing the idea. Together with ACP’s announcement, the letter suggests that Medicare for All is gaining mainstream credibility.

“The fact that the largest medical specialty society in the country explicitly and officially endorsed Medicare for All is a huge deal — even if they also endorsed another option,” Gaffney said.

ACP’s support of both Medicare for All and strong public option reforms comes with warnings that limiting provider payments too aggressively could hurt doctors and hospitals that operate with low margins, ultimately hurting patients. This is no small thing.

Actual legislation to create either a Medicare for All or ambitious public option system could entail limits on provider income that many physicians would find objectionable. Yet without enough control over health spending, the math of reform gets tricky and it’s difficult to deliver the benefits advocates promise.

But though it’s a tough problem to solve, as policy and politics, McLean says more and more physicians understand it’s worth the effort. “We can do better, our patients deserve better,” he said. “No system is perfect but we can get a lot closer than we are.”

https://www.huffpost.com…

Labor should not bargain against itself on Medicare for All

By Dr. Martin Luther King, Jr.
Illinois AFL-CIO Convention, October 1965

“At the turn of the century women earned approximately ten cents an hour, and men were fortunate to receive twenty cents an hour. The average work week was sixty to seventy hours. During the thirties, wages were a secondary issue; to have a job at all was the difference between the agony of starvation and a flicker of life. The nation, now so vigorous, reeled and tottered almost to total collapse. The labor movement was the principal force that transformed misery and despair into hope and progress. Out of its bold struggles, economic and social reform gave birth to unemployment insurance, old age pensions, government relief for the destitute, and above all new wage levels that meant not mere survival, but a tolerable life. The captains of industry did not lead this transformation; they resisted it until they were overcome. When in the thirties the wave of union organization crested over our nation, it carried to secure shores not only itself but the whole society.”

https://www.afscme.org…

The Labor Movement Must Fight for Medicare for All — Not Employer-Based Plans

By Mark Dudzic
Jacobin, January 17, 2020

Unions have been at the forefront of almost every progressive policy advance for a century. So why are AFL-CIO president Richard Trumka and American Federation of Teachers president Randi Weingarten denouncing Medicare for All by parroting talking points crafted by health care industry lobbyists?

The spectacle of national labor leaders defending a system that is the biggest cause of strikes, lockouts, and concession bargaining is mind-boggling. For an entire generation now, unions in the United States have traded wages and other benefits for shrinking coverage by employer-provided health insurance (or for the ever-increasing employer contributions required to maintain similarly shrinking benefits from union-sponsored health and welfare funds).

Like it or not, employment-based health care is simply unsustainable. The Milliman Medical Index reports that the 2018 total health care costs for a family of four with decent employment-based coverage exceed $28,000 per year. That is $14 per hour worked for a full-time employee — almost twice the federal minimum wage. The employer pays $15,000 of that, and $13,000 is paid by the worker through co-insurance, out-of-pocket charges, co-pays, deductibles, and all the other myriad ways that the medical-industrial complex extracts money from our pockets. These amounts already exceed the average hourly wage in food services and retail occupations and are increasing two times faster than the rate of wage increases for all workers, putting them on track to exceed average wages in manufacturing and other core industries within the next decade. The percentage of total health care costs paid by the worker has gone up nearly every year since it was first tracked in the 1990s.

Employment-based health care is also a major driver of wage stagnation. Every worker trades wages for health care.

And even the best employment-based health care is not there when we need it the most: when we lose our jobs, change jobs, go on strike, or struggle with long-term illness.

Medicare for All would take health care off the bargaining table and increase union bargaining leverage in nearly every negotiation. It would allow union-sponsored health and welfare funds the opportunity to reallocate revenues currently sunk into the world’s most expensive and inefficient health care system. Savings could be applied to new “union advantage” programs such as enhanced disability benefits, supplemental unemployment benefits, tuition and training programs, legal services, child- and eldercare, and others. Some revenues could also potentially be reallocated to shore up endangered pension plans.

Medicare for All would also provide better coverage than any employment-based plan in existence today. Opponents of Medicare for All often conflate the constricted benefits offered under today’s Medicare program after more than fifty years of underfunding and privatization attempts with the greatly expanded and improved benefits proposed under Medicare for All – HR 1384 — Rep. Pramila Jayapal’s Medicare for All Bill.

I challenge any advocate of employment-based coverage to show me a plan that matches the level of comprehensive services, freedom of choice, and absence of out-of-pocket costs proposed by HR 1384.

Union members should be justly proud of the long battle that unions have waged to protect their right to access affordable, quality health care, and the Labor Campaign for Single Payer stands in solidarity with all workers everywhere who fight to protect these hard-won gains. But our movement is at an historic juncture. Now is not the time to muddy the waters or bargain against ourselves. We need labor to lead as we work to make this a key issue in the 2020 elections and to hold politicians accountable in 2021 and beyond. And we have the right to expect that the union leaders who represent us and the politicians that we support will do more than just parrot the talking points crafted by health care industry lobbyists.

Mark Dudzic is coordinator of the Labor Campaign for Single Payer.

https://jacobinmag.com…

Comment:

By Don McCanne, M.D.

On this day we should consider what Martin Luther King, Jr. would have to say about the fact that workers’ health care benefits are not universal, and, for those who have them, that they have displaced wages that otherwise could help many more achieve the American Dream that King believed should be freely available to all.

Our brothers and sisters in the unions should join with the rest of us in the campaign to see that they and all others can be assured that health care will always be there when needed without having to sacrifice other elements of the American Dream. We can have it all.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Major Doctors’ Group Calls for US to Assure Coverage for All

By The Associated Press

WASHINGTON — With health care an election-year priority, a major doctors’ organization on Monday called for sweeping government action to guarantee coverage for all, reduce costs and improve the basic well-being of Americans.

Declaring that the U.S. health care system “is ill and needs a bold new prescription,” the American College of Physicians endorsed either of the two general approaches being debated by Democratic presidential candidates: a government-run “single-payer” system that would cover everyone, or a new “public option” government plan that would offer comprehensive coverage to compete with private insurance.

But the group’s president, Dr. Robert McLean, said his organization is not signing on to specific proposals, such as Vermont Sen. Bernie Sanders’ “Medicare for All” bill or former Vice President Joe Biden’s combination of a public option, improvements to “Obamacare” and deputizing Medicare to negotiate prescription drug prices.

Instead, he said, the group arrived at its recommendations by analyzing available evidence on what might best address the nation’s problems with high costs, gaps in insurance coverage, uneven quality, and mind-boggling complexity.

“We think there is a realistic chance that either of these two approaches could get us to a much, much better place,” said McLean. “It is not looking to be partisan, but I would say it is unavoidably political because policy is political.”

One problem Sanders’ plan poses for McLean’s group is its reliance on Medicare rates, which are well below what private insurance pays.

Although less well known than the American Medical Association, the group represents doctors who are critical in the health care system. Its 141,000 members in the U.S. are internal medicine specialists, focusing on adults from Medicare recipients to people in their working years covered by employer plans.

Doctors have traditionally been central in the nation’s health care debates. The AMA’s approval helped President Barack Obama pass the Affordable Care Act, and physicians’ groups were a core element of the coalition that blocked President Donald Trump’s efforts to repeal it.

About half of U.S. adults support a national Medicare for All plan, according to recent polling by the nonpartisan Kaiser Family Foundation. A public option garners more support, with about two-thirds backing it. Both ideas face strong opposition from health insurance companies and other industry players.

McLean said his group is seeking comprehensive solutions that address coverage, cost, quality and complexity. Tackling one area and not the others won’t suffice, he said. He said Republican proposals to encourage patients to be better consumers of health care fall short because they don’t address coverage gaps or guarantee comprehensive benefits.

His organization’s framework was outlined in a series of papers published in its journal, Annals of Internal Medicine.

https://www.nytimes.com…

The Labor Movement Must Fight for Medicare for All — Not Employer-Based Plans

Unions have been at the forefront of almost every progressive policy advance for a century. So why are AFL-CIO president Richard Trumka and American Federation of Teachers president Randi Weingarten denouncing Medicare for All by parroting talking points crafted by health care industry lobbyists?

By Mark Dudzic
Jacobin, January 17, 2020

At the June 2019 House Ways and Means Committee Hearing on Medicare for All, Texas Republican Kevin Murphy lamented, “That great health care plan that your union negotiated for you? It’s gone. Banned under Medicare for All.”A right-wing congressman with a 7 percent lifetime voting score from the AFL-CIO crying crocodile tears for great union health care plans can be easily dismissed as just another absurdity of the increasingly dysfunctional American political system. But when Joe “the workingman’s friend” Biden repeats the charge almost word for word and when AFL-CIO president Rich Trumka insists — on Fox News no less! — that “if there isn’t some way to have our plans integrated into the system, then we would not support [Medicare for All],” something is certainly happening out there. Talking points, after all, don’t just come out of thin air. They are carefully crafted and disseminated by a coterie of lobbyists and publicists often working on behalf of shadowy corporate and political interests.

Trumka was shortly joined by American Federation of Teachers (AFT) president Randi Weingarten, who just six months earlier had delivered a full-throated endorsement of the Medicare for All Act at a rally celebrating its introduction. In her September 23, 2019, Politico article, Weingarten walked back that support in favor of a fictitious system in which “employer-based insurance would be allowed to exist to the extent that plans met or exceeded the standards set by the Medicare plan.” Such a system “would allow people who like their current employer-based plan — which seven in ten Americans claim to (although it’s likely they like their doctor, not the plan itself) — to keep it, allow for a gradual transition from one plan to another when necessary, and effectively improve on the model originally created by the Affordable Care Act.”

The spectacle of national labor leaders defending a system that is the biggest cause of strikes, lockouts, and concession bargaining is mind-boggling. For an entire generation now, unions in the United States have traded wages and other benefits for shrinking coverage by employer-provided health insurance (or for the ever-increasing employer contributions required to maintain similarly shrinking benefits from union-sponsored health and welfare funds).

An Accident of History

The US health care system’s linkage to employment is unique among industrialized countries. It emerged as an accident of history in the years just following World War II when Roosevelt’s promise to enact a “Second Bill of Rights” in the postwar period was stopped dead in its tracks by resurgent capital. In 1946, the American Medical Association led the fight to defeat the Wagner-Murray-Dingell Bill that would have created a publicly funded national health insurance program. The following year saw the passage of the Taft-Hartley Act, which, combined with an orgy of anticommunism and race-baiting, set the powerful postwar labor movement into a long retreat.

Unable to expand the social wage by treating public goods such as health care as a basic right available to all, labor helped craft a “second-best solution” of making access to health care a benefit linked to employment. Corporate America piled on and offered elaborate benefits to recruit and retain employees and to keep unions out. This system was flawed from the beginning. It created tiers of coverage that reinforced employment-based racial and gender disparities and massive amounts of “churn” that disrupted continuity of care for even the best insured. Particularly after the expansion of for-profit health insurance and health care providers beginning in the 1970s, more and more administrative inefficiency was built into the system to facilitate profit-taking, until, by the early twenty-first century, the US health care system was twice as expensive as the OECD average.

Nonetheless, in the post-World War II period of high union density and employment stability, many unions were able to negotiate a robust “private welfare state” that provided health care security for tens of millions of working-class Americans. These benefits were almost never handed to workers. Unions had to wage long and unremitting fights to expand and defend employer-based health care. By the 1980s, almost every contract negotiation was faced with employer demands for reductions in coverage and transfer of costs from the employer to the worker. Nonunion workers fared even worse as they were forced to accept whatever the employer offered. And, unlike attempts to cut social insurance benefits like Social Security or Medicare that almost always fail due to massive popular opposition, cuts to employment-based health care benefits take place company by company under cover of night and arouse little or no popular opposition. Today, even those few union members who have been able to preserve good benefits find themselves as islands in a sea of inadequate and precarious health care coverage.

A System in Crisis

Like it or not, employment-based health care is simply unsustainable. The Milliman Medical Index reports that the 2018 total health care costs for a family of four with decent employment-based coverage exceed $28,000 per year. That is $14 per hour worked for a full-time employee — almost twice the federal minimum wage. The employer pays $15,000 of that, and $13,000 is paid by the worker through co-insurance, out-of-pocket charges, co-pays, deductibles, and all the other myriad ways that the medical-industrial complex extracts money from our pockets. These amounts already exceed the average hourly wage in food services and retail occupations and are increasing two times faster than the rate of wage increases for all workers, putting them on track to exceed average wages in manufacturing and other core industries within the next decade. The percentage of total health care costs paid by the worker has gone up nearly every year since it was first tracked in the 1990s. Employment-based health care is coming up upon the limits of Stein’s Law, formulated by economist Herbert Stein in 1985: “If something can’t go on forever, it will stop.”

Employment-based health care is also a major driver of wage stagnation. Every worker trades wages for health care. A recent Gallup poll found that 61 percent of Americans would be willing to trade 10 percent of future wage increases for a guarantee that their health care costs would not go up for five years. This puts workers and their unions at a huge bargaining disadvantage and goes a long way toward explaining why wages continue to stagnate at a time of low unemployment and growing corporate profits.

And even the best employment-based health care is not there when we need it the most: when we lose our jobs, change jobs, go on strike, or struggle with long-term illness.

What was once a source of pride in the “union advantage” has become an anchor around the necks of the US working class. No union leader in their right mind can conjure a scenario where the system of employment-based health care could be stabilized in ways that could provide sustainable health care security for workers and their families. That is why unions representing a majority of organized workers now support HR 1384 — The Medicare for All Act of 2019 and why the AFL-CIO at its 2017 convention unanimously voted to support policies to “move expeditiously to a single-payer Medicare for All system.”

The Medicare for All Solution

Medicare for All would take health care off the bargaining table and increase union bargaining leverage in nearly every negotiation. It would allow union-sponsored health and welfare funds the opportunity to reallocate revenues currently sunk into the world’s most expensive and inefficient health care system. Savings could be applied to new “union advantage” programs such as enhanced disability benefits, supplemental unemployment benefits, tuition and training programs, legal services, child- and eldercare, and others. Some revenues could also potentially be reallocated to shore up endangered pension plans.

Medicare for All would also provide better coverage than any employment-based plan in existence today. Opponents of Medicare for All often conflate the constricted benefits offered under today’s Medicare program after more than fifty years of underfunding and privatization attempts with the greatly expanded and improved benefits proposed under Medicare for All. HR 1384 — Rep. Pramila Jayapal’s Medicare for All Bill with 119 cosponsors — proposes to cover the following benefits without a single co-pay, deductible, or other out-of-pocket cost:

Hospital services, including inpatient and outpatient hospital care, including twenty-four-hour-a-day emergency services and inpatient prescription drugs. (2) Ambulatory patient services. (3) Primary and preventive services, including chronic disease management. (4) Prescription drugs and medical devices, including outpatient prescription drugs, medical devices, and biological products. (5) Mental health and substance abuse treatment services, including inpatient care. (6) Laboratory and diagnostic services. (7) Comprehensive reproductive, maternity, and newborn care. (8) Pediatrics. (9) Oral health, audiology, and vision services. (10) Rehabilitative and habilitative services and devices. (11) Emergency services and transportation. (12) Early and periodic screening, diagnostic, and treatment services, as described in sections 1902(a)(10)(A), 1902(a)(43), 1905(a)(4)(B), and 1905(r) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A); 1396a(a)(43); 1396d(a)(4)(B); 1396d(r)). (13) Necessary transportation to receive health care services for persons with disabilities or low-income individuals (as determined by the Secretary). (14) Long-term care services and support (as described in section 204).

By comparison, the highly touted federal employees’ health benefit plan merely offers the choice of a number of fairly comprehensive private insurance products with the typical array of co-pays, deductibles, and narrow networks. For all of this, federal employees must kick in 28 percent of the weighted average premium for all plans.

Arguably, union employees working for the City of New York might have some of the bestv coverage of any working-class American. They can get fully employer-paid coverage in the default Emblem Health/HIP plan which has almost no co-pays or deductibles (workers may also choose other private insurance plans that do require employee contributions). They also receive generous dental, optical, and prescription coverage. But even here, workers must use a narrow provider network or face substantial co-pays, and the plan falls far short of HR 1384 in its coverage of long-term care, disability services, and community and home-based care. Moreover, every contract negotiation is held hostage to the imperative to hold on to these extraordinary benefits at almost any cost. I challenge any advocate of employment-based coverage to show me a plan that matches the level of comprehensive services, freedom of choice, and absence of out-of-pocket costs proposed by HR 1384. 

Like global warming, the case for replacing our dysfunctional, multi-payer, for-profit health care system with a publicly funded, universal system with a single standard of care for all is so compelling that it has reached the level of scientific fact. Nonetheless, too many national labor leaders continue to sing the praises of employment-based health care benefits, while too many others give merely rhetorical support for Medicare for All — passing resolutions at conferences and conventions to please union activists while continuing to devote the bulk of their union’s mobilizing and legislative efforts to support for incremental and defensive policy fixes. Only a few national unions have begun to commit the kind of resources and organizing capacity that will be needed to defeat the concentrated political and economic power of the medical-industrial complex.

Union Backpedaling

As momentum for Medicare for All builds, we are witnessing more backpedaling within the labor movement. And not all of it is confined to national labor leaders (though it certainly is more pronounced at that level). In New York, a single-payer-style state bill — NY Health — has twice passed the State Assembly and is edging toward passage in the State Senate backed by a growing popular movement. While the bill does have considerable labor support, including from the state’s powerful hospital workers and nurses’ unions, a significant section of the labor movement has gone into open opposition. In June of 2018, James Cahill, the president of the New York State Building and Construction Trades Council, joined the CEO of the Business Council pf New York State in co-authoring an op-ed in Crain’s New York Business opposing the bill and “government-run health care.”

Taken by itself, this expression might be dismissed as another sign of the class collaborationism and conservatism than infects significant sections of the building trades. But they were joined by a number of other unions, including the 380,000-member Municipal Labor Council — whose affiliates include a number of “progressive unions” — which told Politico that they “dread the impact of the single-payer proposal in Albany.” It is true that, unlike national proposals, state-level single-payer-style plans are notoriously complex to design and difficult to fund. But this hostility goes beyond having legitimate questions about implementation. The fact that major sectors of the labor movement refuse to engage in an effort to make health care a birthright in a state with near-Canadian levels of union density is profoundly unsettling for those of us who believe that, in order to succeed, labor must be in the forefront of the fight to win Medicare for All.

So what is driving this opposition? Perversely, in New York some of it derives from precisely these high levels of union density. Unions still think they have a seat at the table and may sincerely believe that they can bargain better and more secure benefits that would not be subject to the precariousness of annual state budget debates. This parochial perspective ignores the reality that New York unions are only one election or economic downturn away from catastrophe. They only need to look across the Hudson to see what anti-union Governor Chris Christie did to New Jersey public sector workers’ ability to bargain for health care during his administration (aided and abetted, I would add, by Democratic political elements associated with some of the most politically influential building trades locals).

Putting aside the idiosyncrasies of New York labor politics, many union leaders may also believe that “the members aren’t ready” to support Medicare for All. Loss aversion plays a central part in shaping that belief. Behavioral scientists have observed that people are much more likely to be motivated by the fear of losing something they have than by the prospect of gaining something they want. Fear of loss of health insurance is a major driver of working-class insecurity in the United States. It is no surprise, then, that the lobbyists and publicists working on behalf of the medical-industrial complex would focus on this theme in their effort to scare the American people away from a just health care system. Some of that fear has infected union members. The failure to confront such fears, of course, is a classic mistake that anyone who’s ever been through an organizing campaign would know to avoid. The real problem here is union leaders who fail to articulate a vision of working-class politics that will inspire and unify union members.

These concerns are compounded in the wake of the Janus decision, which has made public sector union membership completely voluntary. Many public sector union leaders are convinced that the best way to persuade workers to maintain their union membership is to show how the union adds value in their workplace. Negotiating health insurance benefits that are much better than those enjoyed by most other working-class Americans is one way to do that without necessarily having to engage in risky internal organizing and mobilizing activities that may end up undermining existing union leadership.

Some unions have raised the specter of job loss as a reason to oppose Medicare for All. This is a legitimate concern. Studies have shown that close to two million workers will be displaced due to the administrative efficiencies of Medicare for All. While both the House and Senate bills provide funding for transition benefits for these workers, decades of working-class experience with bearing the cost of environmental-, trade-, and automation-related job losses have made workers rightly skeptical of any promises of economic security. The Labor Campaign for Single Payer has called for centering these worker concerns in the political and legislative battles to come and has warned that a failure to do so will give our opponents the opportunity to divide workers against each other.

Unions have also expressed concern that employers would reap the benefit of all the sunken wages that unions have agreed to divert to maintain decent private insurance coverage. This would assume that, in the transition to Medicare for All, unions would be so weak and/or incompetent that they would be unable to recapture those already bargained monies. Even assuming a worst-case scenario, this objection is tantamount to someone opposing student loan forgiveness because they’ve already paid off a chunk of their loan.

There are also several institutional factors that can work to discourage union support for Medicare for All. Union health and welfare funds often have substantial brick-and-mortar investments in union facilities and provide a range of member services that often strengthen members’ union identification. A vast web of relationships also exists between union officials and health care vendors, brokers, intermediaries, attorneys, and various hangers-on. Some are outright corrupt. Others are more benign, such as the insurance company that subsidizes their stewards training or the broker that they can call to get a member rapid placement in a substance abuse treatment program. Nonetheless, all these relationships are ultimately corrupting because of the entailments of obligation that they engender with players who have a vested interest in maintaining the status quo.

However, the biggest factor by far that drives union opposition to Medicare for All is many union leaders’ fear of disrupting their political relationships. Unions are multi-issue organizations, and many of their bargaining and organizing goals are impacted by local and national political concerns. The ascendancy of a right-wing, anti-labor political regime is an existential threat to the institutional labor movement as well as to a wide range of working-class concerns. Unions routinely pull their punches in the interest of maintaining these relationships. For example, with a few notable exceptions, unions were nowhere to be seen in the 2016 Democratic Party platform fight around Medicare for All and other issues of central concern to the working class led by Bernie Sanders supporters. Enmeshed in the two-party system and with diminishing leverage, unions often see no alternative. Every election cycle is the most important one in the history of the nation, and, whatever the outcome, unions nearly always emerge weaker from each round.

This political practice engenders cynicism and apathy among union members and provides the space for right-wing populism to take root within some sections of the working class. The past decade has seen the reemergence of a refreshing political independence in some of the most dynamic sections of the labor movement. By challenging the status quo, they have inspired their members to take risks and have forced important concessions from the political establishment. Medicare for All, because it seeks to reclaim a public good on behalf of the entire working class, can be an important wedge issue in building out an independent working-class politics.

The Path Forward

Our experience in the Labor Campaign for Single Payer has shown that support for our cause is greatest at the front lines of the labor movement, where leaders and staffers have to deal on a daily basis with the consequences of private, for-profit health care. Our goal has been to work with those activists as they find ways to constructively engage with national labor leadership. After AFL-CIO president Trumka’s Labor Day appearance on Fox News, for example, we asked unionists to write him to remind him that support for Medicare for All is the official policy of America’s largest labor federation. Over 2,500 people answered the call. These are the leaders who will drive change in our movement and ultimately bring the formidable political and mobilization resources of institutional labor into the battle to make health care a right for everyone in America. When that happens, we will win.

As Washington State Labor Council president Larry Brown stated, “Unions do not serve their members well by trying to circle the wagons around an unsustainable model of employment-based health care.” Our labor movement will thrive when we express the aspirations of all workers and speak on behalf of the entire working class.

Union members should be justly proud of the long battle that unions have waged to protect their right to access affordable, quality health care, and the Labor Campaign for Single Payer stands in solidarity with all workers everywhere who fight to protect these hard-won gains. But our movement is at an historic juncture. Now is not the time to muddy the waters or bargain against ourselves. We need labor to lead as we work to make this a key issue in the 2020 elections and to hold politicians accountable in 2021 and beyond. And we have the right to expect that the union leaders who represent us and the politicians that we support will do more than just parrot the talking points crafted by health care industry lobbyists.

Mark Dudzic is coordinator of the Labor Campaign for Single Payer.

https://jacobinmag.com…

Health care inflation? It’s the insurer administrative costs, stupid.

Energy and Health Insurance Drive Inflation Higher in October

By Dean Baker
Center for Economic and Policy Research, November 13, 2019

Over the year, the overall CPI is up 1.8 percent, while the core index is up 2.3 percent. There is some modest evidence of accelerating inflation in the core CPI.

The major item driving the core inflation rate higher is medical care, with the index rising by 4.3 percent over the last year and at an annualized rate of 6.6 percent, comparing the last three months with the prior three months. This index accounts for more than 11.0 percent of the core CPI.

Within the medical care index, by far the biggest problem is health insurance. This index has risen 20.1 percent over the last year and at a 22.9 percent rate, comparing the last three months with the prior three. It is important to remember that this is just the administrative costs and profits of insurers, this index is not measuring premiums.

The index for hospital and related services is also rising rapidly, increasing by 3.4 percent over the last year and rising at a 7.8 percent annual rate, comparing the last three months with the prior three months. The rapid inflation in this sector likely reflects increased consolidation in the industry. By contrast, the index for professional medical services rose by just 0.1 percent in October and is up 1.6 percent over the last year.

Inflation in most other sectors is well contained.

Overall, this report shows that inflation remains well-contained almost everywhere, with the major exception of the health care sector.

http://cepr.net…

Comment:

By Don McCanne, M.D.

Everyone is concerned about health care costs, except maybe the insurers. We continue to debate what to do about it. This report should give us some guidance.

Currently inflation is well contained, except in medical care. Professional medical services are not contributing to health care inflation. But because of consolidation in the industry, hospital and related services are contributing somewhat to the increase in the medical care index.

But by far the biggest problem is health insurance. This index has risen over 20 percent in the past year, and that is just for the administrative costs and profits of the insurers, not for premiums.

So what solutions are we debating? Conservatives want market solutions, but they have been unable to come up with any proposals that would not make the situation worse. Moderates want to add to the current system a public option Medicare for Some that would preserve the role of the private insurers who are largely responsible for these inflationary administrative costs and profits. Only those advocating for the single payer model of an improved Medicare for All are supporting a proposal that would eliminate most of these administrative excesses and their unmerited profits.

The perpetual delay in enacting and implementing single payer Medicare for All has wasted trillions of dollars that we could have recovered over the past couple of decades. Are we going to continue with inaction while we have these silly debates over Medicare for All, Medicare for Some, or Medicare for None? Too many are experiencing preventable financial hardship, physical suffering, and even death. Shame on us!

For those who need a reminder of what we could have:

Landmark administrative waste study updated:
https://pnhp.org…

Projected costs of single payer in the United States:
https://pnhp.org…

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