By Tara Straw
Health Affairs Blog, December 3, 2019

The Affordable Care Act (ACA) extended health coverage to more than 20 million people and strengthened consumer protections for millions more, but it didn’t dramatically change employer-sponsored coverage, the primary source of private health insurance. Employer coverage often works well, allowing many people to enroll in comprehensive health benefits using employer contributions that make premiums affordable. But compared to middle and upper-income employees, low-income workers are often offered less robust coverage, get less employer help with their premiums, and must pay a greater share of their income toward health care costs. Among workers with job-based coverage, those with income below 200 percent of the poverty line spend 14 percent of their income on premiums and out-of-pocket costs, on average. That’s far more than people between 200 and 400 percent of poverty, who spend 7.9 percent of their income, and people over 400 percent of poverty, who spend only 4.5 percent.

Some low-income workers are actually worse off with an offer of employer-sponsored coverage than without one because it locks them out of premium tax credit (PTC) eligibility in the ACA’s health insurance Marketplaces, a prohibition known as the “firewall.”

Under the ACA, the worker’s share of the employee-only premium must not exceed 9.86 percent of family income (in 2019), irrespective of the cost of family coverage, and the plan must cover at least 60 percent of expected medical costs. When an employer’s coverage offer meets that low federal bar, the ACA’s firewall provision makes low-income workers and their family members ineligible to receive a PTC for Marketplace coverage. However, employer coverage that meets the ACA standard may be more expensive and less comprehensive than Marketplace coverage. For example, under the ACA standard, a worker making $18,000 (about 150 percent of poverty) could pay up to nearly $1,800 toward premiums for single coverage in an employer plan. But if allowed to purchase a benchmark Marketplace plan, the worker’s expected contribution, net of the PTC, would be less than $750 (4.15 percent of income in 2019).

Out-of-pocket costs for low-income workers also can be much higher in a typical employer plan than in the Marketplace, after accounting for income-based cost-sharing reductions. To enable more low-income workers to purchase affordable coverage, policymakers should consider eliminating, modifying, or working around the firewall, as well as more far-reaching changes.

Eliminating The Firewall

Fixing The “Family Glitch”

Raising the Bar for Employer-Sponsored Coverage

• Requiring Employers to Pay a Higher Share
• Boosting the Value of Group Plans

Helping Workers Navigate The Options

Modifying The Employer Mandate

These options are discussed in greater detail in a Center on Budget and Policy Priorities policy analysis.

https://www.healthaffairs.org…

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“Trapped by the Firewall: Policy Changes Are Needed to Improve Health Coverage for Low-Income Workers”

By Tara Straw
Center on Budget and Policy Priorities

For a more comprehensive report on this topic (highly recommended):

https://www.cbpp.org…

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Comment:

By Don McCanne, M.D.

When the policy community was designing the Affordable Care Act, you would think that they would have paid particular attention to the design of health care coverage for low-income workers and their families. In fact, the system does not work very well for far too many of them.

Tara Straw describes some flawed design features and then suggests several possibilities to improve coverage. Most of the recommendations have tradeoffs. More importantly, in the overall picture, they are only minor tweaks to our highly dysfunctional health care financing system. Yesterday’s Quote of the Day on the public option listed major structural problems with our health care financing system, none of which would be corrected by a public option, nor would they be corrected by merely tweaking the Affordable Care Act.

Many of the politicians and members of the media are now parroting the meme that people who want their private plans should be able to keep them. That means keeping the horrendous injustices built into our highly flawed health care financing system.

For a reminder of what those flaws are that would persist unless we enacted and implemented a single payer model of an improved Medicare for all, use the following link:

https://pnhp.org…

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

By Margot Sanger-Katz
The New York Times, December 3, 2019

The single-payer health plans proposed by Senators Bernie Sanders and Elizabeth Warren are often assailed as being too disruptive. A government plan for everyone, the argument goes, would mean that tens of millions of Americans would have to give up health insurance they like.

Democratic presidential candidates with more moderate brands have their own proposal: a “public option” that would preserve the current private insurance market, while giving people the opportunity to choose government insurance.

A public option would be less disruptive than a plan that instantly eliminated private insurance. But a public option that is inexpensive and attractive could shake up the private market and also wind up erasing some current insurance arrangements. Conversely, a public option that is expensive and unattractive might not do much good at all.

A public option would cover a smaller population at first, and might have to negotiate with hospitals for good deals, just as other insurance companies do. In those circumstances, several economists said, the public option might look a lot like existing insurance: pretty expensive, and covering a limited set of doctors and hospitals.

“What would happen?” said Sherry Glied, the dean of the N.Y.U. Wagner Graduate School of Public Service, and a former health official in the Obama administration. “Almost nothing.” Ms. Glied said that the public nature of the plan, alone, would not do much to distinguish it from private offerings.

Many of the candidates have been vague on key details, like whether the public-option plan would pay health care providers Medicare prices or some other price. They have also been unclear about whether the government itself would offer the public option, or whether it would allow private carriers to operate it.

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NYT Reader Comment:

By Don McCanne, M.D.

The worst feature of the public option is that it leaves in place our highly dysfunctional, fragmented system of financing health care which is largely responsible for our very high health care costs through profound administrative waste and inappropriately high pricing.

Merely adding a public option will not repair these fundamental defects in our financing system but would only add one more player to the egregiously wasteful administrative burden.

Switching to a single payer model of Medicare for All would recover hundreds of billions of dollars in administrative waste while also increasing savings through publicly administered pricing (e.g., lowering excessive drug prices).

Also, public financing of the universal risk pool through equitable progressive taxes would finally make health care affordable for each of us. Plus it returns choice to the patients of physicians and hospitals instead of the choice of restrictive health plans.

Tinkering with a public option totally fails to address the actual monumental problems with our health care financing that are causing us so much grief.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Before we decide whether or not a public option health insurance choice is a good idea, we should define the problems with our current system of financing health care that need to be addressed.

• Our system is outrageously expensive, at twice the average per capita costs of other nations
• Our administratively complex, dysfunctional multipayer system of financing health care wastes about $500 billion per year which would be recoverable under a single payer model
• The combination of insurance premiums, deductibles and other cost sharing creates financial hardships and makes health care truly unaffordable for too many individuals and families
• The very high costs of health care now exceed the ability of even middle-income families to meet their proportionate share of costs of plans in which they may be enrolled, at the same time that income and wealth inequality have left too many unable to meet the costs of basic needs – a problem that requires equitable funding (progressive taxes)
• Even with basic guaranteed benefits, too many plans leave out coverage for important essential health care services and products
• Pharmaceuticals remain outrageously priced, often impairing access to essential medications
• Most plans use restricted provider networks, limiting choice of physicians and hospitals, while assessing penalties for out-of-network care
• Changing eligibility for various insurance programs based on employment or income or residence or age is disruptive to health care

A well designed single payer model of Medicare for All would correct all of these serious deficiencies in our current health care financing system. Which of these defects would a public option correct? None of them!

So what defect in our financing system would a public option correct? Primarily it would provide one more choice in the market of individual private plans, which didn’t seem to be a problem that was looking for a solution, especially when the optimal solution would provide a single, comprehensive plan for everyone.

The media tell us that polls say that we would rather have the choice of keeping what we have or choosing a Medicare-like option (which is not at all like Medicare) instead of everyone being forced into a single, government-run Medicare for All program. But how many of the respondents are taking into consideration the current health financing deficiencies listed above when they answer the questions posed? Almost none.

Let’s write the poll question they should ask: Would you prefer to continue our current system characterized by (list all of the defects above) with the option of being able to buy another similar individual insurance plan except that it is run by the government, or would you prefer to have automatic comprehensive coverage for life paid for with taxes that you can afford? Oops, lost them one-third of the way through that list. It’s complicated, but the public is being trained to respond with the meme, “I’d rather have the right to choose Medicare if I want it,” not realizing that it’s Faux Medicare they are choosing.

Education. Coalitions. Education. Grassroots efforts. Education. Education.

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

By Roxanne Liu and Brenda Goh
Physician’s Weekly, Reuters, November 30, 2019

China will use its national drug bulk-buy scheme to lower the price of drugs currently sold at higher prices compared with other markets, it said in an official statement.

The move could force international drugmakers to further cut prices and enable copycat medicines to replace imported off-patent brands at faster pace.

Many branded versions of drugs are currently more expensive in China than in other major markets. They could now be subjected to a centralized procurement program where manufacturers will have to go through a bidding process to get the right to supply drugs to public hospitals, the National Health Commission said in a document published on late Friday.

The bulk-buy program, which currently covers 25 types of medicines, allows no more than three successful bidders access to China’s public hospitals, where most Chinese people buy their drugs.

The program caused the price of some drugs to plunge more than 90% when it was introduced last year in some cities, state news agency Xinhua said.

In the first round of nationwide implement of the program, in September, multinationals including Sanofi and Eli Lilly managed to cut some prices low enough to levels close to those offered by local generic makers.

Beijing will strengthen its monitoring of overseas drug market and collect global prices for imported medicines, Friday’s guideline said.

The government is leveraging its large patient population to push non-domestic drugs companies to cut prices to their lowest level globally.

Most foreign drugmakers offered Beijing the lowest prices globally in a recent round of negotiations in order to get some of their new products included in national insurance program, a move that will help them gain access to more patients in less-affluent cities, officials said on Thursday.

https://www.physiciansweekly.com…

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Comment:

By Don McCanne, M.D.

When the marketplace fails the people, and the government has remedies that could correct the deficiencies in the markets to benefit the people, then the government should step in. Outrageous pricing of drugs and of the services of the pharmacy benefit managers is a prime example of market failure.

Right now there is a debate in Congress over taking the feeble step of importing drugs into the United States from Canada in order to take advantage of their generally lower drug prices. The population in California is greater than that of all of Canada. How is it logical that Canada should be a major supplier of drugs throughout the United States? Wouldn’t that be as illogical as sending all drugs to California, having them repriced and then redistributed throughout the United States? Neither well functioning markets nor well functioning public agencies would promote such a ridiculous scheme.

China has a drug pricing problem to which the pharmaceutical firms have not been adequately responsive. Their marketplace is not working for drugs. So what do they propose? They intend to use bulk purchasing through its public agencies. In response, some firms are already lowering their prices to a level that will allow them to bypass the bidding process. The inevitable result is that market prices will be more fair for the buyer and yet still high enough to ensure enough profits to maintain the viability of the pharmaceutical firms.

So what did we do in the United States? Congress specifically prohibited Medicare from negotiating appropriate prices for drugs in the Medicare Part D drug program. They left it to the market through our highly dysfunctional private insurance industry in the form of pharmacy benefit managers – a classic failure of market dynamics.

We can fix this. In fact, a well designed single payer model of Medicare for All would do precisely that – fair prices in a system that is equitably funded so that everyone can receive the medications that they should have.

China seems to recognize the important role that their own government can play in ensuring fair but not excessive compensation for the pharmaceutical industry. Why can’t our government do the same?

I can remember the great pride I had three-quarters of a century ago when standing before the American flag while the national anthem played, and that pride has not left me yet. But if the anti-government forces become much stronger the painful thought arises that it might become more appropriate to reverently kneel before the flag with profound respect for what this nation could be. But let’s not get to the point where protest replaces pride. After all, the nation belongs to all of us, not just the plutocrats.

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

By Robert Reich
November 19, 2019

Republicans and even some Democrats are out to scare you about Medicare for All. They say it’s going to dismantle health care as we know it and it will cost way too much.

Rubbish.

If you’re a typical American, you’re already paying far more for health insurance than people in any other advanced country.

And you’re not getting your money’s worth.

https://robertreich.org…

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Comment:

By Don McCanne, M.D.

It is rumored that some of you had difficult conversations during Thanksgiving dinner yesterday. Although there are certainly many sources for polarized conversations extant today, from our perspective one of the most important is the declining support for the single payer Medicare for All proposal. Failure to move forward with that model of reform will result in greater financial hardship, physical suffering and even death.

In a five minute video, Robert Reich explains in very clear terms why that model of Medicare for All is an imperative. The link also includes a transcript of the video, though the video itself communicates the message more effectively. The video should be shared with those who are confused or even flat out wrong about Medicare for All and also shared with others who are struggling to educate the general population on the topic. Health reform activists should find this to be a great vehicle for spreading the gospel on health care justice for all.

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

By Priyanka Dayal McCluskey
Boston Globe, November 26, 2019

When Senator Elizabeth Warren released her detailed Medicare for All plan this month, a coalition of insurers, hospitals, and pharmaceutical companies denounced it as an unaffordable government takeover that would force Americans to pay more and wait longer for medical care.

But Dr. Eric W. Dickson thought it was the best health care plan he had seen all year.

Dickson, who runs UMass Memorial Health Care, a large Central Massachusetts hospital system, said a national single-payer program could remedy many of the problems in American health care, including the lack of affordable coverage for millions of people, the wide variation in hospital prices, and the administrative burden that is exhausting physicians.

“Medicare for All could definitely address those three things,” said Dickson, whose affinity for single-payer care scored him a Twitter shout-out from Warren. “We have to look at this as an option.”

Dickson’s position on the issue — one central to the 2020 Democratic presidential race — may seem blasphemous for a hospital chief. But he and several other hospital executives and physicians see the debate differently than the lobbying groups to which they pay dues, reflecting a stark divide in the industry.

Kim Hollon, chief executive of Signature Healthcare, the parent company of Brockton Hospital, said a national health care program could ease the administrative workload of the current system, which includes numerous private insurance plans that each have their own rules and requirements for providers.

A single-payer system also could help level the vastly different prices that competing hospitals charge for the same services, Hollon said.

“We’d be fine,” Hollon said. “I’d love to have an equal playing field where we just compete for doing a good job effectively and efficiently.”

Similarly, Kate Walsh, chief executive of Boston Medical Center, said the reimbursement rates in Warren’s proposal would be “wonderful” for her safety-net hospital, which treats a large share of low-income patients on Medicaid.

Tufts Medical Center’s chief executive, Dr. Michael Apkon, spent several years running a hospital in Canada’s national health system and has called the quality of care in Canada “every bit as good as what I’ve experienced here.”

Apkon said he supports a public option — a government-run plan that would compete with private insurance plans — to help make health care more affordable and accessible for Americans.

“If we desire a single-payer system, I think the path to that is a public option that would allow government to set a minimum set of benefits,” Apkon recently told reporters.

Dr. Maryanne C. Bombaugh, president of the 25,000-member Massachusetts Medical Society, said single-payer should be among the options considered for achieving universal health coverage.

“We’re very open to anything that would improve the health of our patients,” Bombaugh said.

Andrew Dreyfus, chief executive of Blue Cross Blue Shield of Massachusetts, said: “It’s a grave mistake for the health care industry to criticize Medicare for All proposals. Instead, we should offer our own views on how to improve the American health care system.”

https://www.bostonglobe.com…

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Comment:

By Don McCanne, M.D.

It is encouraging to see hospital executives acknowledging that a single payer system may be the way we need to go to improve the health care system. Someday…

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

William Hsiao knows more about single payer systems than pretty much any other American. What does he think about ‘Medicare for All’?

By Maura Reynolds
POLITICO, November 25, 2019

Plenty of Americans have opinions about single-payer health systems like “Medicare for All,” and some have even studied them closely. But vanishingly few individuals in the world have actually built one from scratch.

One who has is William Hsiao.

A health care economist now retired from Harvard University, Hsiao designed a national health care system for Taiwan in the 1990s, and helped manage that country’s transition from American-style employer-based insurance to a national single-payer system. He has also designed single-payer reform programs for Cyprus, Colombia and China. And not too long ago, after Vermont voted in 2011 to enact a statewide single-payer system, he worked on what would have been called Green Mountain Care, a project that eventually collapsed because of concerns over financing.

This all gives Hsiao a nearly unique vantage point on the current U.S. debate over Medicare for All. And while he’s a fan of single-payer health care, which he thinks leads both to better health and greater efficiency, he’s a pessimist about its chances to take root in the United States.

The reason? It’s not the economics. It’s the politics.

Given the public’s attachment to doctors and concerns about their own health, Hsiao says there’s a powerful “fear factor” associated with any major change — one easy for opponents to exploit, and hard to overcome. Fans of Medicare for All haven’t yet grappled with the heavy lift of educating the public enough to overcome people’s attachment to the status quo, and the powerful forces that can fan their anxieties.

Opponents of change “have done it before,” he says. “They were very effective in using keywords. The American Medical Association used the words ‘socialized medicine.’ People don’t know what that is. Most Americans do not like ‘socialized’ anything. But if you told most Americans that public schools are ‘socialized education,’ they would be really surprised. Fortunately, we had public schools set up before any powerful interest groups were formed.”

Hsiao was born in China, came to live in the United States when he was 12, and eventually became an insurance actuary. In the late 1960s and early 1970s, he worked for the Social Security Administration, eventually becoming the deputy chief actuary. In that position, Hsiao worked to implement not only the program’s retirement benefits but also the then-new Medicare and Medicaid health care programs for the elderly and disabled. Hsiao says that work convinced him of the value of social insurance and that government has a critical role in providing safety net programs for its citizens.

In recent years, Hsiao, now 83, has consulted with Sen. Bernie Sanders on his Medicare for All plan, and also supports Sen. Elizabeth Warren’s version. But his reality-check prediction is that it will take two more election cycles, at least, before the political groundwork for Medicare for All will be laid.

With powerful lobbies like insurers, hospitals and drug companies dug in against such plans, he points to two other forces that will need to play key roles: big employers, which he sees as nearing an inflection point where they will insist on a better system; and doctors, who are increasingly being paid as salaried employees, which is changing their views of private insurance. “When the United States has a majority of its doctors being on salary, I predict American doctors will come out and support Medicare for All,” Hsiao said.

Hsiao spoke to Politico senior editor Maura Reynolds from his office in Cambridge, Mass., about what the challenges are, why he believes the change needs to happen, and how we might actually pay for it.

This transcript has been edited for length and clarity.

Reynolds: What’s the most important thing that you think proponents of Medicare for All don’t understand about single-payer systems?

Hsiao: The most important thing is that there’s a fear factor, a fear of change. There is a group of people who are opposing Medicare for All, and that includes the private insurance industry, pharmaceutical companies and, of course, some doctors and hospitals. They fear their income may be affected. So, for the common people, the fear is that they don’t understand how it would impact their health care, as well as their health insurance. And for the vested interest groups, they are in fear of their income and revenues.

Reynolds: Aren’t those fears justified?

Hsiao: I think they’re totally unjustified, but there’s a history to it. The last time the United States talked about universal health insurance was under President Truman. Subsequently, President Clinton also tried to propose a plan. And each time, the vested interest groups put on a very effective and powerful campaign to block it by offering common people a great deal of misinformation. In the late 1940s, the American Medical Association led the fight and called universal health insurance “socialized” medicine. And the Clinton plan, there were TV ads that said it would make medical care and claim filing much more complicated. Both of them, those kinds of public campaigns, of course, are untrue.

Reynolds: Is there a case that proponents of single payer should be making to the public that they aren’t making now?

Hsiao: I would actually show film clips from countries that have Medicare for All, like Canada, Taiwan, Germany and other countries. Taiwan educated people first that everyone would be covered by the same health insurance, a comprehensive plan, much better than what most of the people had then. That’s what I think persuaded people.

Reynolds: Many Americans say that they prefer market-based solutions as a lever for public policy, and those can be easier political lifts.

Hsiao: Markets have a serious failure in health care. That’s been proven empirically in the United States and throughout the world. I’ll describe the fundamental failure. You and I, common people, we have a symptom, a headache, a fever. We have pain. We go to a physician for diagnosis and treatment. That’s not like buying a pair of shoes or buying a shirt where the buyer and seller pretty much have an equal position. We go to physicians seeking their expertise. Even if you watch TV ads for drugs, the drug advertisers say, “Talk to your doctor.” That’s because even in their advertisement, they know you would not understand all of the possible effects of that drug.

So the physician holds a superior position in the marketplace. That’s proven. As a result, physicians can charge you any price, particularly if you are in surgery. If you operate on people’s vital organs, like brain, heart, eyes, and even orthopedics — people are willing to go bankrupt to go see a doctor if they need, let’s say, heart surgery. In medicine, actually, there is an opposite effect [from the way the market usually works]: People believe that doctors who charge higher fees must be better. That’s because they don’t understand medicine. So they figure if you can charge higher fees, you must be a better doctor. Those are market failures.

I’ll give you another example. A few decades ago, American doctors who were trying to do the right thing for their patients, for exactly the same service, would charge the poor nothing. If you were rich, they would charge you, let’s say, $8,000 for an operation. If the doctor thinks you are an average earner, he might charge you only $4,000. At the time, this was praised as doctors performing a social service. But that also tells you what kind of market power doctors have over patients. Can you imagine you go to a car dealer; you want to buy a Chevrolet. The Chevrolet dealer sees you as an average citizen and tells you, “That’s $25,000.” For rich people, “That’s $50,000.” You would say, “Wow. There’s something wrong with this market.”

Reynolds: How do you explain the health care industry’s resistance to current measures to increase transparency in pricing?

Hsiao: That’s very unique to the United States. United States has many insurance companies. The insurance companies negotiate with, let’s say, hospitals for the price, for a discount from their list price. By the way, their list price is not based on any facts of the cost; It’s a price that hospitals would like to charge. There’s no cost study to support that price. So if you are an insurance company, you say, “I can bring 50,000 patients to your hospital.” The hospital may give you an 80 percent discount from the list price. If you are representing a company that employs 200 employees and their families, they say, I’ll give you only a 25 percent discount. If you are an insurance company representing only two employees, I may not give you any discount. That’s why the hospitals don’t want to publish their price, because they may have five to 10 different prices, depending on which insurance company negotiates with them and how many insured people they can bring to their hospital.

Reynolds: What’s a better way of setting prices for that hospital?

Hsiao: I would set the price based on the actual cost of the hospital and give them a small margin of profit, so they can have some flexibility to improve and to expand. That’s how Medicare sets its prices.

Reynolds: Right, but many players in health care say Medicare pays far too little — and that if a Medicare for All system were to force doctors and hospitals to accept Medicare prices for everything they do, they’d go out of business. Do you think that’s a fair argument?

Hsiao: No, that’s misinformation. In the United States, in the same community, hospitals have different costs partly because they’re managed differently. Some hospitals are managed well and some hospitals are not managed that well. This was studied three decades ago: In Boston, for example, for a normal baby delivery, the cost and charges could vary three times between hospitals. That’s one other piece of evidence that the market doesn’t work: that in the same community, the price could be varying that much. So those opponents who claim they’re going to lose money, they may be high-cost hospitals. They may be poorly managed or they may be too small to operate. They should have gone out of existence a long time ago.

Reynolds: But hospital closures aren’t a minor problem. There’s real concern about rural hospitals being the first to close, right?

Hsiao: Yes, you should see them differently. Rural hospitals serve a social purpose. But that’s a special category.

Reynolds: One issue any reform faces is that health costs in the U.S. are just far higher than other countries. Why is that?

Hsiao: Efficiency, duplication, very high salaries for some people. Our surgeons, particularly surgeons dealing with vital organs, are making half a million dollars or more every year. Meanwhile, your family doctors and pediatricians are only making $200,000 each year.

Reynolds: And in other countries, is there less disparity between the different levels of—?

Hsiao: Specialties. Yes, there may be a 50 percent differential. Here, we have a differential of 2.5 or 3 times. That’s how the market works. When you’re dealing with people’s vital organs, with people in fear of their lives, you can charge them much higher.

Reynolds: One of the big arguments in the presidential campaign right now is about how the country would actually pay for a universal system. There’s a lot of discussion over whether taxes would increase, particularly for the middle class. There’s less discussion about whether we should retain an employer-based system, and whether employers should contribute. You’ve recently written that the growth of the gig economy, of less formal forms of employment, is also creating problems for the employer-based model. What’s your recommendation for a better financing system for the United States?

Hsiao: I would base the financing of health care on income because, in an advanced economy, some people’s incomes are from lots of things — rent, dividends, interest and capital gains — not just wages. So the first principle is to tax people based on their income. But I support what Senator Warren has proposed, a tax on financial transactions. You add on only a little bit on each financial transaction, [but] you can generate tremendous amounts of income.

Under Senator Sanders’ proposal, and I worked on the cost of it, you can save close to $800 billion a year — $800 billion a year — from inefficiency, from fraud and abuse of claims, and from duplication of services and also, from using your buying power to bargain with pharmaceutical companies for a reasonable price. That $800 billion has to be used partly to pay for the uninsured people and the underinsured people. Even then, every American, on average, could save $1,000 every year. Those are the numbers.

Now, if you tax rich people more, or like Senator Warren proposes, then, of course, rich people would not save [money]. But 90 percent or more of Americans will find they actually can save money from Medicare for All. That point has not been made strongly at all by the proponents of Medicare for All.

Reynolds: You’ve been around these issues for a long time. Do you think that we’re actually at a moment now in the United States where the American public is ready for this kind of sweeping health care change? Or do you think that we’re not there yet?

Hsiao: My honest answer, even though I know that this is recorded, is that I don’t think we are there yet.

Reynolds: Why is that?

Hsiao: We’re not there yet because the common, average American is not educated yet and there is a lot of misinformation being directed at them. And you haven’t even seen the insurance industry and pharmaceutical industry come out yet with really well-organized campaigns against it. The private insurance industry’s annual revenue is $1.3 trillion. The pharmaceutical industry’s annual income is $400 billion.

They only have to use one-thousandth of 1 percent of their revenue to fight [this]. They can elect the key decision-makers in Congress, [the Senate and the House of Representatives], because they can mobilize literally a billion dollars. And those powerful, wealthy, well-organized, vested interest groups have not come out openly yet. That’s the reality of American money, politics.

Reynolds: And you think when those monied interest groups do start fighting, that they will swamp this new interest in Medicare for All?

Hsiao: Yes. Look at what happened with Clinton’s plan. [It was] only the insurance companies who came out in an organized way for the Clinton plan, and the Clinton plan couldn’t even get a hearing before the U.S. Congress. No committee in the U.S. Congress held a hearing about what Clinton proposed. Of course, Hillary Clinton overplanned the Clinton plan. She planned out every detail; she left no decision for congressmen and senators. But still, not even one hearing. However, I do think two elections from now, the United States may see Medicare for All.

Reynolds: Why two elections?

Hsiao: To make a big change like this, you need to educate the public. You need to sharpen the issues and sharpen the key points. Right now, there’s a lot of confusion in the public’s mind and even among the political candidates.

Reynolds: But it sounds like you feel that economically, there really isn’t any question that either single-payer or a public option is the right answer for the United States. The question in your mind is the politics.

Hsiao: I think that most people who specialize in this field, the majority at least, think that single payer is the right solution because it’s much more efficient. You create a unified electronic record that can improve the quality of care and also give patients much better information about their history and their treatments.

I see changes in America. American employers find health insurance, the costs are rising faster than they can afford. As a result, because of the costs of health insurance for their employees, they can’t give them raises. Meanwhile, their employees demand higher cash wages, as well as to keep their health insurance. That can’t last that long.

Reynolds: So do you think that the employers hold the key to solving this problem?

Hsiao: They do. They are silent right now. But if you look at three powerful, big companies — Amazon, JPMorgan, Berkshire Hathaway — they have united together trying to form a health company, trying to innovate to do something. That tells you these corporations find this burden something they cannot continue to afford. That’s one change.

Another change is American doctors are supporting Medicare for All in larger numbers. American doctors today, 47 percent of them are salaried now. They are not in private practice. The doctors who oppose Medicare for All, the older doctors who are in private practice, they like the autonomy of their own office and they also do not want any interference from any semi-government agency. But the salaried doctors today find that the paperwork imposed on them by insurance companies is so horrendous that they cannot really devote enough time to the patients. They are in support of Medicare for All. When the United States has a majority of its doctors being on salary, I predict American doctors will come out and support Medicare for All. The American Medical Association, the American Hospital Association will not be able to say, “We are against it,” like they did before.

Reynolds: Doctors hold the blame for scuttling a national health care system after World War II, but you think that they hold the key to solving that problem when the next generation of physicians is in the majority?

Hsiao: Yes, and that majority is going to emerge in the next five years. Look at the figures. Already 47 percent of American practicing doctors are salaried. And every year that number increases by 1 or 2 percentage points.

https://www.politico.com…

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Comment:

By Don McCanne, M.D.

William Hsiao certainly understands the issues, and so we need to listen to him when we try to understand why Americans have not yet met the political threshold required to move Congress to enact the moral imperative of the single payer model of an improved Medicare for All.

Hsiao tells us, “We’re not there yet because the common, average American is not educated yet and there is a lot of misinformation being directed at them.”

Many believe they understand the issues, but when you hear them say that they want the right to keep their private insurance rather than be forced into a government program, it is highly likely that they do not understand the vast superiority of single payer Medicare for All. The fact that simple sound bites can cause too many of them to reject Medicare for All demonstrates that Hsiao is correct; they are not yet adequately educated on the topic.

The rules are still the same. When the policy is right, but the politics are wrong, change the politics. Coalitions. Grass roots organizing. Education. Education. Education.

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By Jeffrey D. Sachs
Common Dreams, November 20, 2019

The American political debate over health care is absurd. Americans pay twice as much as any other nation for health care, and then are told daily that they “can’t afford” to switch to a lower-cost system very similar to those of Canada and Europe. If President Donald Trump and the plutocratic Republican party were the only ones carrying this ridiculous message, it would be understandable. Yet this message is also coming from media pundits aligned with the Democratic Party and the most conservative wing of the party.

Let’s be clear on the central point. Medicare for All, as first proposed by Bernie Sanders and endorsed by Elizabeth Warren, is affordable precisely because it is cheaper, much cheaper, than the current system.
America’s health care system relies on local monopolies (such as a health care provider centered at the sole major hospital in a city) and national monopolies, notably pharmaceutical companies holding exclusive patents.

In other countries, the government sets delivery prices and typically pays the health bills through the budget. In the US, the monopolists set the prices.

The sky-high revenues end up as huge corporate profits, wasteful administrative costs, useless and even harmful advertising and lavish salaries. Health care CEOs are making gargantuan salaries, many exceeding $10 million per year.

Who loses? Almost all Americans, whose insurance costs and out-of-pocket outlays inevitably lead to lower income because of unaffordable health care costs, untreated chronic illnesses, premature mortality and personal bankruptcies. Single-payer systems such as in Canada and Europe are cheaper, fairer and have better outcomes.

A recent international comparison of the performance of 11 national health systems on five main dimensions (care process, access, efficiency, equity and health care outcomes) ranked the US health system dead last.

Despite all of this, the US pundits profess to be alarmed about the prospect of Medicare for All. There has been a wave of op-eds and columns published (for example, here and here and here) declaring that Medicare for All would lead to massive tax increases, and that Sanders’ and Warren’s support for Medicare for All threatens to reelect Trump. It’s ridiculous.

Both Sanders and Warren poll well against Trump, ahead in the overall popular vote (though like all Democrats, facing headwinds of the Electoral College).

And at this stage of a national campaign, the goal should be to explain to voters the vast benefits of a single-payer system rather than to prejudge the politics based on self-fulfilling fearmongering.

Yes, one way or another, taxes would rise with Medicare for All, but private health outlays would go down by much more. Total health costs would fall.

That idea is not so hard to understand.

One influential pundit, economist Paul Krugman, has come around. In the 2016 election cycle, Krugman railed against Medicare for All. Yet after Warren laid out her proposal, Krugman supported Medicare for All. In truth, he was simply returning to the economically sound observations that he had long made before 2016.

The pundits seem to believe that Americans will rebel at “higher taxes.” Actually, Americans are much smarter than that. They know that their current private health care payments, whether insurance premiums or out-of-pocket, are nothing other than “taxes” they pay to stay alive. They’ll agree to pay higher taxes to the government if those new taxes eliminate larger private health care bills — again, there are “taxes” by any other name — that they now pay.

Some mainstream pundits are simply repeating what they hear from Democratic Party conservatives and centrists, the wing that has been dominant since Clinton’s election in 1992. They are following the lead of Nancy Pelosi, Pete Buttigieg and others who are trashing Medicare for All.

What in the world are these leading Democratic Party politicians doing in opposing the transition to a fairer, more efficient and lower cost health care system? I would suggest it’s not a lack of understanding. It’s the power of campaign financing. These Democrats are funded by the status quo. The health sector contributed $265 million to federal campaigns in 2018, of which 56% went to Democrats. The sector spends nearly $500 million per year on lobbying. Money talks. Meanwhile, Americans go bankrupt or die early.

There remains the issue of the best way to raise budget revenues for Medicare for All. The basic answer is to use progressive taxation to fund the program. In this way, the nation as a whole will pay much less for health care and the vast majority of households will as well. The highest income households will end up paying a bit more because their funds will not only finance their own health care but will help to pay the health care costs of the poorest households as well.

Sanders rightly proposed a menu of options to pay for Medicare for All, including payroll and income taxation. Warren has proposed one specific approach: progressive taxes on the super-rich and the corporate sector but also a surprisingly regressive “head tax” on companies. She took great pride in not charging a penny of new income or payroll taxes on middle class households. But the proposed head tax on companies would hit wages indirectly and regressively.

Still, both Sanders’ and Warrens’ approaches would result in a more equitable and less expensive system. For most households, overall health care costs will decline.

The most worrisome thing about Warren’s statement as she introduced her Medicare for All plan, is her emphasis on “not one penny” of new middle-class taxes. Here we go again. The Democrats have, for far too long, copied the Republican mantra about “no new taxes,” even as our public debt soars, our infrastructure and public services collapse and inequality reaches stratospheric dimensions.

To honor the silly stricture of “no new taxes” directly paid by middle-class households, Warren ended up endorsing a regressive head tax paid by the employer, which would end up hitting lower-wage workers even though its paid by their employers.

Let’s hope this blunder is a one-time stumble for Warren. Most importantly, both Sanders and Warren are pointing the correct way to reform America’s costly, unfair and inefficient health care system. And this is a goal that most Americans support.

Jeffrey D. Sachs is the Director of The Earth Institute, Professor of Sustainable Development, and Professor of Health Policy and Management at Columbia University. He is Special Advisor to United Nations Secretary-General Ban Ki-moon on the Millennium Development Goals, having held the same position under former UN Secretary-General Kofi Annan. He is Director of the UN Sustainable Development Solutions Network. He is co-founder and Chief Strategist of Millennium Promise Alliance, and is director of the Millennium Villages Project. A recent survey by The Economist Magazine ranked Professor Sachs as among the world’s three most influential living economists of the past decade. Sachs is the author, most recently, of “The Age of Sustainable Development,” 2015 with Ban Ki-moon.

https://www.commondreams.org…

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Comment:

By Don McCanne, M.D.

This article on Medicare for All is important not only because it is authored by one of the world’s leading economists but also because it should put an end to the opposition to funding single payer Medicare for All though the tax system. Progressive taxes are the most efficient and equitable method of funding health care for all of us.

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By John E. McDonough
The Milbank Quarterly, November 2019

August 19, 2019 was a big day for The Business Roundtable (TBR), the Washington, DC non-profit association of chief executive officers of major US companies. The organization released a new “Statement on the Purpose of the Corporation” signed by 183 CEOs declaring that the interests of workers, customers, communities, and “other stakeholders” should be as important as the interests of a company’s shareholders. This represented a significant change from its 1997 Statement that declared “the principal object of a business is to generate economic returns to its owners.”

While actions, not statements, will reveal real intent over time, this change was noteworthy—including for the US health care sector. The subject has deep roots in American society, especially in the advocacy of the late economist Milton Friedman, who derided corporate social responsibility as “fundamentally subversive” and asserted that “there is one and only one social responsibility of business—to use its resources and engage in activities designed to increase its profits.”

In the 1970s and 1980s, Friedman’s notion powered a movement in the United States, Great Britain, and around the globe called “neoliberalism” that promoted deregulation, defanged labor unions, shrunken government, and ever lower taxes. From business schools to high cathedrals of capitalism “greed is good” became more than a movie line from Wall Street and its iconic Gordon Gekko. Binyamin Applebaum’s new book, The Economists’ Hour, lays out the neoliberal narrative, warts and all, in compelling detail.

What about US health care and this neoliberal era in which we still breathe? The connections are multiple, deep, and noteworthy. For starters, of the 183 CEO signers of the TBR statement, only 11 come from companies primarily embedded in the health sector, such as Pfizer, CVS Health, and Siemens, far less than a proportionate share of health care’s 18% jumbo slice of the US economy. And it is not difficult to view TBR’s statement as whitewash, especially when signers include CEOs of Johnson & Johnson and Mallinckrodt Pharmaceuticals, companies that are neck deep in the nation’s opioid marketing scandal.

Influential US political and economic historians refer to the period from the late 1970s through today as the “Reagan era,” crowned during the presidency of Ronald Reagan who declared in his inaugural address that “(i)n this present crisis, government is not the solution to our problem, government is the problem.” His term in office ushered in the modern era of tax cuts, growing inequality, wage stagnation, diminished unionization, and repeated assaults on government legitimacy. The “Neoliberal Era” may be a better fit.

Coincidentally or not, in the early 1980s US national health spending as a percent of gross domestic product (GDP) split from rates in other advanced nations toward its current extreme outlier status. US spending on health increased from about 8% of GDP in the late 1970s to 17.8% in 2017, far ahead of the nation with the second highest rate of national spending on health, Switzerland, at 12.2%.

In return for this massive societal investment in medical care, we have the world’s most technologically advanced health care system along with the highest prices in the world for any category of medical services or products one can imagine. The rush of private investment capital into our medical sector has resulted in cutting-edge medical care, advanced drugs and medical devices, and the highest salaries of any professionals in American society.

In these 40 years, we also have seen three consecutive years of declining life expectancy, a deep anomaly among our international peers, humiliating rates of infant and maternal mortality, shocking levels of gun violence, and extreme incidence of overweight and obesity. As economist John Komlos has documented, during World War II, native born Americans were the tallest among advanced nations, both men and women—we are now among the shortest. For good measure, Americans are also among the most dissatisfied with our health care system. For what it is worth, money doesn’t buy us good health or happiness.

In this epoch, we have seen enormous growth in private investor funding into a sector formerly dominated by nonprofits or government, in hospitals, physician practices, home health, hospice, air ambulances, and much more. The pharmaceutical industry has always been for-profit, yet its extraordinary concentration has ballooned its pricing structure. The for-profit health sector keeps evolving, assuming new forms. As Gondi and Song document, between 2010 and 2017 the value of private equity deals involving acquisition of health-related companies, mostly hospitals and physician practices, increased 187% reaching $42.6 billion.

Could the investor dominance of much of US health care explain at least part of our outlier status on health spending and outcomes? It is hard to imagine that the investor-driven corporatization of American society could have left medical care untouched. Even today, the most common complaint from conservatives and Republicans about US health care is that government regulation thwarts the free market.

The notion that we could put this massive bulk of toothpaste back into the tube seems preposterous. The economic and political power of the incumbent system would easily stymie any serious challenge, including the apparent one, a nationalized “Medicare for All” structure. Assuming anything of this magnitude could get through Congress—or the Supreme Court—is a daunting stretch. And yet, the real frustrations of Americans with a system organized first and foremost to serve money and power before patients deserve attention.

If, as the Business Roundtable advocates, we are embarking on a new national conversation concerning the role of the for-profit corporation in American society, perhaps we should also instigate a parallel and sustained national examination and conversation about the history, experience, and results from for-profit corporatization of our health and medical care sector. It is clear that this revolution produces good and bad results for American society and for the world. Is it time for a reckoning?

John E. McDonough, DrPH, MPA, is a professor of public health practice at the Harvard University TH Chan School of Public Health in the Department of Health Policy and Management.

https://www.milbank.org…

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Comment:

By Don McCanne, M.D.

It is important to understand the concept of neoliberalism. It has divided the political left in this nation. No longer is there an unwavering reliance on public social programs since many on the left now believe that the private sector should provide the prevailing influence (forget the right). Application of neoliberal ideology is responsible for flat wages, income and wealth inequality, diminishing worker representation, increasing tax inequity, and suppression of beneficial public regulation.

An extremely important current manifestation of the inequities of neoliberalism is the internal attack on the left against the single payer model of Medicare for All. The single payer concept is one of the most important that would correct the social injustices and health care injustices that are so prevalent in our nation. Not only would it finally ensure that everyone would have access to health care, it would also reduce the injustices inherent in income inequality, not to mention improving the way that we spend health care dollars so that we would be receiving greater value and higher quality of care. Yet the neoliberal element within the Democratic Party is conducting a vicious campaign designed to destroy support for an equitable Medicare for All, while vocally supporting one of the greatest contributors to health care injustice – the private insurance industry and the fragmented, dysfunctional financing system it supports. But then supporting private solutions to public problems is what neoliberalism is all about.

The neoliberals have reduced the Medicare for All debate down to merely allowing people to buy an individual government plan, misnamed Medicare, while leaving all of the other dysfunctions in place that cause high costs, impaired access, mediocre outcomes, and financial hardship. Sadly, checking the campaign donations received by the Democratic candidates who are opposing single payer Medicare for All will confirm their neoliberal bona fides.

John McDonough asks if it is time for a reckoning. Way past, I’d say.

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