PNHP

Decrease in private nongroup coverage leaves more uninsured

Decrease in private nongroup coverage leaves more uninsured

Health Insurance Coverage Declined for Nonelderly Americans Between 2016 and 2017, Primarily in States That Did Not Expand Medicaid

By Laura Skopec, John Holahan, and Caroline Elmendorf
Robert Wood Johnson Foundation, Urban Institute, August 15, 2019

The Issue

Between 2013 and 2016, the uninsurance rate for nonelderly Americans from birth to age 64 fell every year, and 18.5 million more Americans had health insurance coverage in 2016 than in 2013. However, these coverage gains stalled in 2017. Using the American Community Survey, this research finds that uninsurance increased between 2016 and 2017, despite a strong economy and accompanying increases in incomes and employer-sponsored insurance (ESI) coverage.

Key Findings

  • The uninsured rate climbed from 10.0 percent in 2016 to 10.2 percent in 2017, the first increase since 2013, after significant declines driven by the Affordable Care Act (ACA). This decline resulted in 700,000 more uninsured people in 2017 than in 2016.
  • The uninsured rate held stable in Medicaid expansion states at 7.6 percent, but increased from 13.7 percent to 14.3 percent in states that did not expand Medicaid.
  • Non-Medicaid expansion states lost marketplace coverage at twice the rate of expansion states.

Conclusion

Factoring in population growth in 2017, gains in ESI mitigated, but did not overcome reductions in Medicaid and CHIP and ACA marketplace coverage. Researchers observed broadly distributed losses across all age groups and income levels. Non-Hispanic white and black nonelderly people, those with at least some college education, and those living in the South and Midwest, experienced disproportionate coverage losses. The authors conclude that these increases in uninsurance will likely occur disproportionally in nonexpasion states, given their greater reliance on private coverage.

From the Brief

Overall, coverage losses were concentrated in the 19 states that did not expand Medicaid eligibility under the Affordable Care Act by July 1, 2017. Between 2016 and 2017, uninsurance held stable in Medicaid expansion states but increased by 0.5 percentage points in nonexpansion states. Though both expansion and nonexpansion states saw increases in employer-sponsored insurance and decreases in Medicaid/CHIP and private nongroup coverage over this period, the percentage-point decline in private nongroup coverage in nonexpansion states was nearly double that in expansion states (-0.6 percentage points versus -0.3 percentage points), precipitating larger coverage losses.

The increasing uninsurance rate in nonexpansion states between 2016 and 2017 may reflect their greater exposure to changes in the availability and affordability of marketplace and private nongroup coverage. In nonexpansion states, nonelderly people with incomes between 100 percent and 138 percent of the federal poverty level are eligible for marketplace subsidies to purchase private nongroup coverage, rather than Medicaid/CHIP coverage, so coverage gains in these states between 2013 and 2016 relied more on the availability and affordability of private nongroup coverage than coverage gains in Medicaid expansion states. Further changes to private nongroup coverage and marketplace policies in 2018 and 2019, including shorter open enrollment periods, availability of short-term, limited-duration policies, loss of federal funds to support cost-sharing subsidies, and repeal of the individual mandate to purchase coverage, may also disproportionately reduce coverage in nonexpansion states in the coming years.

https://www.rwjf.org…

Comment:

By Don McCanne, M.D.

With the implementation of the Affordable Care Act (ACA), 18.5 million more Americans had health insurance coverage in 2016 than in 2013. However, the numbers of uninsured declined by 700,000 between 2016 and 2017. The decline was predominantly in the private nongroup and ACA marketplace plans and occurred primarily in states that did not expand their Medicaid eligibility.

Although the greatest success of ACA was in the expansion of Medicaid, the Medicaid program already existed and could have been expanded without enactment of ACA. The other ACA program – establishment of the private insurance exchanges or marketplaces – has fallen short of goals of universality and affordability, and enrollment began reversing in 2016. ACA also increased regulatory oversight, but at a cost of increased financial barriers to care through higher deductibles, and diminished access to care because of wider use of restricted provider networks. There is also some question about the expansion of Medicaid since many were forced into Medicaid managed care programs that seem to be falling short on performance.

The current debate over reform is whether 1) to continue to try to tweak ACA, perhaps adding more administrative complexity through a public option, in spite of the post-ACA highly flawed, dysfunctional health financing infrastructure, or 2) to replace the system with an as yet undefined Republican plan which would likely transfer more of the responsibility of obtaining care to individual patients making care even less affordable and less accessible, or 3) to enact and implement a single payer model of an improved version of Medicare that would cover everyone. There is really only one reasonable choice here: Single Payer Medicare for All – that is if we want to have a high quality health care system that takes care of everyone of us and is affordable for each of us.

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

A cure for our dysfunctional health-care system

By David McLanahan, M.D.
The Seattle Times, August 19, 2019

Re: “Murder-suicide is suspected in pair’s deaths” [Aug. 11, B7]:

The news of the elderly couple’s death is another in the litany of tragedies inflicted upon American families by our dysfunctional health-care system.

As the article points out, current Medicare and Medicaid cover only 65% of medical expenses. As well as bearing the discomfort of illness, elderly people face deductibles, co-pays, high-cost medications, other out-of-pocket expenses and oppressive insurance paperwork. They often face the prospect of going bankrupt, losing their life savings, if any, and the prospect of asking family members and friends to help out. We all can understand this couple’s resolution.

The tragic decision facing this family would likely have been averted if they were covered by Improved Medicare for All, such as embodied in Rep. Pramila Jayapal’s H.R. 1384. This legislation would enable all of us to receive the health care we need from birth without any financial worries.

It’s time for all of our representatives — national, state, and local — to follow the lead of their constituents to join us in supporting justice in health care.

https://www.seattletimes.com…

Sweet Dreams: The Future of Medicine

By Brent W. Beasley, M.D., M.B.A.
Physician Leadership Journal, August 19, 2019

Enter the brave new world of science fiction, and discover the benefits of universal coverage, deep-learning artificial intelligence, and solutions to pharmaceutical affordability — all of which is within our grasp.

I’VE TOLD MY FRIENDS THAT I know  we won’t time travel in the future because the first thing I would do is return to the past to tell myself that it’s going to happen. That was a great after-dinner conversation until …

During a recent lunch hour, I was sitting on a park bench at our medical school campus, frustrated by the third prior-authorization denial of the morning, when the smell of sulfur tickled my nose, a quick breeze blew through my hair, a sound like a clap of thunder startled me, and, as if an elevator opened in front of me, a person looking a lot like my father stepped through a crack in space and said, “There will be time travel in our future!”

I was most surprised. I stood up next to myself and stared. I actually touched my — or, rather, I should say, his so you can keep us apart — forehead and noted the deep wrinkles of laugh lines and sorrows. It was me, or more precisely will be me. We sat down, chuckled together and talked.

He wouldn’t answer about my future, my children’s lives, my friends — something about avoiding paradoxes and becoming my own grandfather. So, we were stumped. What could my older me say about the future?

“Well, I suppose I could tell you about the future of medicine!” he exclaimed.

“Aren’t you concerned I could mess it up?” I asked.

“As if you have any power to change the current or future state of medicine?” he harrumphed. “Of course, I’m not concerned.”

“You have a point,” I shrugged. “So, what does the future hold for health care?”

He thought with eyes squinted. Finally, he announced, “I can tell you that universal coverage passed in the U.S. Congress.”

“You’re joking? The liberals finally pushed it through?” I asked, jaw hanging.

“Of course not! The business community rose up en masse when they realized that, instead of corporations paying a trillion dollars in health care costs per year, all U.S. citizens could be covered, as other first-world countries have done, at a huge savings to them. Individual taxes went up, but we pay nothing for health insurance and have no out of pocket costs. Three trillion dollars in health care savings the first decade! Not only that, the administrative costs burdening doctors’ offices dropped like a rock overnight.”

“Wow,” I exclaimed. “I never thought that would happen. Did Bernie live to see the day?”

“They rolled him out to wave at the crowd,” he affirmed. “In the first year, many of the racial disparities in care disappeared as all people had equal coverage,” he affirmed. “There was evidence that would result back before 2020, when the Affordable Care Act Medicaid expansion states provided improved care to people of color and those in poverty.”1,2

“Did the government take over the hospitals?” I asked.

“Nope,” he shook his head, “they left them alone. Universal coverage was only about ensuring all citizens had insurance.”

“But what about free enterprise? Competition in the market place?” I retorted.

He snorted. “Once all the public held the same ‘currency,’ ” he said, making air quotes, “health systems became truly competitive, regardless of their location and payer mix.”

“Didn’t health care costs keep rising?” I asked naively.

He laughed. “No, it was exactly as Anderson kept telling us back in the day: ‘It’s the prices, stupid!’ Having one large payer doing the negotiating ensured high-value care was provided at affordable prices.”3

“So, what else you got in that brave new world?” I prodded, elbows on my knees, and eager. He placed his hands behind his head, and leaned back.

“Let’s see,” he pondered. “Artificial intelligence … that’s been a game changer,” he said, pointing his finger at my chest and nodding.

“You mean robot doctors?” I asked, eyes wide.

He looked at me with disdain. “I mean the ‘deep learning’ kind of AI that helps with diagnosis and treatment.4 My smartwatch app listens to patient encounters, tracks symptoms and signs, and spits out a prioritized differential diagnosis with an evidence-based workup and treatment plan individualized for the patient. The diagnostic accuracy is much higher than any physician could develop alone. At first it was off-putting, and my patients looked askew when they heard the app talking to me in the exam room. A decade later, patients expect it.”

“I’m not sure I’d feel comfortable with that kind of intrusion,” I added, eyebrows crossed.

“You won’t. I wasn’t,” he demurred. He raised an eyebrow, “More problematic is AI radiology and pathology. Even in your days, computer-based radiology and pathology were more sensitive than the human ability to find problems.5 That trend continued, and the specificity only improved with time. There are very few radiologists and pathologists in practice anymore. They exist in our future mainly to characterize anomalies and oddities.”

I stroked my chin. Should I alert our medical students so they make informed decisions about career choice? Or would that be meddling with the future?

“And then, you’ll be glad to know we don’t enter data into EHRs anymore,” he smirked.

“Great Osler’s ghost!” I exclaimed.

“Instead, we have a video camera in the room, recording the visit. It parses into an electronic document the history, the exam, the diagnoses, and the treatment plans discussed. It creates a relatively short note, since,” he smiled, “with universal coverage, nobody is concerned about documenting for payment reasons.”

My excitement was growing.

“Tell me about the pharmaceutical industry. Have you tamed the beasts yet?” I asked expectantly.

He nodded, and stuck his bottom lip out. “It’s better. Universal coverage gave Americans one strong bargaining partner for Big Pharma. The Food and Drug Administration, which sits under the executive branch of government, finally limited the patentability of inconsequential changes in “me too” medicines, stopped extending patents, and put more resources into reviewing generic drugs—all to increase their availability. They also got tough on new devices.”

We both leaned back against the park bench and looked up into the wild blue yonder.

“Wow,” I said after a minute, shaking my head slowly, not taking my eyes off the white billowing clouds set in the sky, “it sounds like a great place to practice medicine.”

“It truly is,” he nodded, then looked over at me. “But, now you have to get back to the clinic and see your patient.” He grabbed my arm and shook me. I pushed his hand away. He seemed very insistent and shook me more. I looked over at him.

“Dr. Beasley,” he said with a woman’s voice, “please wake up and come back inside. Ms. Jones is waiting to be seen.”

Suddenly, I awoke and looked up at my nurse, who scowled.

“Wait! Where did I go?” I asked with a start, looking behind and underneath the park bench for my older me, as my nurse put her hands on her hips and tapped her toe, impatiently.

Brent W. Beasley, M.D., M.B.A., is a frequent commentary contributor to the Physician Leadership Journal. He is medical director for internal medicine and a professor in the School of Community Medicine at the University of Oklahoma at Tulsa.

https://www.physicianleaders.org…

REFERENCES

1. Daw JR, Sommers BD. Association of the Affordable Care Act Dependent Coverage Provision With Prenatal Care Use and Birth Outcomes. JAMA. 2018;319(6):579-587.

2. Swaminathan S, Sommers BD, Thorsness R, Mehrotra R, Lee Y, Trivedi AN. Association of Medicaid Expansion With 1-Year Mortality Among Patients With End-Stage Renal Disease. JAMA. 2018 Dec 4;320(21):2242-2250.

3. Anderson GF, Reinhardt UE, Hussey PS, Petrosyan V. It’s the prices, stupid: why the United States is so different from other countries. Health Aff (Millwood). 2003 May-Jun;22(3):89-105.

4. Hinton G. Deep Learning—A Technology With the Potential to Transform Health Care. JAMA.2018;320(11):1101–1102.

5. Jha S, Topol EJ. Adapting to Artificial Intelligence: Radiologists and Pathologists as Information Specialists. JAMA.2016;316(22):2353–2354.

We’re doctors, and we’re debunking myths about Medicare for All

By Eve Shapiro, M.D. and Paul Gordon, M.D., M.P.H.
Arizona Daily Star, August 17, 2019

As physicians who have been working on improving our health care system by implementing an improved “Medicare for All,” we are dismayed by the current debate on health care reform, both on the part of the journalists and politicians.

We hope to clear up some of the myths that have been commonly portrayed in the media.

Myth No. 1: Medicare for All will cause Americans to lose their private health insurance coverage.

Fact: yes, but it will be replaced by a comprehensive government-financed (not government-controlled) insurance plan that will cover all Americans and include all physicians.

Your current physician from your private health insurance plan, will be part of the Medicare for All plan. There will be no out-of-pocket costs, no copays, no deductibles, no surprise billing or risk of medical bankruptcy.

After all, what do private insurance companies contribute to health care other than adding to complexity, paying CEOs exorbitant salaries (in the 100s of millions of dollars) and reaping enormous profits? Right now, over 20% of all the money spent on health care goes to these companies, which provide no benefit.

That money could be used to insure the 20 million Americans without health coverage now.

Myth No.2: Taxes will go up.

Yes, Medicare for All will be paid for by a progressive tax and possibly other taxes on the wealthy and financial transactions. For the vast majority of Americans, their costs on health care will drop significantly.

Currently, health insurance costs the average family of four over $12,000 a year from premiums, copays and deductibles.

This will be replaced by an equitable tax based on income and most people will wind up paying far less in new taxes than they are currently paying for all of their healthcare costs.

Myth No. 3: We can’t afford it.

Currently, the U.S. pays more than twice as much as most other developed countries and our health outcomes are worse than theirs. These other countries all have a version of single-payer, and if they have any private insurance, they are closely regulated and must be nonprofit.

In other words, we can’t afford NOT to introduce Medicare for All because our current costs are going to keep rising.

Myth No. 4: It’s too disruptive.

Changes in employment or marital status, reaching age 26, or increased income above eligibility thresholds for Medicaid or exchange subsidies currently disrupt coverage for needed care. Improved Medicare for All is cradle to grave coverage that each of us can afford.

Having no cost at the time of service is important to avoid disruptions. Medicare for All is actually less disruptive.

Myth No. 5: We need to take smaller, safer steps.

Incremental steps, such as a Medicaid or Medicare public option, have been proposed by several of the Democratic candidates.

Yet it is putting a Band-Aid on a dirty, infected wound and won’t solve our health-care problems. For-profit insurance companies collude with the drug and large hospital corporations, creating the current extreme costs for health care and gaps in care that are so prevalent in our country.

If we continue private insurance with the public option, two problems emerge. We won’t get the savings we can get from eliminating private insurance and the private insurance companies will cherry pick the healthier people and the public option will not survive.

The improved Medicare for All legislation includes vision, dental, hearing, mental health and long-term care.

It will eliminate the financial burden of premium, deductibles and copays so nobody would ever have to choose between paying their bills and going to the doctor; medical bankruptcy will be a thing of the past.

Dr. Eve Shapiro is a pediatrician and Dr. Paul Gordon is a family practice physician in Tucson.

https://tucson.com…

Trump Is Scaring Immigrants Away from Healthcare Services to Help the Rich

The new public charge rule was created to isolate working class people from the healthcare benefits they need to survive.

By Adam Gaffney, M.D., M.P.H.
Vice, August 16, 2019

Ana felt that she had to make a choice: obtain desperately-needed health services—like therapy—for her nine-year old daughter with autism, or risk that her family would have to leave the country or be separated, NPR reported last January. As an immigrant living in Texas, Ana feared that seeking more services for her daughter could jeopardize the process of obtaining legal permanent residency status (a “green card”), even though her daughter was a citizen enrolled in Medicaid.

Such fears—well-founded or not—may be growing. On Monday, the Trump administration fanned them when it released a new regulation branding legal immigrants “public charges,” and hence persona non grata, as punishment for using programs like Medicaid or food assistance. The rule also makes wealth a key criterion by which immigrants will be sorted when it comes to determining who can stay, and who must go.

In response, some immigrants will predictably avoid or disenroll from social programs—including healthcare—to which they are entitled. But even immigrants who are not targeted by the rule will invariably be confused and fearful of it, said Leah Zallman, a colleague at Harvard Medical School and the Cambridge Health Alliance who studies immigrant health. Like Ana, some will be afraid that even enrolling family members in government programs could jeopardize their immigration status—potentially leading to the separation of their family. And so, Zallman told me, parents “are dis-enrolling kids even when the kids have legal access to these benefits and are not subject to the rule.”

This “chilling effect,” as researchers call it, is a feature of such programs, not a bug. It would be a mistake to see the public charge rule as the consequence of ignorance among administration policymakers, or a failure to read the relevant public health literature. Their obvious purpose—in design if not in word—is redistribution: taking healthcare from low-income families in order to pad the bank accounts of the rich. This was the story of the 2017 Obamacare repeal bills, just as it is the story of Medicaid work requirements, and the public charge rule today.

A few months after the public charge rule was proposed last October, for instance, a study from the Urban Institute found that about a fifth of adults in low-income immigrant families were already avoiding government programs out of fear of sinking their prospects of obtaining legal permanent residency.

One recent study in JAMA Pediatrics, led by Zallman, found that more than eight million children are at risk of losing access to health coverage or food assistance because of the rule. Those at risk include children with serious medical conditions—including hundreds of thousands with asthma and epilepsy. Without treatment, children with asthma can struggle to breathe, miss school, wind up in the ER or hospital—even asphyxiate. Failure to treat epilepsy, in turn, can lead to recurrent, dangerous, life-disrupting seizures. But that is simply a price the administration is willing to pay.

In 1882, in an earlier age of flourishing nativism, Congress passed the first “public charge” exclusion into federal law. However, the “public charge” rule has had a narrow scope in recent years, applying only to those who received cash assistance or public nursing-home care. The Trump administration’s new regulation upends that, casting legal immigrants who use a broad range of services—ranging from food stamps to housing assistance to Medicaid—as undesirables. Such “public charges” can then be denied a change in immigration status, such as issuance of a “green card.”

The new public charge rule hence weaves the administration’s xenophobic agenda into its broader regressive economic agenda. The administration’s head immigration official Ken Cuccinelli defended this draconian approach in an interview on NPR Tuesday by revising the famous quote inscribed on the Statue of Liberty’s pedestal. “Give me your tired and your poor,” he said, “who can stand on their own two feet, and who will not become a public charge.”

Not surprisingly, the rule mirrors the administration’s other health policies, such as the Medicaid work requirements championed by CMS administrator Seema Verma. Just like the public rule, Medicaid work requirements are ostensibly designed to reward a good work ethic. But in reality, both mainly serve to confuse working-class people—and squeeze them out of health coverage.

More than 18,000 individuals lost Medicaid coverage after work requirements went into effect in Arkansas last year, even though few were actually targeted by the policy as written. A failure to understand the arcane requirements and exclusions “may explain why thousands of persons lost coverage even though more than 95% of the target population appeared to meet the requirements or qualify for an exemption,” as a recent study in the New England Journal concluded.

The stakes are high, because programs like Medicaid can be a lifeline for working-class families, immigrant and non-immigrant alike. Activist Kristian Hernandez, whose parents both emigrated from Mexico and who today helps guide immigrants applying for asylum through the legal process in Texas, told me how important food and healthcare benefits were for her working-class family growing up: “[W]e wouldn’t have been able to survive otherwise,” she said. Hernandez fears that the rule could keep immigrant families in a similar position from such benefits today.

The public charge rule is cut from the same cloth as the administration’s larger redistributive agenda. Together, these policies are engineered to take healthcare (and other benefits) from the working class—disproportionately immigrants and people of color—so as to benefit the privileged few. It’s class warfare, and the kids with asthma and epilepsy are the collateral damage.

Adam Gaffney is a physician and public health researcher at Harvard Medical School and the Cambridge Health Alliance. He serves as president of the advocacy organization, Physicians for a National Health Program.

https://www.vice.com…

AMA bails out of partnership opposed to Medicare for All

AMA drops out of industry coalition opposed to Medicare expansion

By Dan Diamond and Adam Cancryn
POLITICO, August 15, 2019

The American Medical Association has quit a coalition that’s led the health industry’s fight against Medicare expansion, the first crack in its opposition to Democratic candidates’ proposals.

The AMA’s logo is no longer visible on the website of the Partnership for America’s Health Care Future, and multiple individuals with knowledge of the decision told POLITICO that the physicians’ organization decided to drop out after the coalition broadened its opposition last month from “Medicare for All” to more incremental proposals like former Vice President Joe Biden’s plan for a government-run public option. The AMA in June agreed at an annual meeting to study the feasibility of a public option after years of opposition to single-payer health care.

The AMA confirmed its departure. “Missing in the recent debate is an ongoing discussion of practical solutions that will result in more affordable insurance options,” CEO James Madara said in a statement to POLITICO, adding that the association recently laid out proposals to help achieve universal coverage. “The AMA decided to leave the Partnership for America’s Health Care Future so that we can devote more time to advocating for these policies that will address current coverage gaps and dysfunction in our health care system.”

The partnership — comprised of nearly 60 groups, including the American Hospital Association and AHIP — has spent millions of dollars advertising against Democrats’ Medicare expansion ideas and is currently running a messaging campaign against Biden’s public option proposal.

The AMA was among the partnership’s founding members in spring 2018. Several other member organizations affirmed that they will remain part of the industry coalition, blaming the AMA’s departure on internal dissension between younger doctors who support Democrats’ proposals and older physicians who remain wary of expanding government-run coverage.

https://www.politico.com…

Comment:

By PNHP President Adam Gaffney, M.D., M.P.H.

Yesterday, the American Medical Association announced that it is leaving the Partnership for America’s Health Care Future, a coalition of private insurance, pharmaceutical, and for-profit hospital companies whose sole purpose is to fight single-payer Medicare for All.

This is a big victory for single-payer supporters. In June, a coalition of doctors, nurses, students, seniors, and disability rights advocates descended on the AMA annual meeting in Chicago. We held a lively march and rally in the streets outside the meeting, while a group of activists launched a surprise “die-in” in the middle of the conference proceedings. Our demands to the AMA were clear: Leave the Partnership for America’s Health Care Future and drop your opposition to single payer.

While the AMA voted to maintain its anti-single payer policy, the razor-thin margin — 53% to 47% — stunned observers. And today we celebrate our second victory: The AMA’s resignation from this shameful campaign against health care justice.

I’m grateful to everyone who participated in this campaign, especially the SNaHP students (Students for a National Health Program) who originally conceived of the action. It was truly a team effort, from those of you who marched with me in Chicago, organized your fellow activists to attend, wrote letters and op-eds, talked to news reporters, and shared the #AMAGetOutTheWay campaign on social media.

As our movement grows, the industry is going to fight even harder against improved Medicare for All. We must be prepared, and we must continue to push the AMA to build on this first step by not only dropping its opposition to single payer, but by fully supporting improved Medicare for All.

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

AMA Drops Out of Group Opposing Medicare for All

Wants to study a public option and other potential solutions

By Joyce Frieden
MedPage Today, August 16, 2019

The American Medical Association has dropped out of the Partnership for America’s Health Care Future, a coalition of healthcare stakeholders dedicated to torpedoing the idea of a single-payer healthcare system such as Medicare for All.

The coalition “has extensively highlighted the many serious problems with Medicare for All and other proposals that would lead to a single payer health care system,” James Madara, the AMA’s executive vice president and CEO, said in a statement about the move, which was first reported by Politico. “Missing in the recent debate is an ongoing discussion of practical solutions that will result in more affordable insurance options.”

“Practical solutions have been identified and continue to be championed by the AMA,” Madara continued. “The AMA decided to leave the Partnership for America’s Health Care Future so that we can devote more time to advocating for these policies that will address current coverage gaps and dysfunction in our health care system.” He emphasized that the association “[remains] opposed to Medicare for All, and policies that reduce patient choice and competition, and are built on flawed financing policies.”

In response, the coalition issued a cordial statement saying it “strongly agrees with the American Medical Association (AMA) that Medicare for all is the wrong approach for America’s healthcare and we have appreciated the opportunity to work with them throughout the past year.” The partnership’s members include America’s Health Insurance Plans, the American Hospital Association, the BlueCross BlueShield Association, the Biotechnology Innovation Organization, and other groups that would be affected by any move to a publicly financed health insurance program.

“Today, too many individuals and families who do not have employer sponsored insurance and are ineligible for government subsidies face costly premiums and high deductibles that restrict their access to care. Action is needed now to assist this population without disrupting coverage that works for most Americans,” he said. “Additional policy improvements will further the goal of expanding coverage and offering more affordable options for the uninsured and those struggling to secure meaningful health insurance coverage.”

Such options could possibly include a “public option” that would allow people to buy into a public program such as Medicare if they would like. At its annual meeting in June, the AMA House of Delegates referred the AMA Board of Trustees to a resolution calling for the organization to “study the impacts of various approaches that offer a public option … including but not limited to a Medicare buy-in; a public option offered on health insurance exchanges; and buying into either the Federal Employees Health Benefits Program or a state employee health plan.” (The Partnership for America’s Health Care Future opposes a public option, which it says could “decimate” rural hospitals’ finances.)

The resolution also reaffirmed AMA policy which states that coverage options offered in a health insurance exchange “be self-supporting; have uniform solvency requirements; not receive special advantages from government subsidies; include payment rates established through meaningful negotiations and contracts; not require provider participation; and not restrict enrollees’ access to out-of-network physicians.” The board will report back to the delegates on the resolution, possibly as early as the association’s interim meeting in November.

Medicare for All was a flashpoint at the June meeting, as several hundred protesters gathered outside the meeting hotel to demand that the AMA support Medicare for All; several dozen protesters came inside the main meeting room and staged a “die-in” on the House of Delegates floor.

At least one group was happy with the AMA’s exit from the partnership. “This is a big victory for single-payer supporters,” Adam Gaffney, MD, president of Physicians for a National Health Program (PNHP), which supports single-payer, said in a statement. “For decades, the AMA has been on the wrong side of history, fighting efforts to establish Medicare and Medicaid in the 1960s, and resisting movements to bring racial equality to the delivery and practice of health care … The AMA’s exit from this explicitly anti-single payer lobbying group shows that change is within reach.” PNHP was one of several groups that organized the protest at the AMA meeting.

https://www.medpagetoday.com…

The Cost-Effectiveness of Medicare for All

A health consultant says the free market has failed to rein in medical costs.

By Ken Lefkowitz
New York Times, Letters, August 16, 2019

To the Editor:

Re: “The Tough Calls on ‘Medicare for All’” (The Upshot, Aug. 13):

The discussions about choice and competition, as well as cost, ignore some critical information and perspectives.

American health care is financed through a free market that has proved ineffective in controlling costs because it requires transparency so consumers can compare prices. But the dizzying complexity of both medical care and insurance plan design precludes the consumer from making informed choices. Primary care physicians strongly influence choice, and insurance company provider networks limit choice even further.

Also, single-payer universal health care, or Medicare for all, is quite cost-effective. It has proved to be less costly in other countries. It will wring out the duplicative and wasteful administrative costs of the free marketplace and provide powerful national negotiating leverage to stabilize medical provider and pharmacy costs.

A University of Massachusetts study demonstrated that Medicare for all can cover all citizens, including today’s uninsured, eliminating deductibles and co-pays, and still save an estimated $600 billion.

Even those who receive health care through their unions or companies should welcome such a plan, since premiums, deductibles and co-pays have been rising at a rapid rate in their plans.

The writer, a consultant, has designed and managed health care plans for major companies.

https://www.nytimes.com…

Medicare for All Explained Podcast: Episode 18

Interview with Kristy Fogle

August 15, 2019

Emergency medicine physician assistant and Maryland Progressive Healthcare Coalition founder Kristy Fogle discusses her recent organizing work and reminds listeners that all private health insurance plans pale in comparison to improved Medicare for All. Hosted by Joseph Sparks. Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

JG Kahn & E Marseille: Fears and facts of Medicare for All

Medicare for all: fears and facts

By Drs. James G. Kahn and Elliot Marseille
The Hill, August 14, 2019

Each candidate has their own way to fix what ails health insurance. Everyone claimed “Medicare” at the heart of their strategy. Sen. Bernie Sanders (D-Vt.) and Sen. Elizabeth Warren (D-Mass.) urged sweeping reform, while former Vice President Joe Biden and others advocated tinkering at the margins, stoking fear of big change.

What does it all mean?

After the first Democratic debate, we wrote a Cheat Sheet to clarify key concepts, and reviewed the minimal role of private insurance under “Medicare for all.” This time, we’re tackling people’s fears about reform and comparing the proposed plans.

Let’s start with three fears raised in the debate:

Should I be afraid of losing my insurance? Yes — under the current system. Unless you’re on Medicare, your health insurance is not guaranteed. Your employer can cancel the plan you like, forcing you to find a new doctor.

You may change jobs, or be laid off and lose your insurance. The premium may rise so much that you can no longer afford it. Coverage that’s guaranteed wherever (or whether) you work requires insurance that covers people based on U.S. residency rather than employment, like Rep. Pramila Jayapal’s (D-Wash.) Medicare for All Act of 2019.

Should I worry that taxes will go up? With Medicare for all, taxes will replace rising premiums, copays and deductibles.

These taxes will be progressive. The more you earn, the higher rate you pay. That’s fairer than charging for health insurance based on age, without regard to income, like now. The Affordable Care Act provides premium subsidies for some poorer people, but not for all and requires high deductibles and copays. For most people, the new taxes for health care will be less than what they currently pay in premiums and out-of-pocket costs. Low and middle-income families will save money. High-income families will pay more.

Should I fear losing choice of doctor? Sadly, we already have. Unless you’re on traditional Medicare, you can’t choose any doctor or hospital you like (except if you pay the costs yourself). Some presidential candidates say the choice worth making is between health insurers. Isn’t it more important to choose the doctor and hospital that provides your care, as permitted under Medicare for all?

Now, let’s compare the candidates’ plans. There are three approaches (see side-by-side table):

Medicare for all (single payer) provides coverage for life, regardless of health, wealth, or work status. Everyone has a comprehensive benefit package, accepted by all doctors. A public agency directly pays doctors and hospitals’ negotiated rates. Medicare for all combines superb coverage with lower costs. How? By simplifying every aspect of insurance, from enrollment to coverage to billing.

This results in massive administrative savings ($400-500 billion per year) and lower drug prices. How we pay for health care would also change. Taxes would rise, especially on the wealthy, but premiums and out-of-pocket costs would disappear. Most importantly, health care would cost our society less — 5 to 8 percent less in most studies, while covering everyone.

Public Option (or Medicare expansion) means we keep the current super-complex mix of private and public plans, while letting some people buy into Medicare. This protects private insurance companies, and so keeps the bad stuff — restricted doctor networks, deductibles and copays, and administrative bloat.

Medicare Advantage for all Sen. Kamala Harris (D-Calif.) recently proposed an approach based on Medicare Advantage, the HMO part of Medicare. This assures a large role for private insurers. Thus, it has most of the same drawbacks as the Medicare public option, with few savings opportunities. It would leave private insurers and all their unnecessary expenses burdening Americans for another decade.

Is Medicare for All “fairytale economics,” as former Rep. John Delaney said? It’s a system widely used in other countries — and works incredibly well. The real fairy tale is that we can still afford insurance middlemen taking a cut out of our health-care budget.

Is it too drastic? During the Great Depression, we launched America’s biggest social insurance program: Social Security. It’s a great example of how the government can protect us against economic risk and improve our lives. Medicare for all is a grand solution in a grand American tradition. This kind of health-care reform is not only possible, it’s essential.

James G. Kahn, M.D., is an emeritus professor of health policy at the University of California San Francisco. Dr. Elliot Marseille, DrPH, is CEO of Health Strategies International.

https://thehill.com…

Comment:

By Don McCanne, M.D.

Many of the conversations taking place today on Medicare for All are strong on opinion and weak on facts. When we get the facts straight it becomes obvious that the single payer model of Medicare for All is an imperative.

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Why doesn’t the United States have universal health care? The answer has everything to do with race.

By Jeneen Interlandi
New York Times, August 14, 2019

The smallpox virus hopscotched across the post-Civil War South, invading the makeshift camps where many thousands of newly freed African-Americans had taken refuge but leaving surrounding white communities comparatively unscathed. This pattern of affliction was no mystery: In the late 1860s, doctors had yet to discover viruses, but they knew that poor nutrition made people more susceptible to illness and that poor sanitation contributed to the spread of disease. They also knew that quarantine and vaccination could stop an outbreak in its tracks; they had used those very tools to prevent a smallpox outbreak from ravaging the Union Army.

Smallpox was not the only health disparity facing the newly emancipated, who at the close of the Civil War faced a considerably higher mortality rate than that of whites. Despite their urgent pleas for assistance, white leaders were deeply ambivalent about intervening. They worried about black epidemics spilling into their own communities and wanted the formerly enslaved to be healthy enough to return to plantation work. But they also feared that free and healthy African-Americans would upend the racial hierarchy, the historian Jim Downs writes in his 2012 book, “Sick From Freedom.”

Federal policy, he notes, reflected white ambivalence at every turn. Congress established the medical division of the Freedmen’s Bureau — the nation’s first federal health care program — to address the health crisis, but officials deployed just 120 or so doctors across the war-torn South, then ignored those doctors’ pleas for personnel and equipment. They erected more than 40 hospitals but prematurely shuttered most of them.

White legislators argued that free assistance of any kind would breed dependence and that when it came to black infirmity, hard labor was a better salve than white medicine. As the death toll rose, they developed a new theory: Blacks were so ill suited to freedom that the entire race was going extinct. “No charitable black scheme can wash out the color of the Negro, change his inferior nature or save him from his inevitable fate,” an Ohio congressman said.

One of the most eloquent rejoinders to the theory of black extinction came from Rebecca Lee Crumpler, the nation’s first black female doctor. Crumpler was born free and trained and practiced in Boston. At the close of the war, she joined the Freedmen’s Bureau and worked in the freed people’s communities of Virginia. In 1883, she published one of the first treatises on the burden of disease in black communities. “They seem to forget there is a cause for every ailment,” she wrote. “And that it may be in their power to remove it.”

In the decades following Reconstruction, the former slave states came to wield enormous congressional power through a voting bloc that was uniformly segregationist and overwhelmingly Democratic. That bloc preserved the nation’s racial stratification by securing local control of federal programs under a mantra of “states’ rights” and, in some cases, by adding qualifications directly to federal laws with discriminatory intent.

As the Columbia University historian Ira Katznelson and others have documented, it was largely at the behest of Southern Democrats that farm and domestic workers — more than half the nation’s black work force at the time — were excluded from New Deal policies, including the Social Security and Wagner Acts of 1935 (the Wagner Act ensured the right of workers to collective bargaining), and the Fair Labor Standards Act of 1938, which set a minimum wage and established the eight-hour workday. The same voting bloc ensured states controlled crucial programs like Aid to Dependent Children and the 1944 Servicemen’s Readjustment Act, better known as the G.I. Bill, allowing state leaders to effectively exclude black people.

In 1945, when President Truman called on Congress to expand the nation’s hospital system as part of a larger health care plan, Southern Democrats obtained key concessions that shaped the American medical landscape for decades to come. The Hill-Burton Act provided federal grants for hospital construction to communities in need, giving funding priority to rural areas (many of them in the South). But it also ensured that states controlled the disbursement of funds and could segregate resulting facilities.

Professional societies like the American Medical Association barred black doctors; medical schools excluded black students, and most hospitals and health clinics segregated black patients. Federal health care policy was designed, both implicitly and explicitly, to exclude black Americans. As a result, they faced an array of inequities — including statistically shorter, sicker lives than their white counterparts. What’s more, access to good medical care was predicated on a system of employer-based insurance that was inherently difficult for black Americans to get. “They were denied most of the jobs that offered coverage,” says David Barton Smith, an emeritus historian of health care policy at Temple University. “And even when some of them got health insurance, as the Pullman porters did, they couldn’t make use of white facilities.”

In the shadows of this exclusion, black communities created their own health systems. Lay black women began a national community health care movement that included fund-raising for black health facilities; campaigns to educate black communities about nutrition, sanitation and disease prevention; and programs like National Negro Health Week that drew national attention to racial health disparities. Black doctors and nurses — most of them trained at one of two black medical colleges, Meharry and Howard — established their own professional organizations and began a concerted war against medical apartheid. By the 1950s, they were pushing for a federal health care system for all citizens.

That fight put the National Medical Association (the leading black medical society) into direct conflict with the A.M.A., which was opposed to any nationalized health plan. In the late 1930s and the 1940s, the group helped defeat two such proposals with a vitriolic campaign that informs present-day debates: They called the idea socialist and un-American and warned of government intervention in the doctor-patient relationship. The group used the same arguments in the mid-’60s, when proponents of national health insurance introduced Medicare. This time, the N.M.A. developed a countermessage: Health care was a basic human right.

Medicare and Medicaid were part of a broader plan that finally brought the legal segregation of hospitals to an end: The 1964 Civil Rights Act outlawed segregation for any entity receiving federal funds, and the new health care programs soon placed every hospital in the country in that category. But they still excluded millions of Americans. Those who did not fit into specific age, employment or income groups had little to no access to health care.

In 2010, the Affordable Care Act brought health insurance to nearly 20 million previously uninsured adults. The biggest beneficiaries of this boon were people of color, many of whom obtained coverage through the law’s Medicaid expansion. That coverage contributed to a measurable decrease in some racial health disparities, but the success was neither as enduring nor as widespread as it might have been. Several states, most of them in the former Confederacy, refused to participate in Medicaid expansion. And several are still trying to make access to the program contingent on onerous new work requirements. The results of both policies have been unequivocal. States that expanded Medicaid saw a drop in disease-related deaths, according to the National Bureau of Economic Research. But in Arkansas, the first state to implement work requirements, nearly 20,000 people were forced off the insurance plan.

One hundred and fifty years after the freed people of the South first petitioned the government for basic medical care, the United States remains the only high-income country in the world where such care is not guaranteed to every citizen. In the United States, racial health disparities have proved as foundational as democracy itself. “There has never been any period in American history where the health of blacks was equal to that of whites,” Evelynn Hammonds, a historian of science at Harvard University, says. “Disparity is built into the system.” Medicare, Medicaid and the Affordable Care Act have helped shrink those disparities. But no federal health policy yet has eradicated them.

Jeneen Interlandi is a member of The Times’s editorial board and a staff writer for the magazine.

https://www.nytimes.com…

Medicare ACO outcomes are indistinguishable from zero

Association Between Care Management and Outcomes Among Patients With Complex Needs in Medicare Accountable Care Organizations

By Mariétou H. Ouayogodé, PhD, Alexander J. Mainor, JD, MPH, Ellen Meara, PhD, Julie P. W. Bynum, MD, MPH, and Carrie H. Colla, PhD
JAMA Network Open, July 12, 2019

Abstract

Importance

People with complex needs account for a disproportionate amount of Medicare spending, partially because of fragmented care delivered across multiple practitioners and settings. Accountable care organization (ACO) contracts give practitioners incentives to improve care coordination to the extent that coordination initiatives reduce total spending or improve quality.

Objective

To assess the association between ACO-reported care management and coordination activities and quality, utilization, spending, and health care system interactions in older adults with complex needs.

Design, Setting, and Participants

In this cross-sectional study, survey information on care management and coordination processes from 244 Medicare Shared Savings Program ACOs in the 2017-2018 National Survey of ACOs (of 351 Medicare ACO respondents; response rate, 69%) conducted from July 20, 2017, to February 15, 2018, was linked to 2016 Medicare administrative claims data. Medicare beneficiaries 66 years or older who were defined as having complex needs because of frailty or 2 or more chronic conditions associated with high costs and clinical need were included.

Exposures

Beneficiary attribution to ACO reporting comprehensive (top tertile) care management and coordination activities.

Main Outcomes and Measures

All-cause prevention quality indicator admissions, 30-day all-cause readmissions, acute care and critical access hospital admissions, evaluation and management visits in ambulatory settings, inpatient days, emergency department visits, total spending, post–acute care spending, health care contact days, and continuity of care (from Medicare claims).

Results

Among 1 402 582 Medicare beneficiaries with complex conditions, the mean (SD) age was 78 (8.0) years and 55.1% were female. Compared with beneficiaries assigned to ACOs in the bottom tertile of care management and coordination activities, those assigned to ACOs in the top tertile had identical median prevention quality indicator admissions and 30-day all-cause readmissions (0 per beneficiary across all tertiles), hospitalization and emergency department visits (1.0 per beneficiary in bottom and top tertiles), evaluation and management visits in ambulatory settings (14.0 per beneficiary [interquartile range (IQR), 8.0-21.0] in both tertiles), longer median inpatient days (11.0 [IQR, 4.0-33.0] vs 10.0 [IQR, 4.0-32.0]), higher median annual spending ($14 350 [IQR, $4876-$36 119] vs $14 229 [IQR, $4805-$36 268]), lower median health care contact days (28.0 [IQR, 17.0-44.0] vs 29.0 [IQR, 18.0-45.0]), and lower continuity-of-care index (0.12 [IQR, 0.08-0.20] vs 0.13 [IQR, 0.08-0.21]). Accounting for within-patient correlation, quality, utilization, and spending outcomes among patients with complex needs attributed to ACOs were not statistically different comparing the top vs bottom tertile of care management and coordination activities.

Conclusions and Relevance

The ACO self-reports of care management and coordination capacity were not associated with differences in spending or measured outcomes for patients with complex needs. Future efforts to care for patients with complex needs should assess whether strategies found to be effective in other settings are being used, and if so, why they fail to meet expectations.

From the Discussion

To measure whether ACO efforts to manage and coordinate care are associated with health care utilization and spending outcomes in groups likely to benefit from such services, we used data from the NSACO to form a care management and coordination index that plausibly targets older patients with complex health needs. We found wide variation in reported care management and coordination activities across MSSP participants. For example, when index scores were ranked by the level of care management activity reported, we observed large differences in the use of evidence-based approaches to care transitions for hospitalized patients. In multivariate analyses of patient-level measures for 244 ACO respondents, we found that high levels of care management and coordination intensity were not associated with significant differences in hospitalizations, inpatient days, E&M visits in ambulatory settings, spending, and health care system contact days despite large samples of beneficiaries in each group of ACOs.

Although our study is not definitive and includes several limitations, our estimates on various outcomes are indistinguishable from zero, indicating a call to invest in these areas with caution and to track local results in careful evaluations. Our results suggest that organizations should consider the effectiveness of investing heavily in care coordination activities that are difficult to implement.

https://www.ncbi.nlm.nih.gov…

Comment:

By Don McCanne, M.D.

Regarding this study of outcomes among patients with complex needs in Medicare accountable care organizations, these authors report, “our estimates on various outcomes are indistinguishable from zero.” If there were any merit to ACOs, it should certainly show up in patients with complex needs.

As with many other studies that are reporting negligible results in their evaluations of accountable care organizations, these authors also recommend, “As ACOs focus on expanding care coordination and management efforts, it is important to continually evaluate the effectiveness of those programs for different patient populations.” More study of the same unsuccessful, mindless policy options?

There are endless conferences, seminars, and journal articles on accountable care organizations, all for naught. Yet where are the conferences on the single payer model of Medicare for All? These other conferences are a distraction from what we need to be doing – moving forward with enacting and implementing a model that would be truly effective, efficient, equitable, and affordable for all; Single Payer Medicare for All. Accountable care organizations are a dead end.

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