By Adam Gaffney, M.D., M.P.H.
Washington Post, May 8, 2019

The blood sugar rises, and nausea and vomiting follow. The blood acidifies, the breath hastens, dehydration and then delirium ensue: That’s how ketoacidosis, a feared complication of diabetes, progresses. Diabetic ketoacidosis, which results in nearly 190,000 hospitalizations a year, is a condition I treat frequently as an ICU physician: We infuse intravenous insulin, saline and electrolytes, while carefully tracking sugar levels and blood chemistries and vital signs. If all goes well, the sugar normalizes, acid levels fall, the breath begins to slow, the appetite returns. Not always, however: Every year, hundreds of people die of the condition.

What makes this such a tragedy is that the complication is typically preventable through the regular use of insulin. Yet the soaring price of that drug has put it beyond the reach of many — and for many of the 29 million Americans without insurance, insulin might be unaffordable at any price.

But what about ketoacidosis in a country with universal health care? I joined some colleagues at Harvard Medical School, the Cambridge Health Alliance and the City University of New York to collaborate with a team of researchers at the University of Manitoba in Canada to find out.

We compared ketoacidosis hospitalization rates in the United States and Canada, focusing on the transition from adolescence to young adulthood — a vulnerable time when many young people lose or change health coverage. Our results, published in the Journal of General Internal Medicine, were striking. Based on our analysis of two large databases of hospitalized patients — one covering the United States and the other the province of Manitoba — we found that the hospitalization rate for diabetic ketoacidosis among children and adolescents was somewhat higher in the United States than in Canada. However, as teenagers became young adults, the rate soared by 90 percent in the United States, compared with a 23 percent rise in Manitoba.

At least three major differences in the way our nations finance health care could contribute to this result. First, uninsured rates rise dramatically in young adulthood in the United States. And as numerous studies have demonstrated (to say nothing of common sense), the uninsured go without all types of needed medical care, ranging from doctors’ visits to prescription drugs. In Canada, in contrast, this is not a problem; the uninsured rate is zero.

A second factor might be Americans’ exposure to onerous out-of-pocket costs for medical care. Forty-six percent of privately insured adults have “high-deductible” health plans that require them to spend substantial amounts of money out of pocket before insurance kicks in. Such plans may be dangerous for patients with diabetes. A 2017 study, for instance, found that individuals with diabetes who were pushed by their employers into a high-deductible health plan saw specialists less but wound up in the ER with acute complications more. In Canada, in contrast, physician care and hospital care is free at the time of care; co-pays and deductibles are $0.

The Canadian system does not universally cover prescription drugs as comprehensively as it does other care, unlike places such as Wales or Scotland, where everyone has drug coverage without co-pays or deductibles. Still, drugs are more affordable in Canada than the United States: In 2015, Bloomberg reported that one 3-milliliter pen of long-acting insulin cost $186 in the United States (accounting for rebates), three times the $67 it cost in Canada. Meanwhile, about 16.8 percent of older adults in the United States report not filling a drug prescription or skipping dosages of a medication because of cost — about double the proportion in Canada.

Finally, there is a related problem that researchers call “churn.” Most Americans have little stability in their insurance coverage: Your plan can change every time your boss says so, or whenever you (or maybe your partner or your parents) lose or change jobs. A recent analysis from Axios estimated that 2 million workers, together with their families, lose or change coverage every month. Churn is not merely inconvenient, though; it can be hazardous to your health. A 2016 study found that churners with low incomes frequently face dangerous disruptions in care: 20 percent change doctors, while 34 percent skip medications or stopped taking them because of discontinuities in coverage. In Canada, in contrast, there is no churn, because there is but one “single payer” that provides universal coverage seamlessly throughout the life span, without insurance networks or disruptive plan-switching.

Discontinuities in coverage don’t affect only the young. Take Meaghan Carter, a 47-year-old nurse with Type I diabetes who was found dead on her couch last Christmas, as USA Today recently reported. At the time of her death, the paper noted, she was temporarily uninsured because she was in between jobs, and she had $50 in the bank and no insulin left in her fridge, leading her family to attribute her death to ketoacidosis.

Making the American health-care system work for patients with chronic diseases such as diabetes requires rectifying not just one, but all three of these interconnected dysfunctions. Yet of the various health-care reform proposals under discussion today, only one — single-payer, “Medicare-for-all” — would do so: It would cover all the insured, basically eliminate financial barriers to care such as co-pays and deductibles, and bring to an end the dangerous disruptions of coverage that are so common in our fragmented system. This is one reason that I, like so many in the medical profession, support it.

Individuals with chronic illnesses such as diabetes deserve no less. Without such a transformative reform, it seems likely that we’ll still have patients with ketoacidosis coming through the doors of ICUs, breathing deep, dry as a bone, acid levels soaring — even when it might have been avoided had a better, more just health-care system been in place.

Dr. Adam Gaffney is an Instructor in medicine at Harvard Medical School and a pulmonary and critical care physician at the Cambridge Health Alliance and serves as president of Physicians for a National Health Program.

https://www.washingtonpost.com…

The Incidence of Diabetic Ketoacidosis During “Emerging Adulthood” in the USA and Canada: A Population-Based Study

Journal of General Internal Medicine, May 8, 2019

https://link.springer.com…

Comment:

By Don McCanne, M.D.

The fact that a 3-milliliter pen of long-acting insulin costs $67 in Canada is shameful. Canadian diabetics of limited means can have difficulty affording that and may be tempted to reduce the dose or go without, risking the onset of ketoacidosis and even death.

It has often been said that no health care system is perfect, and that is true. But contrast Canada with the United States. That same dose of insulin costs $186 in the United States. Even of greater concern, the diabetic in the United States may be uninsured or has a significant chance of having inadequate coverage. For young adult diabetics going out on their own in the United States, the incidence of ketoacidosis soared 90 percent, whereas it increased 23 percent in Manitoba.

Canada can do better (pharmacare anyone?). But the United States? We certainly have no excuse either. We have the resources and the health policy know-how to do better than Canada and every other nation in the world. We should not have one single death from ketoacidosis that is due to financial barriers between the diabetic and her life-saving insulin.

We need a single payer Medicare for All system to eliminate the financial barriers to health care so that we can give more attention to reducing the other socioeconomic barriers as well.

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

By Gretchen Jacobson, Tricia Neuman, and Anthony Damico
Kaiser Family Foundation Issue Brief, May 2019

People on Medicare can choose coverage from either traditional Medicare or Medicare Advantage plans, typically trading off broad access to providers for potentially lower premiums and out-of-pocket costs. Beneficiaries who choose Medicare Advantage may differ from those in traditional Medicare in both measurable and unmeasurable ways, which may influence their use of services and spending. Yet, Medicare payments to Medicare Advantage plans per enrollee are based on average spending among beneficiaries in traditional Medicare.

This analysis looks at whether beneficiaries who choose to enroll in Medicare Advantage plans have lower spending, on average – before they enroll in Medicare Advantage plans – than similar people who remain in traditional Medicare. We compare average traditional Medicare spending and use of services in 2015 among beneficiaries who switched to Medicare Advantage plans in 2016 with those who remained in traditional Medicare that year, after adjusting for health risk. We adjust Medicare spending values for health conditions and other factors, with a model similar to the CMS HCC Risk Adjustment Model that is used to adjust payments to Medicare Advantage plans.

Key Findings

• People who switched from traditional Medicare to Medicare Advantage in 2016 spent $1,253 less in 2015, on average, than beneficiaries who remained in traditional Medicare, after adjusting for health risk.
• Even among traditional Medicare beneficiaries with specific health conditions, those who shifted to Medicare Advantage in 2016 had lower average spending in 2015, including people with diabetes ($1,072), asthma ($1,410), and breast or prostate cancer ($1,517).

Even after risk adjustment, the results indicate that beneficiaries who choose Medicare Advantage have lower Medicare spending – before they enroll in Medicare Advantage plans – than similar beneficiaries who remain in traditional Medicare, suggesting that basing payments to plans on the spending of those in traditional Medicare may systematically overestimate expected costs of Medicare Advantage enrollees.

Overview

Medicare payments to Medicare HMOs and PPOs, known as Medicare Advantage plans, have always been based on Medicare spending by similar people in traditional Medicare, partly because Medicare has never had accurate, complete data on the use of services or health care spending for beneficiaries in Medicare Advantage plans. The assumption has been that adjusting payments to plans for health status and other factors accounts for differences between beneficiaries in traditional Medicare and those in Medicare Advantage plans. Profits are assumed to be due to plans reducing spending by either managing fees (e.g., by having lower-cost hospitals in their network) or changing patterns of care (e.g., reducing hospital readmissions), rather than to favorable selection. Nonetheless, selection bias has been an ongoing concern and the subject of many studies over the years, with mixed evidence of favorable selection. This question is important because it affects the accuracy of Medicare payments to plans on behalf of 20 million Medicare beneficiaries, and rising.

This is the first known analysis to examine whether beneficiaries who choose to enroll in Medicare Advantage plans have lower spending and use fewer services – before enrolling in Medicare Advantage – than similar people in traditional Medicare. If Medicare Advantage enrollees use fewer services and have lower Medicare spending before they enroll in Medicare Advantage plans, compared to similar beneficiaries in traditional Medicare, then basing payments to Medicare Advantage plans on the Medicare spending for similar beneficiaries in traditional Medicare would overestimate the expected costs of Medicare Advantage enrollees and overpay plans by billions of dollars over the next decade. Studies that have looked at differences in the use of services and Medicare spending for Medicare Advantage enrollees compared to beneficiaries in traditional Medicare that did not account for actual prior differences may have overestimated the extent to which plans are reducing enrollees’ spending or use of services.

Discussion

This analysis examines whether beneficiaries who choose to enroll in Medicare Advantage plans have lower spending and use fewer services – before enrolling in Medicare Advantage – than similar people in traditional Medicare. The study found that beneficiaries who chose to enroll in a Medicare Advantage plan in 2016 had average expenditures in traditional Medicare (in 2015) that were $1,253 less, on average, than similar beneficiaries who remained in traditional Medicare. Similar differences in spending were found across all demographics and chronic conditions, even after adjusting for health risk factors. The results suggest that favorable self-selection into Medicare Advantage plans is occurring, even among traditional Medicare beneficiaries with similar health conditions. The findings raise questions as to why beneficiaries who are higher utilizers are less likely to go into Medicare Advantage and instead remain in traditional Medicare.

Other studies have examined services used by people while they were enrolled in Medicare Advantage plans, based on limited data, and have generally found that beneficiaries in Medicare Advantage plans use fewer services than those in traditional Medicare. Notably, the authors of these studies almost universally attribute differences in service utilization to care management by the plans – rather than to pre-existing differences in care seeking behavior and use of health services. This study suggests that differences in health care use, and spending, are evident before beneficiaries decided to enroll in Medicare Advantage plans or remain in traditional Medicare, raising questions about the extent to which plans are actually lowering spending or managing care.

It is not clear whether the differences in spending observed in this study increase, decrease, or persist over time as beneficiaries age, which has implications for whether a similar difference in spending could be assumed for all Medicare Advantage enrollees. Likewise, it is not clear how this difference in spending will change as the share of counties with the majority of beneficiaries in Medicare Advantage plans grows. This missing information could have important implications for Medicare spending. Potential overpayments could amount to billions in excess Medicare spending over a ten-year period if the observed differences in spending hold up as beneficiaries age and Medicare Advantage enrollment continues to rise. To illustrate, if the difference in average Medicare spending ($1,253) applied to just 10 percent of all Medicare Advantage enrollees in 2016, or 1.8 million enrollees, it would amount to more than $2 billion in excess spending in one year alone.

Policymakers could consider adjusting payments to reflect Medicare Advantage enrollees’ prior use of health care services, which could lower total Medicare spending and in turn reduce Medicare Part B premiums and deductibles for all beneficiaries. With more than 20 million enrollees in Medicare Advantage plans and Medicare payments to plans projected to reach $250 billion in 2019, the stakes are high for making payments to plans as accurate as possible.

https://www.kff.org…

Comment:

By Don McCanne, M.D.

It has long been contended that private Medicare Advantage plans have been able to reduce spending and thus increase profits by managing fees and by changing patterns of care (managed care). But this study indicates that Medicare Advantage patients already had had lower spending when they were enrolled in the traditional Medicare program and thus suggests that “favorable self-selection into Medicare Advantage plans is occurring.” Since Medicare Advantage payments are based on average spending in the traditional program, the Medicare Advantage plans are being overpaid for these patients with lower health care costs.

There are many reasons that private Medicare Advantage plans are a worse choice, even though marketing techniques have made them popular. Administrative costs are higher in the private plans. Choice of health care professionals is less because of the networks used by the private plans as opposed to the unlimited choices in the traditional Medicare program. Also administrative chicanery has been used by the government to increase payment rates for the private plans in an effort to move toward privatization of Medicare. Now we see that apparently healthier patients with fewer needs are enrolling in the private plans yet they are being paid as if they are comparable to the average health status of those in the traditional program. Once again, the taxpayer is being ripped off in order to support the private insurers that offer the Medicare Advantage plans.

Ironically, the single payer Medicare for All model provides superior benefits with much greater choices in care than does the private Medicare Advantage model. Yet politicians and the insurance industry have convinced the public that they are getting a better deal through the private insurers. As one famous politician said, “It’s complicated.” But it is not that complicated to understand when you see that private insurers benefit and taxpayers lose.

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By Noam N. Levey
Los Angeles Times, May 2, 2019

Soaring deductibles and medical bills are pushing millions of American families to the breaking point, fueling an affordability crisis that is pulling in middle-class households with health insurance as well as the poor and uninsured.

In the last 12 years, annual deductibles in job-based health plans have nearly quadrupled and now average more than $1,300.

Yet Americans’ savings are not keeping pace, data show. And more than four in 10 workers enrolled in a high-deductible plan report they don’t have enough savings to cover the deductible.

One in six Americans who get insurance through their jobs say they’ve had to make “difficult sacrifices” to pay for healthcare in the last year, including cutting back on food, moving in with friends or family, or taking extra jobs. And one in five say healthcare costs have eaten up all or most of their savings

The conclusions are based in part on a nationwide poll The Times conducted in partnership with the nonprofit Kaiser Family Foundation, or KFF. Two Washington-based think tanks — the Health Care Cost Institute and the Employee Benefit Research Institute — provided supplemental analysis.

The conclusions are based in part on a nationwide poll The Times conducted in partnership with the nonprofit Kaiser Family Foundation, or KFF. Two Washington-based think tanks — the Health Care Cost Institute and the Employee Benefit Research Institute — provided supplemental analysis.

And it is feeding resentments and deepening inequalities, as healthier and wealthier Americans are able to save for unexpected medical bills while the less fortunate struggle to balance costly care with other necessities.

Hardest hit in the cost shift are lower-income workers and those with serious medical conditions such as diabetes, heart disease and cancer — who are more than twice as likely as healthier workers, according to the Times/KFF poll, to report problems paying medical bills and to say they’ve cut back on spending for food, clothing and other household items.

“There has been a quiet revolution in what health insurance means in this country,” said Drew Altman, the longtime head of the Kaiser Family Foundation. “This happened under the radar while everyone was focused on the Affordable Care Act.”

The 2010 healthcare law — often called Obamacare — provided landmark protections to Americans once shut out of health coverage. But as Democrats and Republicans fought over the law, Altman said, neither focused on the rapid run-up in costs for people covered through work.

“We forgot that most people get their insurance through an employer, and for them, the issue is medical bills that they increasingly cannot afford,” Altman said.

This wasn’t how the high-deductible revolution was supposed to play out.

Twenty years ago, amid a backlash against HMO restrictions on people’s ability to choose their doctors, high-deductible plans were billed as a way to empower patients and free them from the unpopular constraints of managed care.

Even then there were red flags: As far back as the 1970s, a landmark study by the California-based Rand Corp. had found that requiring people to pay more out of pocket caused them to cut back on medical care they needed as well as on unnecessary services.

Backers of the high-deductible strategy nevertheless argued that patients, given “skin in the game,” would become active consumers who would force drugmakers, hospitals and other medical providers to rein in prices.

“The thing that caught people’s imagination was this idea of unleashing American patients as consumers,” said Dr. Arnie Milstein, medical director of the California-based Pacific Business Group on Health, an organization of large companies, including Boeing, Safeway, Walmart and Wells Fargo.

Employers, desperate for a way to control healthcare spending, saw an opportunity to hold down costs.

Many of the first companies to offer high-deductible plans gave employees seed money for medical savings accounts, with the idea that the cash would help workers pay their deductibles. Within a few years, the George W. Bush administration — backed later by Congress — carved out tax benefits for the accounts.

As high-deductible plans caught fire, however, many employers saw they could save even more by not contributing to their employees’ accounts.

The change left workers responsible for saving for healthcare on their own.
Yet government data show that most workers haven’t had extra money to set aside.

“In the real world, average people are living paycheck to paycheck,” said Helen Darling, the former head of the National Business Group on Health, a leading employer organization focused on health benefits. “Unfortunately, that never got through to the policy debate.”
Moreover, the vision of legions of patients becoming engaged shoppers pushing down prices has turned out to be a mirage.

In a major reversal from 15 years ago, six in 10 Americans with job-based coverage now call affordability the most important feature of a health plan, outranking previous top concerns such as a broad choice of doctors and hospitals and a wide range of benefits.

https://www.latimes.com…

Kaiser Family Foundation/LA Times Survey Of Adults With Employer-Sponsored Health Insurance:
http://files.kff.org…

Comment:

By Don McCanne, M.D.

Several politicians who got on the single payer Medicare for All bandwagon are now backing off saying that people should be able to keep the insurance they get at work. But why? Health care under employer-sponsored plans has become much less affordable for those who happen to need health care. It isn’t working the way most people think it should, and the majority believe that the government should do something about that.

The design features of single payer Medicare for All make the insurance itself affordable for everyone by using progressive tax policies, while eliminating the financial barriers at the point of care, ensuring that everyone has affordable access to care. The current employer-sponsored plans are going in the opposite direction – health care that is less and less affordable, especially for those with needs. Our politicians need to know what the public thinks about that since they don’t seem to be listening those of us who are providing them with the grim facts.

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

By Raina Lipsitz
The Nation, May 2, 2019

The Albany machine is working to torpedo the New York Health Act—again.

New York’s Democratic voters sent a new class of true-blue legislators to Albany in 2018. With the governor’s office and both houses of the state legislature firmly under Democratic control—and a raft of progressive bills rapidly signed into law—many hoped this would be the year New York finally enacted single-payer health care.

Health care was, after all, a top concern of voters in 2018, and support for single-payer legislation is strong and growing.

Yet recent reports indicate that the New York State Senate has no plans to vote on legislation this session, preferring to hold more hearings on a bill that has been proposed in the legislature since 1992. Assembly member Richard Gottfried, whom I interviewed in February, has sponsored the pro-single-payer New York Health Act (NYHA) for nearly 30 years, and the Assembly passed his bill in the past four legislative sessions. But a number of new or re-elected state senators, faced with the fresh possibility that single-payer might actually become a reality, have walked back their formerly full-throated support.

Pressed to clarify their positions, (Governor) Cuomo and a number of Democratic legislators played variations on this tune: Single-payer is ideal, but here and now—at the state level and without the elusive waiver—is not the time or place.

Cuomo has gained from strengthening alliances with legislators who support cost-free Democratic priorities but oppose or are willing to backtrack on those that require money. He and his allies prefer to avoid inconveniencing wealthy donors or worrying suburban voters. Cuomo fears the rich will flee New York if they have to pay higher taxes.

Knowing some unions oppose the bill “breaks my heart,” Dr. Martha Livingston told me in a phone conversation. She is the chair of SUNY Old Westbury’s public health department, the vice chair of the NY Metro chapter of Physicians for a National Health Program, and a national board member of the Labor Campaign for Single Payer Healthcare. “I speak as a union activist in my own union,” she said, and “my position and other unions’ position is, if we can get health care off the bargaining table, we can advocate for so much more in our members’ pockets.”

Katie Robbins directs the Campaign for New York Health and works for the New York State Nurses Association, the state’s largest union for registered nurses. The NYSNA and 1199SEIU are the NYHA’s two most powerful union backers. Robbins said in a phone conversation that she and her allies are “disappointed” that public-sector unions oppose the bill. She takes their concerns seriously and has called for “a labor roundtable to work through these issues.” It is, she said, both possible and “necessary” to make the bill work for unions.

State Senator Gustavo Rivera, the chair of the Health Committee and the bill’s sponsor in his chamber, acknowledged in a phone conversation that “attacks from the right” and “resistance from the left” have created “a very narrow path” to passing the NYHA.

Divisions over the NYHA exist both within and among unions. Many rank-and-file members have no opinion on or support single-payer at the state level, while many leaders oppose it. The Movement of Rank and File Educators (MORE) is an opposition caucus in the United Federation of Teachers. MORE member Peter Lamphere was blunt about why he thought UFT president Michael Mulgrew supported the Municipal Labor Committee’s decision to send a letter opposing the NYHA to Cuomo, Assembly Speaker Carl Heastie, and Senate Majority Leader Andrea Stewart-Cousins.

“Mulgrew has caved to Cuomo and some of the more conservative elements in the union movement on NYHA,” Lamphere wrote in an email. “MORE has a position in favor of [statewide] single payer and we campaigned on this in the UFT elections.”

Asked whether UFT members voted to oppose the bill, Mulgrew said the Municipal Labor Committee decided to send an opposition letter, and he was elected to serve on the committee. “You’re an elected rep from your union,” he said. “If you had to, every time you were asked to vote or to give your opinion, stop and go back to your union, you’d never get any of that work done.”

Few New York Democrats openly oppose it. But the New York Health Act won’t pass until they are all willing to fight.

“Single-payer is clearly the morally correct choice to make, and we need to be on the right side of history,” Dan Lupkin, a MORE member, told me on the phone. “There is a case to be made, and the union should be making the case for the greater good.”

It’s a case people like Gottfried have been making for decades. But insurance-industry money, tax phobia, political cowardice, and anxiety over scrapping a broken but familiar system remain.

At an April forum on the NYHA at Brooklyn College… “What you ought to care about is how much money leaves your wallet,” Gottfried told one skeptical man. “Under the act, less money will leave your wallet…. The fact that the money, after it leaves your wallet, is called a tax as opposed to a premium and a deductible and a copay—all that means is that the money will be going to an entity that is accountable to you as a voter, as opposed to going to an entity that is accountable to insurance company stockholders.”

This year, Cuomo called for a commission to study health care. The Senate is delaying a vote on the NYHA until public hearings are held.

Single-payer legislation has been studied, debated, proposed, and refined for three-quarters of a century. The only question left is how to make lawmakers do it.

https://www.thenation.com…

Comment:

By Don McCanne, M.D. 

New York seems to be primed to be the first state to enact a single payer system, but rumblings have indicated that there is some resistance within the state. The article in The Nation, excerpted above, provides clues to the intrigue involving the governor, a couple of unions, and some hesitant Democratic legislators.

I asked Assemblyman Richard Gottfried, who authored the New York Health Act (with Senator Gustavo Rivera sponsoring it in the Senate), if he had any comment on this article. His response:

“The article is generally accurate. Many large unions strongly support the NYHA— the NYS Nurses Assoc., 1199, 32BJ SEIU (building service workers), RWDSU (retail workers), UAW, much of the CWA, etc. The building trades in NYC have questions but want to work them out with us. They all know the importance of getting health benefits off the bargaining table and understand the advantages of single payer for their members. But most of our public sector unions are opposing it. We’re working on their concerns.

“Yes, there are legislators who campaigned in support of the bill and now need reassurance. Senator Rivera and I are talking with them.”

With the amount of money that we are already spending, we could easily have comprehensive health care for absolutely everyone, but mere politics remains the barrier. Mere politics? Is that the penalty we pay for supporting democracy in action? Leaving health care screwed up is some penalty for trying to do the right thing.

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By K. Robin Yabroff, Jingxuan Zhao, Xuesong Han, Zhiyuan Zheng
Journal of General Internal Medicine, May 1, 2019

Abstract

Background

High patient out-of-pocket (OOP) spending for medical care is associated with medical debt, distress about household finances, and forgoing medical care because of cost in the USA.

Objective

To examine the national prevalence of medical financial hardship domains: (1) material conditions from increased OOP expenses (e.g., medical debt), (2) psychological responses (e.g., distress), and (3) coping behaviors (e.g., forgoing care); and factors associated with financial hardship.

Design and Participants

We identified adults aged 18–64 years (N = 68,828) and ≥ 65 years (N = 24,614) from the 2015–2017 National Health Interview Survey. Multivariable analyses of nationally representative cross-sectional survey data were stratified by age group, 18–64 years and ≥ 65 years.

Main Measures

Prevalence of material, psychological, and behavioral hardship and hardship intensity.

Key Results

Approximately 137.1 million (95% CI 132.7–141.5) adults reported any medical financial hardship in the past year. Hardship is more common for material, psychological and behavioral domains in adults aged 18–64 years (28.9%, 46.9%, and 21.2%, respectively) than in adults aged ≥ 65 years (15.3%, 28.4%, and 12.7%, respectively; all p < .001). Lower educational attainment and more health conditions were strongly associated with hardship intensity in multivariable analyses in both age groups (p < .001). In the younger group, the uninsured were more likely to report multiple domains of hardship (52.8%), compared to those with some public (26.5%) or private insurance (23.2%) (p < .001). In the older group, individuals with Medicare only were more likely to report hardship in multiple domains (17.1%) compared to those with Medicare and public (12.1%) or Medicare and private coverage (10.1%) (p < .001).

Conclusions

Medical financial hardship is common in the USA, especially in adults aged 18–64 years and those without health insurance coverage. With trends towards higher patient cost-sharing and increasing health care costs, risks of hardship may increase in the future.

https://link.springer.com…

Comment:

By Don McCanne, M.D.

This study from the Surveillance and Health Services Research Program of the American Cancer Society once again confirms what we already knew. Medical financial hardship is common in the United States. It affects about 137 million adults. Although hardship is greater in the 18-64 age group, the prevalence in the Medicare age group is significant as well.

This study is particularly important right now because there is a debate raging over whether we should enact a genuine single payer Medicare for All program to replace our current health care financing system, or if we should perpetuate the current system, heavily dependent on employer-sponsored plans, while adding a public option – the option of a buy-in to the Medicare program.

Unfortunately, our Medicare program has significant deficiencies, as this study further confirms. Merely adding a Medicare-like public option will make only a dent in the 137 million adults that already face financial hardship. It would leave in place the tremendous administrative excesses and other deficiencies of our dysfunctional multi-payer financing system.

In contrast, the true single payer Medicare for All model introduces major improvements in the Medicare program that would prevent financial hardship, and then this improved version of Medicare would be expanded to include everyone. Plus the universal risk pool established is funded with equitable progressive taxes, making it affordable for everyone, while replacing our inequitable, fragmented, often regressive financing system of premiums, deductibles, taxes, cash, and perpetual debt.

So we can prevent financial hardship due to health care, but we cannot do it by merely adding a public option. We need the real thing – a genuine, single payer, improved Medicare for all, not the outdated and inadequate Medicare for some.

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

Congress of the United States, Congressional Budget Office, May 2019

At a Glance

Some Members of Congress have proposed establishing a single-payer health care system in the United States to ensure that virtually everyone has health insurance. In a typical single-payer system, people enroll in a health plan operated by the government, and the receipts and expenditures associated with the plan appear in the government’s budget.

This report describes the primary features of single-payer systems, and it discusses some of the design considerations and choices that policymakers will face as they develop proposals for establishing such a system in the United States. The report does not address all of the issues involved in designing, implementing, and transitioning to a single-payer system, nor does it analyze the budgetary effects of any specific proposal.

Some of the key design considerations for policymakers interested in establishing a single-payer system include the following:

• How would the government administer a single-payer health plan?
• Who would be eligible for the plan, and what benefits would it cover?
• What cost sharing, if any, would the plan require?
• What role, if any, would private insurance and other public programs have?
• Which providers would be allowed to participate, and who would own the hospitals and employ the providers?
• How would the single-payer system set provider payment rates and purchase prescription drugs?
• How would the single-payer system contain health care costs?
• How would the system be financed?

For each question, this report discusses various options and provides a qualitative assessment of the trade-offs they present.

https://www.cbo.gov…

Full Report (PDF – 34 pages): Key Design Components and Considerations for Establishing a Single-Payer Health Care System:
https://www.cbo.gov…

Comment:

By Don McCanne, M.D.

This is the CBO report requested by Congress describing various features that should be considered in designing a single payer health care system. Single payer advocates already involved in health policy work can easily answer each of the questions above, but reading the report will still be useful. The reason is that when any potential single payer legislation has advanced to the point of committee markup, these features will likely be intensively debated.

It is imperative that we establish well in advance why there should be no compromise in a well designed model of single payer such as that advanced by Physicians for a National Health Program. It would be terrible if we finally enacted single payer only to have it be designed as a bureaucratic boondoggle. So read the report so you can prepare your defense of single payer nirvana.

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Testimony of Ady Barkan (speaking through a computer because of the limitations of his amyotrophic lateral sclerosis)
House of Representatives, Committee on Rules, April 30, 2019

Closing Remarks

Crucially, Medicare For All is the only way to make our healthcare system more efficient. Over the past three years, I have seen first hand how the current system creates absurdly wasteful cost-shifting, delays, billing disputes, rationing, and worry. Administrative waste is costing us hundreds of billions of dollars every year. Medicare For All will streamline the entire system, letting doctors and nurses focus on delivering care instead of on paperwork. As a single payer program, Medicare For All will be able to eliminate immoral price gouging by pharmaceutical and device companies. The fundamental truth is that too many corporations make too much money off of our illnesses, and they are spending gazillions of dollars lobbying and campaigning and fighting to stop us from building something better.

It is very important to emphasize the following point: these cost savings are only possible through a genuine Medicare For All system. Other proposals to increase health insurance coverage, such as those that would make Medicare compete with private insurance, would not facilitate administrative and billing savings.

There are many other major benefits to Medicare For All, and these are detailed in the written testimony submitted by the nurses and others.

But my time to deliver this testimony is running out. And, in a much more profound sense, my time to deliver this message to the American people is running out as well. So I want to end on this third and final note.

Our time on this earth is the most precious resource we have. A Medicare For All system will save all of us tremendous time. For doctors and nurses and providers, it will mean more time giving high quality care. And for patients and our families, it will mean less time dealing with a broken health care system and more time doing the things we love, together.

Some people argue that although Medicare for All is a great idea, we need to move slowly to get there. But I needed Medicare for All yesterday. Millions of people need it today. The time to pass this law is now.

Winning this reform will not be easy. The monied interests will do everything in their power to stop us. And yet despite these obstacles and despite the personal challenges that I face, I sit before you today a hopeful man, a hopeful husband, and a hopeful father.

I am hopeful because right now, there is a mass movement of people from all over this country, rising up. Nurses, doctors, patients, caregivers, family members — we are all insisting that there is a better way to structure our society, a better way to care for one another, a better way to use our precious time together.

And so my closing message is not for the members of this committee. It is for the American people.

Join us in this struggle. Be a hero for your family, your communities, your country. Come give your passion and your energy and your precious time to this movement. It is a battle worth waging, and a battle worth winning. For my son Carl, for your children, and for our children’s children.

We have a once in a generation opportunity to win what we really deserve. No more half measures. No more healthcare for some. We can win Medicare for All.

This is our Congress. This is our democracy. And this is our future for the making.

Transcript of Ady Barkan’s full testimony:
https://docs.house.gov…

Video clip of Ady Barkan’s testimony:
https://www.c-span.org…

For links to written testimony of all witnesses:
https://rules.house.gov…

For video of the entire hearing:
https://www.c-span.org…

Comment:

By Don McCanne, M.D.

In spite of feeble opposition testimony, the message came through loud and clear that the United States must enact a single payer Medicare for All program if we wish to have health care justice for all.

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