PNHP

The coverage of the uninsured has plateaued

The coverage of the uninsured has plateaued

Health Insurance Coverage in the United States: 2017

By Edward R. Berchick, Emily Hood, and Jessica C. Barnett
United States Census Bureau, Current Population Survey Annual Social and Economic Supplement (CPS ASEC), September 2018

In 2017, 8.8 percent of people, or 28.5 million, did not have health insurance at any point during the year. The uninsured rate and number of uninsured in 2017 were not statistically different from 2016 (8.8 percent or 28.1 million).

https://www.census.gov…

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Comment:

By Don McCanne, M.D.

This definitive report on the health insurance status of U.S. residents provides an extensive breakdown of the statistics on insurance coverage, but the one highlight above pretty well summarizes the status. There was no statistically significant change in the numbers of uninsured between 2016 and 2017.

Although the reported change from 28.1 million to 28.5 million uninsured may not be statistically significant, there are likely 400,000 people out there who personally believe it is significant for themselves even if the statistical analysis is dismissive of it. At any rate, there are still over 28 million people who can’t be pleased with their lack of insurance coverage.

The major lesson in this report is that the gain from the Affordable Care Act has appeared to plateau, although the numbers may not have fully stabilized yet, largely because of the policies being adopted by the Trump administration and the various state governments. But it is safe to say that complete elimination of uninsurance is not imminent and cannot possibly occur without a major policy change.

One of the least promising policy changes would be a Medicare public option, or Medicare buy-in, which some have mislabeled as Medicare for All. It would provide only one more option in the market of plans that already exists and thus would have very little impact on overall coverage or affordability since the other options are already available.

Of course, the most promising policy change under consideration that would be fully effective would be a single payer national health program – a bona fide Improved Medicare for All.

It has now been a decade since we started down the path of Obamacare. Regarding the goals of universality, equity, affordability, administrative efficiency, and guaranteed lifetime coverage, it is clear that the Affordable Care Act has been a failure. Rather than merely adding a Medicare Advantage-like public option to our expensive but mediocre system, we should finally provide the fix our system truly needs – an Improved Medicare for All. Just make sure it’s the real thing.

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Where do we stand now with health care?

By George Bohmfalk, M.D.
The Aspen (Colo.) Times, September 13, 2018
(Part 2 of 6. Read parts 1, 3, 4, 5 and 6.)

In this series of weekly articles, I will describe the current status of health care in America and how we might improve it. Inasmuch as most people younger than 65 have no great need to understand what Medicare is, and as Medicare may be a good model on which to build a universal system, I’ll briefly explain a bit about it.

Medicare began over 50 years ago, in response to poor medical care and high poverty rates among our seniors. It has succeeded in alleviating both of these crises and continues to be a very popular and efficient health insurance program. Medicare is a universal, single-payer system, meaning that it covers everyone in the designated group, and that payments for medical care are all made via a single source — the federal government. Funding comes from both taxes and premiums. In striking contrast to some European-style socialized systems, medical care under Medicare is privately delivered, at private hospitals by doctors in private practice. Every Traditional Medicare enrollee has free choice of doctors and hospitals.

Notwithstanding its many successes, Medicare is not a perfect system. Its most glaring deficiency is that it pays only 80 percent of charges, leaving the enrollee to pay the remainder, either out-of-pocket or through Medigap plans sold by for-profit private insurers. While seemingly small, this 20 percent difference, along with deductibles and copayments, can become an insurmountable financial burden in complex cases. Seniors are filing bankruptcy because of medical debt.

Another major deficiency when Medicare began was that it did not cover prescription drugs. As medicines became unaffordable to many seniors, Congress attempted to remedy this in 2003 by adding Medicare Part D, the prescription drug program, available for an added premium. Unfortunately, the pharmaceutical lobby arranged for a provision to be included in the law that forbids Medicare from negotiating drug prices. As a result, we in the world’s largest pharmaceutical market pay the world’s highest prescription drug prices. Productive young people are dying because they can’t afford insulin, once one of the least expensive and most life-saving prescription drugs.

Traditional Medicare still does not cover dental, hearing or vision care, aspects which can have large impacts on our overall health. I once operated on a man whose tooth infection spread to his brain. Dental problems contribute to arterial disease, and poor hearing and eyesight lead to higher injury rates and accelerated mental deterioration. These and other deficiencies can be readily corrected in a national Improved Medicare for All program.

Where do we stand now overall? Unfortunately, we don’t have the best health care system in the world. We do have many great doctors and hospitals, but we pay about twice per person what most other industrialized countries pay for their excellent health care. Yet nearly 30 million of us remain uninsured and 40 million underinsured. You may know someone, or find yourself, among the underinsured. These are folks who believe they have good insurance, often through their employer, but when a health issue arises, the high deductibles and copayments are daunting. If you’re underinsured, you may be forced to choose among wiping out your life savings to pay for care, filing for bankruptcy when the bills come in, or delaying or declining needed care, if that’s possible.

Even people with good insurance are often surprised by its deficiencies and disruptions. In order to maximize their profits, insurers seek discounts from doctors and hospitals and form provider networks of those low-bid participants. These narrow networks become very inconvenient when you are covered only at a remote hospital or forced to change doctors. There are dozens of stories of people being stuck with $25,000 to $60,000 bills from air ambulance companies that were not in their insurance networks. How were they to know that beforehand? Health insurance isn’t what it used to be, and it’s getting worse.

You might think that paying such high prices gets us good results, but it doesn’t. Reports by the OECD (Organisation for Economic Co-operation and Development) show that we rank below most industrialized nations in many health outcomes, including life expectancy. Our maternal and infant mortality rates are among the highest. We pay the most, and get the least for it.

In subsequent articles, we’ll see where all our money is going and how it might be redirected to improve our nation’s health. The short answer is by expanding Medicare to cover everyone, and improving it to remove the deficiencies described above.

Spoiler alert: In the end, we’ll spend less overall. It’s a mind-boggling thing.

Dr. George Bohmfalk practiced neurosurgery in Texas before retiring to spend half of each year in the Roaring Fork Valley. He is active in Physicians for a National Health Program, a physician-driven group advocating for a single-payer health care system.

https://www.aspentimes.com…

How can we afford not to adopt single payer?

By Thomas Gates, M.D.
Lancaster News (Penn.), September 13, 2018

The Sept. 10 letter “How can we afford ‘Medicare for all’?” asks the wrong question. The real question is, “How can we continue to afford our current fragmented and wasteful health care system?”

U.S. health care expenditures in 2016 were $3.3 trillion — $10,348 per capita — or 17.9 percent of gross domestic product, a far higher percentage of our income than any other country. A former administrator of the Centers for Medicare and Medicaid Services estimated that up to 30 percent of U.S. health expenditures are waste, largely driven by high administrative costs of for-profit insurance companies. Total overhead for private insurance is 16.8 percent, more than four times that of Medicare and Medicaid. Our current system leaves 12.9 percent of Americans uninsured, while the insured are stuck with ever-increasing premiums, co-pays and deductibles.

The letter cites a study that puts the “Medicare for all” cost at $2.5 trillion, versus our current cost of $3.3 trillion (over half of which is already government funded). That’s $800 billion in savings: How can we afford not to adopt single payer? Yes, it would mean new taxes, but by eliminating insurance premiums, deductibles, co-pays and most out-of-pocket expenses, 95 percent of Americans would end up saving money.

Our expensive health care system makes individuals and society poorer. Single payer would be far more equitable and far less expensive. What are we waiting for?

Dr. Thomas Gates resides in Manheim Township.

https://lancasteronline.com…

Without pharmaceutical price regulation, gouging is to be expected

Pharma chief defends 400% drug price rise as a ‘moral requirement’

By David Crow
Financial Times, September 11, 2018

A pharma executive has defended his decision to raise the price of an antibiotic mixture to more than $2,000 a bottle, arguing there was a “moral requirement to sell the product at the highest price.”

Last month, Nostrum Laboratories, a small Missouri-based drugmaker, more than quadrupled the price of a bottle of nitrofurantoin from $474.75 to $2,392, according to Elsevier’s Gold Standard drug database.

Nitrofurantoin is an antibiotic used to treat bladder infections that was first marketed in 1953, which appears on the World Health Organization’s list of essential medicines.

In an interview, Nirmal Mulye, Nostrum chief executive, said he had priced the product according to market dynamics, adding: “I think it is a moral requirement to make money when you can…to sell the product for the highest price.”

Mr. Mulye said Nostrum was responding to a price rise from Casper Pharma, which makes a branded version of the product known as Furadantin. Casper increased the price of its product by 182 per cent between the end of 2015 and March 2018, taking a bottle to $2,800, according to the Elsevier database.

He also defended the actions of Martin Shkreli, who became infamous in 2015 for his decision to raise the price of an Aids and cancer drug from $13.50 to $750 per tablet. Shkreli was jailed earlier this year on unrelated fraud charges.

“I agree with Martin Shkreli that when he raised the price of his drug he was within his rights because he had to reward his shareholders,” said Mr. Mulye.

Mr. Mulye pointed out that Shkreli was able to increase the price of Daraprim so dramatically because his company was the only one making it.

“If he’s the only one selling it then he can make as much money as he can,” said Mr. Mulye. “This is a capitalist economy and if you can’t make money you can’t stay in business.”

In a tweet responding to Mr. Mulye’s comments, Scott Gottlieb, FDA commissioner, said, “There’s no moral imperative to price gouge and take advantage of patients. FDA will continue to promote competition so speculators and those with no regard to public health consequences can’t take advantage of patients who need medicine.”

https://www.ft.com…

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Comment:

By Don McCanne, M.D.

Appalling drug price gouging will continue until our government fulfills its responsibility to protect the consumer, that is, the patient. FDA Commissioner Scott Gottlieb represents the view of current and previous administrations when he says that we need to promote competition, as if the market will take care of it.

But that’s not the way markets really work. The 400 percent price increase of this generic nitrofurantoin was to bring the price closer to the competition – the branded version, Furadantin. Nostrum chief executive Nirmal Mulye explains to us the way markets really work, “I think it is a moral requirement to make money when you can…to sell the product for the highest price.” A moral requirement, he says.

Maybe we should begin discussions of nationalizing the pharmaceutical industry. That might make them nervous enough that they would finally agree to regulation of prices as is done in other civilized nations. Whether they agree or not, we need to do it.

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Inequities of social spending

The Government-Citizen Disconnect

By Suzanne Mettler
Russell Sage Foundation

From Chapter 1 – A Time of Contradiction

Over the past four decades, Americans’ relationship to the federal government has evolved in a deeply paradoxical manner. As a society, we appear to regard government with ever greater disdain, as evidenced by popular discourse, numerous polls, and election results. Yet people depend on the federal government more than ever to help them attain economic security, health care and educational opportunity.

Yet over these very same decades, Americans have increasingly counted on the federal government’s assistance in their personal lives. Nationwide, the share of the average citizen’s income that flows from federal social “transfers” – including Social Security, food stamps, the Earned Income Tax Credit (EITC), and more than forty other programs – increased from 7 percent in 1969 to 17 percent in 2014. On a per capita basis, the rate grew fairly steadily over time, escalated more quickly with the onset of the 2008 financial downturn, and then declined somewhat more recently. The amount received by the average person increased from $1,853 in 1969 to $7,729 in 2014, in 2014 dollars.

These figures do not include the most generous social benefits, which are either channeled through the tax code, such as home mortgage interest deduction, or provided in tandem with private organizations, such as tax-subsidized, employer-provided health and retirement benefits. These policies serve the same function as social benefits delivered as direct payments or services – such as helping families to afford health care, housing, or education – but in permitting beneficiaries simply to pay less in taxes, they differ in design. If we consider only public social spending or government transfers, the U.S. welfare state is smaller as a percentage of GDP than that of other affluent nations, ranking twenty-fourth worldwide, but if we account also for the social expenditures channeled through the tax code and tax-subsidized payments from employers, the United States has the second largest welfare state in the world after France.

From Chapter 3 – We Are All Beneficiaries

Sheila Turner, who was born in 1973, is a self-described “stay-at-home-mom” who lives in Dallas, Texas, in a middle-income household. She considers herself to be extremely conservative on politics and identifies with the Republican Party. When asked what she thinks of when she hears the term “government social programs,” she says, “Giving money to those who don’t want to work.” Her views of such programs are “mostly negative,” she reports, because they provide support for “people who don’t prioritize their budgets and pay for their (own) bills.” She believes that “government does a poor job of managing things,” and that “people should provide for themselves.”

Yet Turner readily acknowledges that her family has used several specific policies. Her daughter used financial aid to attend college, both Pell Grants and student loans. Her husband used Unemployment Insurance for several months while unemployed, about which she comments, “Every little bit helps when you have no income.” She and her family have also utilized several features of the tax code, including the EITC, the home mortgage interest deduction, and the tax-free status of employer-provided health and retirement benefits. She does not view these tax expenditures as government social benefits, but rather as incentives for making certain decisions, explaining, “They give people a reward for using their money the right way”

American rhetoric about government benefits implies that we are a deeply divided nation of “us” and “them,” the deserving and the undeserving. Yet the evidence tells a different story. When we consider individual Americans across different incomes, parties, and ages, nearly all have used social benefits, and although usage patterns vary, particularly with respect to policy types, the commonalities loom larger than the differences. Similarly, when we consider Americans with respect to the communities across the country where they live, whether rich or poor, they are far more likely to use more such benefits today than Americans did thirty-five years ago. We nearly all benefit from the federal government’s social policies, and we nearly all contribute to those policies. whether through payroll taxes, income taxes, or both.

Percentage of Americans Who Report Having Ever Used Specific Social Policies:

55.3 – Employer-provided retirement (current only)
49.9 – Employer-provided health care (current only)
45.6 – Home mortgage interest deduction
38.5 – Unemployment insurance
34.4 – Earned Income Tax Credit
27.4 – Student loans
25.7 – Child and Dependent Care Tax Credit
25.4 – Food stamps
22.2 – Medicare
17.5 – Medicaid
16.0 – Pell Grants
15.8 – Social Security – retirement and survivors’
13.9 – Welfare/public assistance
10.0 – Hope or Lifetime Learning Tax Credit
9.7 – Social Security Disability Insurance
8.7 – Government-subsidized housing
8.1 – Supplemental Security Income
8.0 – Head Start
5.9 – GI Bill
5.1 – 529 plan or Coverdell Education Savings Account
4.6 – Veterans’ benefits (other than GI Bill)

From Chapter 4 – Different Lenses

In sum, when Americans think about government, only in some instances does their memory of the social policies they have benefited from hover at the top of their minds. As a result, the strong antigovernment attitudes that prevail in the United States today can be found even among many people who themselves have benefited a great deal from social policies. These views may attract Americans to candidates and organizations that articulate such views, even if they hold positions that threaten the very policies from which individuals have benefited.

From Chapter 5 – Unequal Voice

How is it that the nation has shifted to electing more officials who want to undermine social policies at the very same time as citizens depend on them more than before? The answer is in part for reasons we saw in chapter 4, that many Americans use benefits that make government’s role less than apparent, and that when they evaluate government, other considerations and affiliations loom more heavily in their minds than their social policy experiences. But it is also a matter of who shows up to participate in political activity. Those who have benefited from more visible government programs are both more aware of the role that government has played in their lives and more supportive of social spending. Yet they tend to participate less than other Americans, for reasons related to their socioeconomic status and also because candidates, parties, and groups do less to mobilize them and involve them. As a result, their voices are less likely to be heard in the political process, which meanwhile overrepresents those who are less aware that government has made a difference for them. The American polity is skewed by a participatory tilt that exaggerates the views of those who remain incognizant of government’s role in their lives and drowns out those of others. But it does not have to be this way.

From Chapter 6 – Reconnecting Citizens and Government

Although the United States has nevertheless increased the extent to which it provides economic security and educational opportunity to citizens, many Americans who are beneficiaries of these policies do not perceive government to be responsive to them. This conundrum amounts to a government-citizen disconnect.

Policy designs do not speak for themselves in communicating the value of government. Even if appealing internet tools and other procedures help citizens make sense of how government has helped them and their families over time, the impact on assessments of government may still be minimal. In our highly polarized polity, where organizational linkages that connect citizens and government have frayed and some groups beat the antigovernment drum, more is needed. Organizations that seek to strengthen democracy must step up to play these roles, making connections for citizens and drawing them into politics when the fate of policies is at stake. They can do so effectively by developing activists, including individuals from communities that are usually excluded from civic engagement. In the process, they can help people see how government matters in their lives – through social policies like those examined here as well as through others – and spur their involvement in the political process.

As Americans face the future, far more unites us than divides us. We are not a nation of moochers and takers. Rather, we are a political community, one built on respect for the ideas that all are created equal and that “we the people’ can govern ourselves. We can advance by honoring our reciprocal obligations to each other through the bonds of citizenship. By reaffirming that quest, we can carry on together, as citizens of a democracy.

Suzanne Mettler is Clinton Rossiter Professor of American Institutions in the Government Department at Cornell University.

http://www.russellsage.org…

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Comment:

By Don McCanne, M.D.

Because much of our social spending is not transparent, most people do not realize just how much they benefit from these government social policies. Those who benefit the most, especially though tax expenditures (tax deductibility of retirement plans, health plans, home mortgage interest, etc.), frequently do not consider the government’s largess accruing to their benefit as a government social program, yet they are resentful when others of lesser means receive more visible support to meet basic needs such as food stamps, unemployment benefits, public assistance, or Medicaid.

Yet the opaque social benefits the wealthy receive to help pay for their large mortgages, generous retirement plans or executive health benefit programs are frequently much more than the person with the food stamps at the super market checkout stand is receiving. Further, there is a prevailing attitude that somehow the person working at a job with poverty-level wages is not deserving of a government handout, whereas the very wealthy individual has somehow earned, as a reward, much greater benefits through tax expenditures, which is still a government handout, but for the rich.

It seems that we could inject a much greater dose of fairness into our social spending programs, and this is where health care financing enters the scene. Everyone should have health care, and they could if we used progressive tax policies to fund an equitable universal system such as an improved Medicare that covered everyone. If the system already existed, the rich would not be resentful of poor people getting the health care that they need. At least the rich don’t seem to be so in other nations that have equitable, universal systems.

We really could have the same here, but we’re going to have to acknowledge that we must change our attitude that low-income workers are not deserving of support for basic needs while the rich are entitled to tax expenditures to support their more extravagant lifestyles.

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Medicare for All and the Myth of the 40% Physician Pay Cut

A single payer system works by cutting administrative waste, not doctors' income

By Carol Paris, M.D.
Common Dreams, September 11, 2018

The surge in support for improved Medicare for All—now up to 70% in recent polling—has single-payer opponents ramping up their scare tactics. The Koch-funded Mercatus Center recently claimed that Medicare for all could only work with painful sacrifices from doctors, specifically by paying us Medicare’s current reimbursement rates, which are about 40% lower than private insurance.

If single payer would cost doctors so much, why do a majority of us now prefer it? I invite supporters of the status quo to spend a week at a typical doctor’s office to understand the out-of-control costs of practicing medicine in our current system.

Let’s look at how doctors actually get paid. Most of us accept a mix of Medicare, Medicaid, and private insurance, which pay mostly on a fee-for-service basis: a certain amount for each exam, scan, or procedure. While rates differ from state to state, private insurance usually pays the most, Medicaid usually pays the least, and Medicare is somewhere in between (and for those patients with no insurance, it’s anybody’s guess).

But don’t assume physicians prefer dealing with private insurers just because they pay more. Private insurers make their money by paying out less in claims than they collect in premiums, and make us jump through bureaucratic hoops to secure payment. Basic tests and treatments must be cleared in advance with insurers or they won’t be covered. Claims are routinely denied. If you’ve ever spent hours on the phone haggling with your insurance company, then you’ve had a small taste of what it’s like to practice medicine today.

Since for-profit insurers ultimately decide what will be covered, it’s like having a third party in the exam room second-guessing our medical decisions. This process disrupts the doctor-patient relationship that we work so hard to build. And copays and coinsurance (what patients pay out-of-pocket) mean that even smaller practices must employ several full-time staff just to handle payments, billing, and collections.

Smaller practices spend an average of $83,000 per year on claims, coverage and billing. Doctors personally spend nine hours each week on billing and admin; that’s time we’re not seeing patients. It’s no surprise that doctors today report unprecedented levels of exhaustion and burnout.

Then there’s the issue of malpractice insurance, which takes a big bite out of doctors’ income. Future medical costs are a large part of malpractice settlements, but are removed from the settlement equation under Medicare for All. Lower potential settlements means lower premiums for doctors.

Dealing with one single payer—Medicare—would mean drastically fewer hours of uncompensated administrative time, fewer office staff, and lower overhead. It’s a tremendous amount of time and money that Mercatus fails to include in their analysis.

In reality, relatively few doctors work in private practice anymore. Due to rampant industry consolidation, most providers actually work on salary for larger health systems or hospitals. Under our current multi-payer system, billing and administration account for one-quarter of U.S. hospital expenditures, twice the level in single-payer nations. Medicare for All would simplify hospital payments by funding them through global budgets (similar to the way fire departments are paid), rather than the current patient-by-patient payments, saving billions more in administrative costs.

At the national level, single payer would cut about $504 billion annually in administrative costs. In other words, single payer works by cutting administrative waste and corporate profits, not doctor incomes.

Overall, we estimate that average physician incomes would remain unchanged under Medicare for All. Some doctors, such as family physicians and pediatricians, might see a pay increase while others, such as highly-paid specialists, might see a slight pay cut. But “painful sacrifices” would not be required.

Single-payer opponents will try to pit doctors against patients by claiming that universal coverage only works by cutting doctor incomes. That’s a false choice. The only winners in the current system are the insurance companies who profit by keeping more of our nation’s health care dollars for themselves. By moving to a single-payer program, doctors can finally get back to our calling: caring for patients.

Dr. Carol Paris is a psychiatrist and president of Physicians for a National Health Program.

https://www.commondreams.org…

Ask Medicaid-eligible individuals what a work requirement would do

Medicaid Recipients’ Early Experience With the Arkansas Medicaid Work Requirement

By Jessica Greene
Health Affairs Blog, September 5, 2018

In June, Arkansas became the first state to implement a work requirement in its Medicaid program.

Little is known to date about how those impacted by the new Medicaid work requirement feel about the policy. To explore Medicaid recipients’ attitudes about Arkansas’ work requirement and their early experiences with the policy, in mid-August I conducted in-depth interviews with 18 adult Medicaid recipients in northeast Arkansas.

While this group is far too small to provide generalizable results, the interviews do illustrate how the state’s policy is interacting with the day-to-day lives of Medicaid recipients to produce serious potential consequences that have little to do with policy’s stated objectives.

Lack Of Awareness

Two thirds of the Medicaid recipients (12/18) I interviewed had not heard anything about the new work requirement. “First time I’ve ever heard anything [about it],” a 31-year old man, who had started a vocational training program the day we spoke, said. “You’d think it’d be on the news or something. I ain’t seen it on the news, and I watch Channel 8 news every night.”

At Risk Of Losing Coverage

Of the nine people who, based on their age, should have received a DHS letter letting them know they were subject to the work requirement, four said they had received a letter. Two said the letters indicated they were exempt because they already met the SNAP work requirement.

The other two were at risk for losing Medicaid coverage. One, a 47-year old woman, said she had received her letter about three months earlier; she believed, incorrectly, that she had three months to report her hours. When I asked her if reporting her hours was an obstacle, she said she was struggling with very stressful life issues, including a mentally ill sister, and as a result the work requirement had not received much of her attention. The other person, a 40-year-old woman, described being overwhelmed by receiving the letter: “Basically… I’m like, okay, I’ve got this letter. I file it and I don’t know what to do with it…”

The other five who should have received a work requirement letter were either not sure if the letter arrived or thought it had not. When asked about receiving a DHS letter, a 42-year-old woman said, “I don’t know, I’m going to have to check and make sure [I didn’t receive the letter], because I need my Medicaid card for my sugar pill and my blood pressure pills.” A 46-year-old man, who had recently completed an inpatient drug treatment program, kicking a multi-decade drug addiction, wasn’t sure either. “I may have [received the letter]…I’m horrible about opening mail….I probably throw’d it away.” While the three others did not believe they received the letter, they were all exempt by either working and/or having children in the home, but likely needed to report their hours and exemptions in the portal to maintain Medicaid coverage.

Policy Not Sparking Work-Related Changes

Of the nine participants who were likely subject to the policy, only two were not meeting the 80 hour work-related activity requirement and did not seem to qualify for an exemption. Both told me that they were actively seeking work, and that the work requirement had not at all impacted their job seeking. In addition, those I interviewed between the ages of 19-29, who will be subject to the policy in 2019, either worked, went to school, and/or had children under 18 years old in the home. No one I spoke with reported that the policy had or would spark them to change their work-related activities.

Online Portal Challenging For Many

Participants described a very wide range of computer and online skills and access. Approximately a third said that reporting hours on the online portal would not be possible for them: “I can’t do that. I don’t have a phone. I don’t have a computer.”

Several, who were confident of their own skills, mentioned family members who would struggle. “Half my family probably doesn’t have a smart phone….A lot of people here don’t have internet still,” a 19-year old woman explained.

Mixed Attitudes About Linking Medicaid And Work-Related Activities

Almost all the participants believed that people who could work should be working. “I believe if you are able to work and you want the extra help that Medicaid gives, then you should work,” said a 28-year old woman who was currently working and has young children. But several expressed concern about those who had mental or physical conditions that would prevent them from meeting the requirement. One man raised questions about people who were “borderline” who were not officially considered disabled but still had serious health conditions. A 42-year-old woman, who works with people with disabilities said, “I think it’ll do more harm than good…. What they supposed to do, just get cut off Medicaid because they can’t meet those requirements?”

Others raised concerns about transportation needed to get to work and volunteering. “Some people don’t have vehicles, and sometimes it’s not necessarily their fault. Sometimes something happens and they lose their money… It’s not fair,” said a 21-year old recipient who is a college student. When I asked a woman who was looking for work whether she had tried to get help from the Department of Workforce Services, she said that she couldn’t get there because it was 30 miles away and there is no public transportation.

Not Going To Lift People Out Of Poverty

Participants were very skeptical about the Governor’s claim that the work requirement policy would help them out of poverty, as many were already working and still struggling financially.

One participant argued that the policy was not about getting people to work at all, but about reducing the number of Medicaid recipients: “It seems like a ploy for the state to save money. That’s all it is. It’s nothing about trying to get people back to work…”

Summing Up

Of the people I interviewed who were at risk of losing Medicaid coverage as a result of the work requirement, most were at risk because they lacked awareness of the policy or were overwhelmed by it, rather than because they were not meeting the 80 hours a month of work-related activities or the terms of an exemption. If this is true more broadly, the state will be ending people’s health coverage for the wrong reasons, adding credence to those who argue this policy is about reducing the rolls, rather than supporting people to get employment.

A 38-year-old woman who recently had to quit her job to get her niece, who she mothers, a birth certificate and other paperwork to start school argued that the policy does not take into account the complex lives of low-income people. “You are saying this should be possible, but you don’t know my circumstances. You haven’t been here,” she explained.

Dr. Jessica Greene is a Professor and the Luciano Chair of Health Care Policy at Baruch College, City University of New York.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Sometimes you simply do not need extensive health policy research to understand what impact various policy proposals would have. As an example, to understand what a work requirement to qualify for Medicaid would mean for the low-income, target population, just ask them.

This brief series of interviews of Medicaid beneficiaries done by Professor Jessica Green provides enough anecdotes that are fully predictable. This relatively unsophisticated, low-income population is already struggling with just trying to make ends meet. Throwing in an employment reporting requirement just further complicates their personal agendas. Besides, none of them believe that the program will cause them to change their work-related activities.

The purpose of Medicaid is to provide access to medical care for individuals who cannot afford it. Does requiring work as a condition of Medicaid enrollment advance that goal? No, just the opposite. Under this requirement many will lose their Medicaid coverage and thus lose access to medical care.

Look. We’re trying to get people the health care that they need. We already understand the policy decisions that would do that. A well designed, single payer, improved Medicare for all would take care of it. We do not need the injection of screwball ideas based on sterile ideology rather than benevolent compassion.

As one interviewee said, “you don’t know my circumstances; you haven’t been here.” But we do know how to get her and everyone else the health care program that they need. That’s what we need to be working on.

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Additional Comment:

By Stephen Tarzynski, M.D.

Republican opposition to government-regulated medical care is partially based on the view that government governs best which governs least. Conservatives associate liberty with markets.

They may not realize it but they have more than a little in common, ideologically, with the early 17th century British statesmen who crafted the Elizabethan Poor Laws. These laws gave local governments the power to raise taxes to maintain almshouses and provide relief for the “worthy” poor, including the elderly. But they also mandated that the “able-bodied poor” be set to work in a House of Industry and sent the “idle poor” to Houses of Correction. In their twisted logic, poor people were only desperate because they were lazy or morally inferior to the wealthy.

GOP legislators echo these obsolete ideas when they talk about indigent “able-bodied adults” needing to work to deserve health insurance.

From my decades of experience as a doctor, it seems to me that no market-driven healthcare system can simultaneously limit costs, guarantee universal coverage and deliver desired outcomes. Overwhelming evidence demonstrates that the best way to reduce costs and guarantee healthcare to everyone is to have the largest risk pool — that is, the entire nation. These facts compel the United States to move to a single-payer system guided by comparisons with other countries’ experiences and by our own American successes, such as Medicare and Medicaid.

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Thanks, Obama?

Barack Obama thinks Medicare for All is a good idea. His support is welcome — but this time, we won’t accept any compromises on a universal, free public health program.

By Tim Higginbotham
Jacobin, September 10, 2018

For the first time in over a decade, Barack Obama is a Medicare for All supporter.

On September 7 in Illinois, Obama promoted the idea while campaigning for Democrats ahead of the 2018 midterm elections. “Democrats aren’t just running on good old ideas like a higher minimum wage,” he said, “they’re running on good new ideas like Medicare for All.” His is the biggest endorsement from the political center for the idea, and a sign that Democrats are beginning to yield to this overwhelmingly popular demand — a recent Reuters/Ipsos poll showed that 70 percent of Americans support the plan.

But Medicare for All supporters should be skeptical of Obama’s support. Centrists are engaged in an ongoing effort to reinterpret what M4A means, which could lead to a watered-down proposal that throws the possibility of achieving single-payer health care into jeopardy.

Back in 2003, Obama spoke glowingly of single-payer, arguing that the only reason it might not happen “immediately” was that first, the Democrats would have to take back the White House and Congress. By 2009, Obama’s stated prerequisite for single-payer had come true. He himself occupied the White House, while Democrats held majorities in both the House and Senate. But by that point, of course, Obama had long abandoned single payer.

In fact, his administration worked to deliberately marginalize the idea and instead rallied support for the Affordable Care Act’s market-centered approach. They even dropped the planned inclusion of a public option when Senator Joe Lieberman threatened to filibuster the ACA in protest.

Ultimately, the powerful Democratic majority passed only a weak, fragmented plan with high costs and uneven benefits. While the ACA helped many people by expanding Medicaid and adding protections for people with preexisting conditions, it failed to combat the true source of the United States’ health-care crisis: the privatized multi-payer system that allows giant for-profit health companies to profit from Americans’ illnesses. Unsurprisingly, after voters replaced Obama with Trump, the key accomplishments of the ACA came under immediate threat.

In the wake of the ACA’s failure to lower costs and achieve universal coverage, single-payer has become a popular, viable demand. It was the lead plank of Bernie Sanders’s 2016 presidential platform and a regular applause line at his mass rallies. Sanders has kept Medicare for All in the spotlight, hosting viral town halls and releasing dozens of social media videos highlighting the plan’s benefits.

Sanders’s message is clearly resonating. Polling shows that Medicare for All now maintains majority support. Progressive candidates have successfully used the demand as a key campaign plank. And grassroots activists have found success taking the message to the streets, with groups like National Nurses United and Democratic Socialists of America running nationwide canvassing campaigns to build on the plan’s popularity.

Yet despite Medicare for All’s overwhelming popular support, many Democratic politicians have been reluctant to sign on. Sanders has earned sixteen cosponsors for his Senate bill, while its companion legislation in the House has 123. That amounts to only 34 percent and 64 percent of Democrats in the Senate and House, respectively — far lower than the 85 percent of Democratic voters who support the plan nationwide, according to the Reuters/Ipsos poll.

But that level of mass demand can’t be ignored forever. It has now become a litmus test for candidates.

Democratic socialists Alexandria Ocasio-Cortez and Rashida Tlaib campaigned heavily on Medicare for All while making waves this summer with upset primary wins in their bids for House seats. Andrew Gillum supported it on his way to winning the Democratic primary in Florida’s gubernatorial race. And nearly all prospective 2020 Democratic presidential candidates have expressed support for the plan, including Kirsten Gillibrand, Cory Booker, Kamala Harris, and Elizabeth Warren. Democrats are finally recognizing that they need Medicare for All — not rhetoric about “fixing the ACA” — in order to win.

Obama’s 180-degree turn on Medicare for All could cement the Democratic establishment’s shift into the M4A camp. It’s now likely that the congressional bills will have strong legislative support should Congress change hands. At the same time, centrist Democrats have a history of grinding down progressive policies into complex, unpopular, market-friendly schemes.

In order for Sanders’s vision of single-payer health care to succeed, the public must remain uncompromising in its demand for a truly ambitious Medicare for All — one that guarantees comprehensive care to every American resident as a single, public program and ensures a just transition that provides severance and jobs training to all workers whose jobs are impacted. Liberal think tanks and pundits are attempting to capitalize on Medicare for All’s popularity by watering it down, arguing that its meaning is ambiguous and could refer to something as meager as a Medicare buy-in — essentially a “public option” plan that would preserve the multi-payer system while allowing people to purchase Medicare coverage.

Given his record, it’s reasonable to expect that Obama will join this effort to co-opt Medicare for All and kowtow to the private insurance industry, the pharmaceutical lobby, and the American Medical Association, which have spent the last century using their power and influence to squash every effort to win a national insurance system. Democrats haven’t confronted this power in the past and, as shown in 2009, can’t be expected to do so even if they manage to take back Congress.

It’s going to take an unshakeable mass movement to win a system that actually provides health care as a right. That means no financial barriers to care — no copays, no deductibles, and no premiums. It means abolishing the private insurance industry once and for all. It means universal care with equal treatment for everyone — not means-tested coverage with a higher standard of care for the rich. It means a single, simple, and bold public program — not a public option that will leave millions underinsured and keep insurance profiteers intact.

Obama’s endorsement is a sign that the demand for Medicare for All is overwhelming. It will hopefully bring much-needed legislative support to the congressional single-payer bills. But Americans cannot allow the people who bungled the Affordable Care Act to undermine this fight, too. Medicare for All means nothing less than a universal, single-payer program that provides comprehensive care, free at the point of delivery. Obama’s support is welcome. But this time, we won’t accept any compromises.

Tim Higginbotham is an organizer with the Democratic Socialists of America’s Medicare for All campaign.

https://www.jacobinmag.com…

Analysis of Work Requirement Exemptions and Medicaid Spending

By Anna L. Goldman, M.D., M.P.H.1,2; Steffie Woolhandler, M.D., M.P.H.3,4; David U. Himmelstein, M.D.3,4; David H. Bor, M.D.1,3; Danny McCormick, M.D., M.P.H.1,3
JAMA Internal Medicine, Research Letter, September 10, 2018

To date, 4 states (Arkansas, Indiana, Kentucky, and New Hampshire) have federal waivers to impose work requirements as a condition of eligibility for Medicaid (although a judge recently stayed Kentucky’s waiver1), and 7 other states (Arizona, Kansas, Maine, Mississippi, Ohio, Utah, and Wisconsin) have submitted waiver applications. The governor of Kentucky2 claimed that excluding “able-bodied” adults will reduce Medicaid enrollment by 16%, ensuring the program’s “fiscal sustainability.” However, such claims may be overstated because many Medicaid enrollees already work, and waivers have specified that many others (eg, people with disabilities and caregivers of young children) will be exempted. To our knowledge, no studies have quantified the potential influence of work requirements on Medicaid spending. We estimated the number of Medicaid enrollees at risk of losing coverage if work requirements are implemented with the exemptions specified in approved waiver applications, and we calculated current Medicaid spending for those enrollees at the national level and among states with approved or pending waivers.

Methods

The Institutional Review Board at Cambridge Health Alliance deemed this study exempt from review and waived the need for informed consent of participants. We identified characteristics of Medicaid enrollees and Medicaid spending on their behalf using the 2015 Medical Expenditure Panel Survey.3 We calculated Medicaid enrollment and expenditures for categories of persons already fulfilling or exempt from work requirements specified in approved waiver applications (Kentucky, Indiana, Arkansas, and New Hampshire) including persons with the following characteristics: older than 64 years or younger than 19 years, employed or actively seeking work, receiving Supplemental Security Income for disability, disabled but not receiving Supplemental Security Income, and serving as caregivers for disabled household members or children younger than 6 years, as well as those who are pregnant, students, or medically frail. These exemptions are common to all approved waivers.

Using total Medicaid enrollment and total Medicaid spending from the Medicaid Budget and Expenditure System, we then calculated the proportion of total Medicaid enrollment and total Medicaid spending accounted for by the residual group of nonworking, nonexempt adults (“work-eligible adults”). We estimated enrollment figures and spending for the work-eligible adults nationally and for states requesting waivers.4,5 We repeated our national analysis using varying age limits, including 50 years and older (Arkansas waiver) and 60 years and older (Indiana waiver). All analyses account for the complex survey design of the MEPS.

Results

Most Medicaid enrollees were already working or exempt (Table 1). If work requirements were applied nationally with all of the exemptions applied, 2.1 million persons could be at risk for disenrollment, representing 2.8% of current Medicaid enrollees, who account for 0.7% (95% CI, 0.4%-1.1%) of Medicaid spending (Table 2). Among those at risk for disenrollment, the mean annual income is $3820, 42.0% are of black or Hispanic race/ethnicity, 18.6% have children younger than 18 years, 26.6% have hypertension, 33.7% have depression/anxiety, and 31.0% report an activity limitation.

In the 6 states (Arizona, Arkansas, Indiana, Kentucky, New Hampshire, and Ohio) that have applied for waivers and have expanded Medicaid through the Patient Protection and Affordable Care Act, the affected group represents 3.4% (95% CI, 1.6%-5.2%) of the current total Medicaid enrollment and 1.1% (95% CI, 0.3%-1.9%) of total Medicaid spending (Table 2). In nonexpansion states that have applied for waivers (Kansas, Maine, Mississippi, Utah, and Wisconsin), work requirements would affect 0.8% (95% CI, 0.0%-1.6%) of current total Medicaid enrollment and 0.04% (95% CI, 0.0% to 0.3%) of total Medicaid spending.

Discussion

After applying exemptions and removing working adults, 2.8% of current Medicaid enrollees would be subject to new work requirements nationally; they account for less than 1% of Medicaid spending. In states that applied for waivers but did not expand Medicaid, potential savings represent less than 0.1% of Medicaid spending.

Our study was limited by several factors. The analysis likely overestimates the population size and Medicaid spending of the work-eligible group because accurate data on several exemption or work categories were unavailable, including addiction or behavioral health treatment, homelessness, volunteer work, and history of foster care. In addition, exemptions specified in waivers vary among states, and we opted to only include exemptions that were present consistently in all states with approved waivers. Exemptions present in only a subset of waivers, such as receipt of unemployment benefits, were not included, which may also have resulted in overestimation of the population size and Medicaid spending by individuals affected by work requirements. Conversely, we may have underestimated the population size and Medicaid spending by the work-eligible group because we did not have information on the number of hours worked per week by employed individuals (adults must work 20 hours per week or 80 hours per month to meet the work requirement); therefore, we classified all individuals reporting employment as fulfilling work requirements. We also classified individuals with an exempt status lasting less than a full year, such as pregnancy, as exempt for the full year. We did so because data on Medicaid expenditures are only available as annual totals, making it impossible to calculate expenditures for less than a full year. Furthermore, there is wide variability in the frequency of redetermination of exemption: in Kentucky, redetermination is required only on an annual basis, while redetermination is monthly in Arkansas. Finally, data in the MEPS are self-reported and thus subject to inaccuracy and may not correspond with data obtained through Medicaid documentation.

Conclusions

Results of our analysis indicate that savings to Medicaid would be minimal if exemptions were precisely applied. However, savings might be much larger (as Kentucky’s governor2 suggested) if work requirements caused a “spillover effect” (ie, loss of coverage by exempt Medicaid enrollees unable to comply with documentation requirements).6 If spillover loss of coverage is the primary mechanism by which work requirements decrease Medicaid enrollment and spending, these savings would likely come at substantial cost in terms of human health.

https://jamanetwork.com…

References

1. Ronnie Maurice Stewart, et al, Plaintiffs v Alex M Azar, II, et al, Defendants. US District Court for the District of Columbia. Filed June 29, 2018. Accessed August 3, 2018.

2. Yetter D. Bevin revises Medicaid plan, seeks to reduce Kentucky’s rolls by another 9,000 people. Louisville Courier Journal. July 7, 2017. Accessed August 3, 2018.

3. Medical Expenditure Panel Survey, Agency for Healthcare Research and Quality. MEPS HC-181: 2015 Full Year Consolidated Data File. HC-174 replaced by HC-181. Released August 2017. Accessed April 23, 2018.

4. Centers for Medicare & Medicaid Services. Source of state enrollment totals: Medicaid December 2015 enrollment files. Accessed August 6, 2018.

5. Medicaid and CHIP Payment and Access Commission. Source of state Medicaid spending totals: MACPAC’s MACStats: Medicaid and CHIP Data Book, Figure 16, December 2016. Accessed June 28, 2018.

6. Garfield R, Rudowitz R, Musumeci M, Henry J. Kaiser Family Foundation. Implications of a Medicaid work requirement: national estimates of potential coverage losses. Published June 27, 2018. Accessed June 28, 2018.

Author Affiliations

1. Cambridge Health Alliance, Cambridge, Massachusetts

2. Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts

3. Department of Medicine, Harvard Medical School, Boston, Massachusetts

4. Department of Medicine, City University of New York at Hunter College, New York

Stan Brock

Stan Brock, 82, Intrepid Provider of Health Care in Remote Areas, Dies

By Sam Roberts
The New York Times, September 6, 2018

Stan Brock died on Aug. 29 at RAM’s offices in Rockford, Tenn., where he had lived ascetically since he founded the nonprofit outfit in 1985. He was 82.

(The Remote Area Medical clinic service, or RAM) began operating initially in British Guiana and then expanded to the United States in 1992, starting out with a single pickup truck that hauled a single dentist’s chair. It opened its first American clinic in Sneedville, Tenn., in 1992 and still runs an airborne ambulance operation in what is now the independent nation of Guyana.

The organization estimates that it has provided medical, vision and dental care to more than 700,000 patients since its founding, in areas ranging from Appalachia to New York City, and in Puerto Rico in the aftermath of Hurricane Maria.

Last year, about 1,400 health professionals volunteered to treat 2,300 people who showed up at one of RAM’s outdoor clinics at the fairgrounds in the western Virginia town of Wise. Some had camped out for three days to make sure they would be treated.

“The health fair reminded me of scenes I’ve witnessed in refugee camps in South Sudan,” Nicholas Kristof wrote in his Op-Ed column in The New York Times. “But here in America?”

“I’m just the voice of the homeless and the underserved,” he said. “But unless they fix these basic things, we’re going to be doing this long after my lifetime.”

Asked in an interview about his legacy, Mr. Brock said, “I hope that a hundred years from now, nobody will remember me at all because this will be a thing of the past.”

“But,” he added, “there seems to be no end in sight.”

https://www.nytimes.com…

***

Comment:

By Don McCanne, M.D.

For those who want to see that all of us receive the health care that we should have, each of us approaches the deficiencies in our own way. Stan Brock’s high-profile efforts were quite unique. Besides serving people in need, he continued to provide us with an unambiguous visual image of how great the unmet need is.

When he recognized that the need was not only in poor countries but also right here in the United States, he began holding these Remote Area Medical (RAM) clinics in this country. At the time he began, the nation was ready for comprehensive health care reform which many thought that we would have under the Clinton administration. When that effort failed, people were still ready. Eventually the Affordable Care Act was enacted, but it was not the comprehensive reform that we needed. A quarter of a century after Brock began, people are still camping out at the RAM clinics in hopes of receiving just a modicum of care, here in America!

When asked about his legacy, Mr. Brock said, “I hope that a hundred years from now, nobody will remember me at all because this will be a thing of the past. But there seems to be no end in sight.”

No end in sight… here in America? We have to change that ASAP.

And thanks, Mr. Brock, for pointing that out.

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A physician/policy wonk faces our health care financing system

As consumers' out-of-pocket costs grow, will the patient bill-of-rights movement rise again?

By Harris Meyer
Modern Healthcare, September 1, 2018

Emergency physician Dr. Matthew Wetschler was body surfing off Ocean Beach in San Francisco last November when a wave slammed him head-first onto the ocean floor, breaking his neck and paralyzing him. Another surfer pulled him out of the water just before he drowned.

He was taken to Zuckerberg San Francisco General Hospital, the closest hospital that was well-equipped to treat him, where neurosurgeons performed surgery to fuse five vertebrae and maintain blood flow to his spinal cord. After months of physical therapy at Santa Clara Medical Center and Valley Medical Center, he’s walking, but still has no feeling in his hands.

During his grueling recovery, Wetschler received frequent calls from bill collectors seeking payment of nearly $500,000 in medical bills from the hospitals and physicians, plus a $13,000 bill from the air ambulance company that flew him 40 miles to Santa Clara for rehab care. Those providers were not in network for his insurer, Oscar Health.

Wetschler’s experience with a large out-of-network bills and opaque healthcare bureaucracies is common. Nearly 18% of hospital stays for members of large-employer health plans resulted in patients facing out-of-network balance bills, the Kaiser Family Foundation recently found. That rose to 27% when patients passed through the emergency department.

Healthcare consumers also face other common problems with cost, coverage and access, which may increase as the federal government allows the expansion of skimpier, less-regulated health plans. These problems include:

* Coverage denials for emergency department visits that insurers later deem unnecessary.

* Lack of access to specialty providers in health plan networks.

* Difficulty in getting coverage for mental health and substance abuse treatment from health plans.

* Delays in receiving care due to plans’ preauthorization requirements on providers.

* Patients’ inability to find out from providers ahead of time how much they will owe for particular services.

* Large out-of-pocket costs for prescription drugs, particularly specialty medicines.

“There’s plenty to do in the area of consumer protection, with high deductibles and out-of-network bills,” said Dr. David Blumenthal, president of the Commonwealth Fund. “But there is an anti-regulatory fervor we’re seeing in Congress and conservative circles that will be an obstacle to moving a consumer-protection agenda.”

Wetschler, the doctor injured in the surfing accident, has finally gotten the hospitals, physicians and his health plan, Oscar Health, to waive most of out-of-network bills. But he still gets calls from collectors on about $27,000 of that total, including $13,000 for air ambulance services from ProTransport-1.

In his view, there should be consumer protections in place so patients don’t find themselves in this type of terrible situation, which can destroy their finances.

“I’m a doctor with a master’s degree in health policy, yet I feel so overwhelmed that it’s almost paralyzing,” Wetschler said. “I’m stuck in no man’s land. For a person with no medical training, what hope is there?”

http://www.modernhealthcare.com…

***

Oscar

Oscar’s story begins, fittingly, in a hospital room. In 2012, Oscar CEO Mario Schlosser and his wife were going through their first pregnancy in New York. Confronted with a maze of insurance jargon and no practical way to identify the best obstetrician, their first meaningful experience with the health care system put them at a loss as to how to navigate care or hold anyone accountable.

Mario’s friend Josh Kushner had recently had his own frustrating encounter following what should’ve been a routine treatment for an injury. Mario and Josh knew that their experiences were reflective of a larger problem in health care: consumers were powerless. That spring, they founded Oscar Health.

Oscar has been focused on one mission – to be a health insurance company centered around the patient.

https://www.hioscar.com/about

***

Comment:

By Don McCanne, M.D.

A young emergency physician with a master’s degree in health policy should understand better than anyone how to interact with our health care financing system. Dr. Wetschler was insured by Oscar, a relatively new health insurance company cofounded by Josh Kushner, the brother of Jared Kushner of White House fame – a company that professes to be centered around the patient. Yet if the system is not working well in this situation, it could hardly be expected to work better for the rest of us.

Imagine having an improved version of Medicare wherein you receive the medical care you need, when you need it, and wherever you need it, and payment is taken care of automatically through a public system of health care financing. Instead we have a system in which even the most innovative insurers, like Oscar, restrict your choices and burden you with further debt. How can Oscar claim to be “a health insurance company centered around the patient” when they create additional problems for the patient that would be unnecessary in a well designed, publicly-financed and publicly-administered system?

It appears that President Trump and his son-in-law and advisor Jared Kushner are not going to help resolve these problems even though there is already more than enough money in the health care system, and they both profess to know a lot about how to manage money. Maybe instead of having a political leadership of money managers dedicated to business interests, we should replace them with political leaders who are dedicated to serving the people. It would really be nice to be rid of these unnecessary barriers to health care, and it wouldn’t cost us any more than we are already spending collectively.

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