PNHP

Koch-Backed Think Tank Finds That “Medicare for All” Would Cut Health Care Spending and Raise Wages. Whoops.

Koch-Backed Think Tank Finds That “Medicare for All” Would Cut Health Care Spending and Raise Wages. Whoops.

By Ryan Grim and Zaid Jilani
The Intercept, July 30, 2018

A new study from the Mercatus Center at George Mason University is making headlines for projecting that Independent Vermont Sen. Bernie Sanders’s “Medicare for All” bill is estimated to cost $32.6 trillion — a number that’s entirely in line with 2016 projections, and is literally old news. But what the Associated Press headline fails to announce is a much more sanguine update: The report, by Senior Research Strategist Charles Blahous, found that under Sanders’s plan, overall health costs would go down, and wages would go up.

The study, which came out of the Koch-funded research center, was initially provided to the AP with a cost estimate that exceeded previous ones by an incredible $3 trillion — a massive error that was found and corrected by Sanders’s staff when approached by AP for comment.

But despite that correction, the report actually yields a wealth of good news for advocates of Sanders’s plan — a remarkable conclusion, given that Blahous is a former Bush administration economist working at a prominent conservative think tank.

Blahous’s paper, titled “The Costs of a National Single-Payer Healthcare System,” estimates total national health expenditures. Even though his cost-saving estimates are more conservative than others, he acknowledges that Sanders’s “Medicare for All” plan would yield a $482 billion reduction in health care spending, and over $1.5 trillion in administrative savings, for a total of $2 trillion less in overall health care expenditures between 2022 and 2031, compared to current spending.

In order to arrive at this number, Blahous looked at how “Medicare for All” could lower administrative costs and provide savings in areas like drug spending. He concluded that by empowering the secretary of Health and Human Services to negotiate for lower drug prices, Sanders’s plan would add “$846 billion in additional savings over the 2022-2031” period. These savings, and others, are offset by certain other costs, like those which come from higher “utilization,” or the increased amount health care services used once everyone is insured.

Blahous’s report also acknowledges some substantial benefits to eliminating employer-sponsored insurance. He writes that these changes “should increase worker wage net of employer-provided health benefits,” while also “relieving individuals, families, and employers of the substantial health expenditures they would experience under current law.” The report even admits that the Sanders bill would serve as a boon to states, freeing them from most Medicaid obligations.

But despite the explicit benefits acknowledged by the Blahous study, health policy experts and single-payer advocates David U. Himmelstein and Steffie Woolhandler, who reviewed the Mercatus study, argue that Blahous actually significantly undercounts savings that could result from “Medicare for All.”

“The Mercatus Center’s estimate of the cost of implementing Sen. Bernie Sanders’ Medicare for All Act (M4A) projects outlandish increases in the utilization of medical care, ignores vast savings under single-payer reform, and fails to even mention the extensive and well-documented evidence on single-payer systems in other nations – which all spend far less per person on health care than we do,” Himmelstein and Woolhandler explain. 

In a written analysis shared with The Intercept, Himmelstein and Woolhandler write that Blahous’s report undercounts administrative savings by more than $8.3 trillion over 10 years. Taking those savings into account would lower Blahous’s estimate from $32.6 trillion to $24.3 trillion.

Additionally, the policy experts believe that Blahous underestimates savings from drug prices; for example, ignoring the success the U.S. Veterans Administration, the Canadian government, and certain European governments have had in negotiating for lower drug prices. If the United States paid European prices, they conclude, another $1.7 trillion would be trimmed from Blahous’s total cost estimate, bringing it down to $22.6 trillion over 10 years.

Himmelstein and Woolhandler also claim that Blahous grossly overestimates how much extra care would be utilized as a result of expanding insurance coverage. Using Blahous’s projections, they note that he is essentially arguing that once every American is covered, there will be 100 million additional doctor visits and several million more hospitalizations each year. But Himmelstein and Woolhandler say that’s wildly off the mark. From their written analysis:

[T]here just aren’t enough doctors and hospital beds to deliver that much care. Doctors are already working 53 hours per week, and experience from past reforms tells us that they won’t increase their hours, nor will they see many more patients per hour.

Instead of a huge surge in utilization, more realistic projections would assume that doctors and hospitals would reduce the amount of unnecessary care to those who are currently not getting what they need. That’s what happened in Canada. Doctors and hospitals can adjust care to meet increasing demand, as happens every year during flu season.

Moreover, no surge materialized when Medicare was implemented and millions of previously uninsured seniors got coverage. Between 1964 (before Medicare) and 1966 (the year when Medicare was fully functioning) there was absolutely no increase in the total number of doctor visit in the U.S.; Americans averaged 4.3 visits per person in 1964 and 4.3 visits per person in 1966. Instead, the number of visits by poor seniors did go up, but the number of visits by healthy and wealthy patients went down slightly. The same thing happened in hospitals. There were no waiting lists, just a reduction in the utilization of unneeded elective care by wealthier patients, and the delivery of more care to sick people who needed it.

Blahous explained the $3 trillion error in an email to The Intercept.

As you might imagine, any draft study like this is shown to many people along the way (at least 20 in this case) and goes through multiple rounds of re-estimation, editing and redrafting.  Estimates in prior drafts were revised in both directions (higher and lower) in subsequent drafts on the way to final publication. One of the more recent drafts before final publication was shown to the Sanders office,” he said. “That draft contained an estimate of long-term care costs reproduced from another study, which was cited because this study had no long-term care model to draw upon.  That previously-published study predated the introduction of the Sanders bill, the language of which the Sanders office asserted was not intended to increase federal financing of long-term care service utilization.  In reality there probably would be some increase in long-term care utilization under M4A because its broader coverage expansion would enable more people to make use of long-term care benefits already authorized under current law through Medicaid.  But rather than attempt to estimate that, I concluded the right thing to do was to reflect the language’s intended effect as represented by the primary sponsor, as was done throughout the study with the other provisions of M4A.  I was very pleased to receive and incorporate their input.

Even using Blahous’s numbers — which may be off by roughly $15 trillion according to Himmelstein and Woolhandler’s estimates  — the conclusion is plain: “Medicare for All” would cover more people, increase the quality of coverage, and cost less than is currently being spent on health care. “Blahous admits that covering the uninsured and upgrading coverage for most others could be achieved at virtually no additional cost through a single payer reform,” Himmelstein and Woolhandler conclude.”Altogether, the increase in federal health spending is dramatic and certainly significant, but the change in projected national health expenditures really isn’t,” he told The Intercept. Especially given the source of the report, that’s news.

https://theintercept.com…

Even Libertarians Admit Medicare for All Would Save Billions

A new study from a libertarian think tank admits that Medicare for All would save a whopping $300 billion.

By Matt Bruenig
Jacobin, July 30, 2018

The US could insure 30 million more Americans and virtually eliminate out-of-pocket health care expenses while saving $300 billion in the process, according to a new report about Medicare for All released by the libertarian Mercatus Center.

In the report, Charles Blahous attempts to roughly score Bernie Sanders’s most recent Medicare-for-All bill and reaches the somewhat surprising (for Mercatus) conclusion that, if the bill were enacted, the new costs it creates would be more than offset by the new savings it generates through administrative efficiencies and reductions in unit prices.

The report’s methods are pretty straightforward. Blahous starts with current projections about how much the country will spend on health care between 2022 and 2031. From there, he adds the costs associated with higher utilization of medical services and then subtracts the savings from lower administrative costs, lower reimbursements for medical services, and lower drug prices. After this bit of arithmetic, Blahous finds that health expenditures would be lower for every year during the first decade of implementation. The net change across the whole ten-year period is a savings of $303 billion.

When talking about Medicare for All, it is important to distinguish between two concepts: national health expenditures and federal health expenditures. National health expenditures refer to all health spending from any source whether made by private employers, state Medicaid programs, or the federal government. It is national health expenditures that, according to the report, will decline by $303 billion.

Federal health expenditures refer to health spending from the federal government in particular. Since the federal government takes on nearly all health spending under Medicare for All, federal health expenditures will necessarily go up a lot, $32.6 trillion over the ten-year period according to Blahous. But this is more of an accounting thing than anything else: rather than paying premiums, deductibles, and co-pays for health care, people will instead pay a tax that is, on average, a bit less than they currently pay into the health care system and, for those on lower incomes, a lot less.

At first glance, it is strange that the Mercatus center, which is libertarian in its orientation and heavily funded by the libertarian Koch family, would publish a report this positive about Medicare for All. The claim that “even the Koch organizations say it will save money while covering everyone” provides a useful bit of rhetoric for proponents of the policy.

But the real game here for Mercatus is to bury the money-saving finding in the report’s tables while headlining the incomprehensibly large $32.6 trillion number in order to trick dim reporters into splashing that number everywhere and freaking out. This is a strategy that already appears to be working, as the Associated Press headline reads: “Study: ‘Medicare for all’ projected to cost $32.6 trillion.”

Messaging strategy aside, there is room to quibble with Blahous’s positive findings. He assumes administrative costs will only drop from 13 percent to 6 percent for those currently privately insured. But, according to the Kaiser Family Foundation, Medicare’s administrative costs have consistently been below 2 percent. He assumes utilization of health services will increase by 11 percent, but aggregate health service utilization is ultimately dependent on the capacity to provide services, meaning utilization could hit a hard limit below the level he projects.

But even if you take the report’s headline figures at face value, the picture it paints is that of an enormous bargain. We get to insure every single person in the country, virtually eliminate cost-sharing, and save everyone from the hell of constantly changing health insurance all while saving money. You would have to be a fool to pass that offer up.

Matt Bruenig is the founder of People’s Policy Project.

https://jacobinmag.com…

Why the Healthcare Justice Movement is Just Getting Started in California and Beyond

By Paul Y. Song, M.D.
Medium, July 29, 2018

As the sun begins to set on California’s two-year legislative session, it will officially signal the death of the Healthy California Act better known as SB562. After Assembly Speaker Anthony Rendon called SB562 “woefully incomplete” and banished it into legislative purgatory, it became quite obvious when none of its original co-sponsors or any other elected official emerged to fight on its behalf, that this would be its ultimate fate.

For all the “woefully incomplete” arguments made against 562 of it not having a funding mechanism, being dependent on federal waivers, and costing too much, Sacramento needs to explain its own hypocrisy. Why did the same assembly take up AB 1184 without providing any funding mechanism? Why did Sacramento rubber stamp Governor Brown’s fiscally irresponsible and grossly over-budget bullet train project and initiate construction without the guaranteed federal dollars and waivers that are desperately needed to complete it? How can Sacramento continue to call SB562 too expensive while ignoring the fact that our state already spends $368 Billion a year on healthcare of which 71 cents is already paid for by California taxpayers? And how can Sacramento continue to ignore and fail to address State Controller Betty Yee’s latest report of a $91.5 Billion unfunded healthcare retiree liability which increased $14 Billion from the year before, or our states’ $24 Billion annual school retiree healthcare liability?

Despite the empty talk by elected officials of being open to single payer, what was “woefully incomplete” in Sacramento was their political will. When the original Cap and Trade Bill (AB 398) died in the California Assembly, it was only through the sheer political will of the Governor, Speaker, and Senate Pro Temp to carry out a “gut and amend” which led to its ultimate passage. Sadly SB562 was not fortunate enough to be offered an honest legislative effort to address legitimate criticisms and concerns or be afforded a similar fate.

As bold as California has been on so many issues, Sacramento has failed to seize this opportunity to lead on real healthcare justice, and would like nothing more than for this movement to dissolve so they can get back to preserving the corporate status quo. They incorrectly assume that like prior single payer efforts, which fizzled without any political retribution from the electorate, that they can continue to ignore the will of their constituents and the harm and frustration many Californians face each day from our existing dysfunctional healthcare system. But, this healthcare movement is very different than before and is only growing stronger and at a far faster rate than insurance premiums.

While Sacramento sweeps SB562 under its legislative rug, it cannot hide from the following facts:

California’s Medicaid system, which currently covers roughly one-out-of-three Californians, remains extremely vulnerable to a heartless Congress hell bent on greatly reducing its Federal funding obligation.

Nearly 3 million Californians, including 250K kids remain uninsured.

With no insurance rate regulation, insurance premiums in CA have increased approximately 250% since 2002, while inflation has gone up 40% and wages for most Californians have remained stagnant. It is no wonder that the number of people who have difficulty paying their monthly premiums has increased from 27% to 37% in 2015 to 2017. Meanwhile, 53% of Californians worry they cannot pay their medical bill if they get sick, and 60% report that it is too difficult for them to afford healthcare in general.

For those who continually confuse universal coverage with actual access to care, they fail to grasp the prevalence of underinsurance. The number of people who report having difficulty with deductibles has increased from 34 to 43% during the last two years. And 44% of people with high deductible expenses will actually delay seeking care.

Coupled with the fact that 37% of people WITH insurance who had medical problems reported borrowing money from family and friends, 34% reported being unable to pay for food or rent, 63% used up all their savings, and 28% recently had a medical bill turned over to an agency, more Americans are afraid of paying for care than they are of getting seriously ill.

And for all the success of Covered California relative to the rest of the US, premiums will go up another 9% this year while 66,000 Californians will only have access to one plan and 216,000 will have access to just two. At the same time, 75% of all Covered California plans continue to have narrow networks.

While there is no perfect healthcare system, most agnostic experts agree that a single payer system, unlike our current system that continually increases cost while decreasing access to care, would indeed save money while increasing coverage and overall access.

As SB562 dies a cowardice death, rather than become dejected or disillusioned, activists should find great solace in what was accomplished. For the first time we had an unprecedented collection of new and lifelong activists of all ages, nationalities, religions, vocations, and socioeconomic groups, come together to demand something far better. This translated into advocacy, organizing, and canvassing in every single assembly district in California and has forever elevated single payer into the public consciousness. In the process, it has ultimately helped both statewide and federal efforts.

Recent attempts to have single payer removed from the California Democratic Party platform were soundly defeated, and due to an overwhelming groundswell of support created by SB562, Kamala Harris listened to the majority of her constituents and was emboldened to be the very first US Senator to co-sponsor Senator Bernie Sanders Medicare-for-all bill S.1804.

With a sustained majority of Americans supporting a single payer Medicare-for-all plan and 74% among Democrats, it has even become a litmus test in most democratic primaries. And in fact, a new Health Tracking Poll by the Kaiser Family Foundation now finds that three-quarters of voters say that a single government plan or Medicare-for-all should be considered, is very important, or the single most important factor in the upcoming election.

So rather than hide from it or view it as a political liability, more elected officials are boldly embracing it and more candidates are proudly running as Medicare-for-all candidates. For the very first time, we now have a Medicare-for-all congressional caucus with 72 members along with 123 co-sponsors of HR676 (the House Medicare-for-all bill), and one-third of Democratic senators who support S.1804.

Still, many view corporate Democrats, not Republicans, as the real obstacle to making this a reality. Max Fine, who helped to create Medicare as a member of John F. Kennedy’s Medicare task force recalls how Democrats moved away from Ted Kennedy’s bill to cover all Americans with government health insurance towards a private insurance solution with absolutely no interest in Medicare-for-all. Fine went on to say “Single payer is the only answer and some day I believe the Republicans will leap ahead of Democrats and lead in its enactment, just as Bismarck in Germany and David Lloyd George and Churchill in the UK.” In fact, some Republicans have already begun to make the case for single payer and even question if our current profligate spending on health care is a conservative value.

For those in Sacramento and beyond who behave like climate change deniers when it comes to healthcare, it is simply getting harder for them to continue to justify a broken and unsustainable system.

But due to the obscene financial resources that are spent by the for-profit medical-industrial-complex (led by the pharmaceutical and insurance industries) to buy our elected officials, relentless organizing and electoral pressure is the only way we will ever break this vicious hold.

To my fellow activists, now is not the time to let up. If anything, we must utilize the organizing success created by SB562 to serve as an unbreakable foundation from which to continue to educate, advocate, mobilize, and eventually translate into undeniable political capital both in Sacramento and D.C.

And if our next Governor is truly committed to keeping California fifth largest economy golden, it would be wise to acknowledge the tremendous burden healthcare costs place on employers and employees alike. As businesses spend more and more on healthcare for their employees and less on wages, capital improvements, and R&D, their employees have begun to feel the brunt as well. In 2018, the average worker will contribute $4200 towards their employer sponsored plan. It is no wonder that Charlie Munger has referred to our “cockamamie” current system as the “tapeworm of American competitiveness.”

We must do everything to ensure that our next Governor’s previously stated commitment towards single payer is not “woefully incomplete”. And we must do everything we can to ensure that each of our state and congressional representatives (especially Democrats) come to support single payer as well.

And as the Centers for Medicare and Medicaid Services Administrator, Seema Verma, has repeatedly labeled single payer as “socialized medicine” and vowed to reject any state waivers for such a plan, it is one more reason for us to do everything we can to wake up and mobilize an apathetic electorate to end this presidential reign of horror.

The harm that countless Californians and Americans face each day at the hands of our broken and immoral system is sadly not going away and neither are we. Sacramento may be able to ignore it, but we simply cannot.

Like our nation’s evolution on marriage equality that had a dramatic sea change in less than a decade, a similar sea change is happening with regard to single payer. So keep up the fight and continue to make your voices heard while spreading the single payer gospel.

We are on the right side, the moral side, and ultimately the winning side.

Dr. Paul Song is a national board member of Physicians for a National Health Program and co-chair of the Campaign for a Healthy California.

https://medium.com…

Celebrate Medicare’s birthday by covering everyone

By F. Douglas Stephenson, L.C.S.W., B.C.D.
The Gainesville (Fla.) Sun, July 28, 2018

This month marks Medicare’s 53rd birthday. In July 1965, Congress enacted Medicare to provide health insurance to people ages 65 and older, regardless of income or medical history.

In the years since, Medicare has become proof that public, universal health coverage is superior to private insurance in every way. Medicare is more efficient than private health insurance and is administered at a cost of 3 percent to 4 percent, as opposed to private, for-profit health insurance, which has administrative costs above 15 percent.

Medicare’s costs have risen more slowly than those of private health insurance. Medicare provides better access to care, better financial protection and higher patient satisfaction.

Although many have negative feelings toward government, and examples of government inefficiency and incompetence abound, the record of private health insurers is far worse. Dozens of financial profiteering scandals have wracked private insurers and HMOs in recent years.

To continue our progress, it’s time to upgrade Medicare by establishing a 21st century “Medicare for All” health insurance system that covers all age groups, cradle to grave. Newborns will leave the hospital with their new Medicare card, and drop it off years later at life’s end.

A bill now filed in Congress, H.R. 676, covers all medically necessary services, including primary care, medically approved diet and nutrition services, inpatient care, outpatient care, emergency care, prescription drugs, long-term care, palliative care, mental health services, dentistry, eye care and substance abuse treatment. Patients have their choice of physicians and other providers, hospitals and clinics.

Co-pays and deductibles paid at health professionals’ offices are ended because payment for health insurance is fully prepaid directly into Medicare, much like Social Security, and covered at first dollar amounts. This means the obsolete 80 percent/20 percent payment split between private health insurance companies and Medicare is eliminated, with Medicare for All covering 100 percent.

All citizens are guaranteed access to decent health care while achieving significant overall savings compared to our existing system by lowering administrative costs, controlling the prices of prescription drugs and fees for physicians and other health-care professionals and hospitals, reducing unnecessary treatments and expanding preventive care.

Good health care would be established as a basic human right, as in almost all other advanced countries. Nobody would have to forego needed treatments because they didn’t have insurance or they couldn’t afford high insurance premiums and co-pays.

Nobody would have to fear a financial disaster because they faced a health care crisis in their family. Virtually all families would end up financially better off and most businesses would also experience cost savings compared to what they pay now to cover their employees.

We finance our new Medicare for All by eliminating profiteering by the private health insurance industry and slashing the system-wide administrative waste they generate, with a single streamlined, nonprofit public payer health insurance system. Such savings, estimated in 2017 to be about $500 billion annually, would be redirected to patient care.

Existing tax revenue would fund much of the system. According to a 2016 study in the American Journal of Public Health, tax-funded expenditures already account for about two-thirds of U.S. health spending. That revenue would be retained and supplemented by modest progressive taxes based on ability to pay, taxes that would typically be fully offset by ending today’s very high premiums paid to the for-profit private insurance industry and out-of-pocket expenses for care.

The vast majority of U.S. households — one study says 95 percent —would come out financially ahead. The system would reap savings by dealing with drug and medical supply companies for lower prices.

More than two dozen independent analyses of federal and state single-payer legislation by agencies such as the Congressional Budget Office, the General Accountability Office, the Lewin Group and Mathematica Policy Research Group have found that the administrative savings and other efficiencies of a single-payer program would provide more than enough resources to provide first-dollar coverage to everyone in the country with no increase in overall U.S. health spending.

A majority of Americans support Medicare and expansion of this program to provide health insurance for all. Write to your senators and representatives and let them know how you feel about expanding Medicare. Ask them to improve and strengthen Medicare with Medicare for All, H.R. 676.

By making health insurance available to all age groups, we can enjoy and celebrate Medicare’s 53rd birthday with the assurance that this life-saving health insurance program will continue.

F. Douglas Stephenson is a retired clinical social work psychotherapist.

http://www.gainesville.com…

Dr. Eric Naumburg on ‘State Circle’

PNHP-MD co-chair Dr. Eric Naumburg appeared on “State Circle” on Maryland Public Television on July 27, 2018. He discussed the advantages of a single-payer national health program and the prospect of passing a state program (as has been proposed in Maryland) versus a national program (as has been proposed by PNHP).

Time has come for Medicare for all

By Zach Thomas
Charlotte Observer, July 27, 2018

In response to “Medicare is turning 53. Here’s best way to celebrate” (July 27. Opinion).

As founding president of what is now Hospice and Palliative Care Charlotte Region, I celebrated the day hospice was included in Medicare’s reimbursement program in the early 1980s. Without Medicare, we’d still be dependent on private health insurance and fund raising.

I totally agree with Dr. George Bohmfalk’s fiscally conservative reasons for extending Medicare for all. Medical costs should not be the No. 1 reason pushing families and businesses into bankruptcy. Health crises can occur at any age.

Like hospice, Medicare for all is an idea whose time has come – and will never go away. We’re all in this together.

Zach Thomas is a board member of Health Care Justice – North Carolina, a PNHP chapter located in Charlotte.

https://www.charlotteobserver.com…

Reducing personal medical debt

Unlike Medical Spending, Medical Bills In Collections Decrease With Patients’ Age

By Michael Batty, Christa Gibbs, and Benedic Ippolito
Health Affairs, July 25, 2018 (published ahead of print)

Abstract

Health policy is often designed to help protect patients’ financial security. However, there is limited understanding of the role medical debt plays in household finances. We used credit report data on more than four million Americans to study the age profile of people whose medical bills were sent to a US collections agency in 2016. We found that, unlike health care use and spending, medical collections decreased substantially with age. The average size of medical debt decreased nearly 40 percent from patients age twenty-seven to sixty-four, with increases in health insurance coverage and incomes likely playing important mediating roles. However, the frequency of medical collections—that is, the proportion of people with a collection by age—was less closely tied to insurance coverage rates. A potential explanation is that most medical collections were relatively modest in size, with more than half of them less than $600 annually. As a result, medical collections could still occur under typical insurance plans. We discuss how these results could inform policies targeting medical debt and insurance regulation, such as restrictions on age rating.

From the Introduction

Using deidentified credit report data on more than four million people, we found that the frequency (proportion of people with a medical collection by age) and size of medical collections peak in the late twenties and decline as age increases. This pattern is similar to that of the percentage of people without health insurance by age, but it differs markedly from the sharp rise in medical spending by age.

Furthermore, while the average size of medical collections exhibits a close relationship with uninsurance rates by age, the portion of people who actually incur any medical debt within a given year does not decline as much at older ages as uninsurance rates do. We augment these findings by showing that many annual medical collections are relatively modest in size (more than half under $600). Insurance typically reduces what patients are asked to pay, but if it includes nontrivial cost sharing, patients may still face bills they cannot afford or do not pay. This may both limit consumers’ demand for insurance and temper expectations for how much all but very generous forms of universal coverage would reduce the medical debt we observed.

From the Policy Implications

As prior research has shown, our results suggest that health insurance is associated with medical debt. In addition, we found that younger adults are more likely than their older peers to have medical collections, despite having lower medical spending. Thus, policies that promote insurance coverage for younger adults may have the greatest effect on reducing medical collections. One such policy is the oft-debated limitation on age rating in the ACA Marketplaces for individual insurance coverage. An actuarially fair system would charge the oldest enrollees premiums closer to five times those of the youngest, compared to the current three-to-one age rating cap. Relaxing this limitation could lower premiums for younger consumers and boost coverage in a group that currently incurs the most medical debt, though at a cost of higher premiums and potentially increased medical debt for older people. The extent to which this would alter the total amount of debt or simply redistribute it in part hinges on consumers’ responsiveness to health insurance premiums and wealth differences across age groups.

While our results suggest that insurance is important for reducing the dollar amount of unpaid debts, they also imply that consumers could still incur a substantial amount of debt even under universal coverage, if such coverage required nontrivial cost sharing. This is consistent with data from the 2016 National Health Interview Survey, which show that 72 percent of the patients ages 20–65 who reported not being able to pay medical bills were insured. Thus, one option is for policy makers to further limit allowable levels of cost sharing (for example, restricting the availability of “catastrophic” plans or requiring higher actuarial values more broadly). However, all else equal, this would increase the price of insurance, potentially discouraging the most price-sensitive consumers from purchasing coverage and raising concerns about moral hazard. Policy makers could increase subsidies to offset the price increases, but this may face political opposition, given recent evidence.

If policy makers are committed to the provision of insurance with substantial cost sharing, as has become increasingly common in many employer-sponsored plans and in the ACA individual market, reducing medical collections would require policy efforts to increase funds available to pay bills—either by increasing after-tax incomes or by promoting savings. Although health savings accounts are the most prominent health-specific savings vehicle, their tax-advantaged structure is considerably less valuable to the lower-income people who likely constitute more of the population with medical debt than higher-income people do. As a result, a continued focus on this type of policy would likely have muted effects on the medical debt of lower-income people.

Finally, consideration of the size distribution of medical debt is important for policies aimed at increasing insurance coverage. For example, Amy Finkelstein and coauthors argue that the availability of uncompensated care reduces the cost of being uninsured (though not fully) and may cause people to not purchase insurance even when the subsidized price is far below their own expected medical expenses. Similarly, Neale Mahoney argues that bankruptcy offers some implicit health insurance for those without formal insurance. Our results indicate that most medical debts are relatively modest in size, which means that they could be incurred before the insured person meets their deductible. Thus, the channels that decrease demand for insurance may be in effect for a wider range of medical expenses than previously thought.

***

Health Affairs Comment:

By Don McCanne, M.D.

The discussion of policy implications really needs to be expanded.

The two primary causes of medical debt that results in collections include being uninsured, which calls for policies that would make coverage truly universal, and underinsurance with excessive patient cost sharing resulting in medical debt.

Most policy discussions of the latter seem to accept consumer directed health care as a given – making the patient sensitive to health care spending through higher deductibles and other cost sharing. This results in policy recommendations that do not eliminate the medical debt issue but rather use trade-offs that only shift the problems, often inequitably.

As an example, setting premiums closer to age-related risk would increase medical debt problems for older individuals, not really a desirable policy. Another example is that increased use of medical savings accounts increases tax expenditures that benefit the wealthy – a highly inequitable method of financing health care that is unfair to our taxpayers. Solutions that are directed to moral hazard and consumer price sensitivity do not solve the problems but merely shift them around.

Exhibit 3 provides a very important lesson. At age 65 there is an abrupt decline in the numbers of uninsured, obviously due to increased enrollment in Medicare. But also within a couple of years medical collections become almost negligible, most likely due to the fact that the deficiencies in Medicare coverage are filled in by other coverage including retiree plans, Medigap plans, Medicare Advantage plans, or dual coverage with Medicaid. This suggests that, instead of increasing administrative complexity and costs through the use of these various supplemental plans, Medicare benefits should be expanded to fill in the gaps in coverage if we want to protect patients from medical debt.

Improving Medicare and expanding it to cover everyone would not only address the medical debt issue, it would also make coverage truly universal, and it would be funded equitably through progressive tax policies. Regarding affordability, the policies characteristic of a well-designed single payer system would use other more patient-friendly measures to control spending such as reduction of our profound administrative waste, use of publicly administered pricing such as negotiated rates and bulk purchasing, and planning and separate budgeting of capital improvements to ensure efficient distribution of our health care delivery resources.

These policies would change the cost trajectory to make it sustainable, not only to benefit individuals but society as a whole. That does not remove the major barrier to reform that the authors also allude to – the political opposition to government financing, even though the decrease in private financing, especially employer-sponsored plans and plans in the individual market that disproportionately burden individuals with modest or low incomes, is a major reason that public insurance systems work so well. To enact the beneficial policies that we need for an equitable, affordable health care financing system for all, we need to change the politics.

https://www.healthaffairs.org…

***

Further Comment:

By Don McCanne, M.D.

An important theme that runs throughout this article: “consumers could still incur a substantial amount of debt even under universal coverage, if such coverage required nontrivial cost sharing.”

Nontrivial cost sharing is the primary cause of medical debt in insured individuals. Deductibles, coinsurance and often copayments are usually more than trivial in today’s private insurance products.

Several other nations have shown that cost sharing has not been necessary to keep health care spending rates at a level well below that of the United States. Cost sharing in the United States has not kept us from spending the most on health care, and it has created unnecessary exposure to medical debt.

We really can provide health care to everyone for free at the point of service while controlling costs though single payer policies that are much more patient friendly and much more effective than consumer-directed cost sharing, and we can pay for the system painlessly through equitable, progressive public financing.

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

Activists Call For Hill To Withdraw From ACA Lawsuit

By Brandon Smith
WFYI Indianapolis, July 27, 2018

Local health care advocates want Attorney General Curtis Hill to withdraw the state from a lawsuit that aims to dismantle the Affordable Care Act.

The advocates delivered letters and a 600-signature petition to Hill’s office Friday.

Indiana is one of 20 states in a lawsuit that seeks to eliminate the Affordable Care Act, also known as Obamacare. The Trump administration announced in June it would no longer defend the federal health care law.

Protect Our Care Indiana spokesperson Kate Shepherd says the lawsuit threatens more than those who use the ACA’s marketplace.

“If successful, insurance companies could once again deny or drop from the coverage the more than 2.7 million Hoosiers with preexisting conditions, like asthma, diabetes, or cancer,” Shepherd says.

Indiana University McKinney School of Law clinical professor Fran Quigley is also the coordinator of People Of Faith For Access To Medicines. He says Hill didn’t need to join the lawsuit.

“Stop misusing the power of your office. Stop misusing the taxpayer funds we’re paying for to administer this lawsuit,” Quigley says.

Hill responded to the petition late Friday afternoon. He said in a statement, since Congress repealed the tax but left the individual mandate in place, the ACA is unconstitutional.

“I hope to see the emergence of sound policies that constitutionally safeguard the healthcare needs of all Americans, including those with pre-existing conditions,” Hill said in a statement. “I support efforts to this end by Gov. [Eric] Holcomb and the General Assembly here in Indiana, and I support such efforts by Congress and the Trump administration on the national level.”

https://www.wfyi.org…

CMS Administrator Seema Verma’s opposition to Medicare for All

Commonwealth Club, July 25, 2018

Seema Verma: Americans enjoy the benefits of the best health care providers and innovators in the world. Yet while the volume of care consumed by American patients has not increased dramatically compared to similar economies, the cost of care in the United States has accelerated at an alarming pace. Health care costs are growing faster than the United States GDP, making it more difficult with each passing year for CMS to ensure health care for generations to come.

The status quo is simply unsustainable, and there is no easy solution. Anyone who tells you that more government spending alone can fix this problem doesn’t understand the issue, because despite the huge increase in funding we saw from Obamacare, many of our health care challenges not only remain but continue to worsen. As a country, we have not figured out how to slow the rate of growth in health care spending.

***

Before I conclude…I want to address one additional issue.

We have all heard the drumbeat for what advocates of a government-run – socialized – health care system call “Medicare for All.” Let me briefly explain why this notion reveals a fundamental lack of understanding about the uniqueness of Medicare to the very specific population that it serves.

First, Medicare is a program to provide care to our most vulnerable, disabled and aging population that needs it. Second, by proposing to expand services offered by Medicare to every American, you further strain Medicare’s funding streams and run the risk of depriving seniors of the coverage they have worked their entire lives to receive.

We have just discussed the challenges that Medicare faces in serving the nation’s seniors, the misaligned financial systems that are driving up costs, and the bureaucratic hurdles faced by doctors and hospitals. We have a lot of work to do to strengthen the existing Medicare program. Putting millions more Americans on Medicare will undermine the health care for the very demographic the program is designed to assist. Ideas like “Medicare for All” would only serve to hurt and divert focus from seniors, all the while expanding the regulatory burden and the misaligned and perverse incentives of a government-run system.

In essence, Medicare for All would become Medicare for None.

By choosing a socialized system, you’re giving the government complete control over the decisions pertaining to your care or whether you receive care at all. It would be the furthest thing from patient-centric care.

Let’s learn from the mistakes made in Medicaid when the Affordable Care Act pushed millions of able-bodied Americans into a program designed for pregnant women, children, aged, and those with disabilities, only to then incentivize states to serve the able-bodied before protecting Americans most in need. We have seen this movie, and the last thing we need to see is the sequel.

I seriously hope those who advocate it take time to understand the complexity of the program and the adverse consequences of their proposal.

Rather than straining Medicare, we are working to strengthen Medicare. We are activating patients to be consumers of health care, to drive providers to compete for patients by innovating and providing value. We are getting rid of burdensome regulations that are barriers to value-based care while realigning incentives so that providers can focus on delivering care that improves quality and lowers cost.

We are running out of time to solve the challenges of our health care system. Not addressing health care costs not only threatens the future of the Medicare program but our country’s future. This administration will never stop driving our system towards delivering value for the patient. This will take every single part of the health care system working together to ensure that we continue to drive towards value. Everybody will need to do their part to create a value-based system, but we need you to do your part as well. Please engage with us. We need and want your ideas and your unique perspective. At some point, we’re all going to be Medicare beneficiaries, so let’s work together to strengthen the program and leverage that strength for the future of our entire health care delivery system. This is not a luxury, but a necessity. The prosperity and the well-being of future generations is dependent on the decisions that we make today. So join us as we ensure those decisions will benefit all Americans. Thank you.

***

Q&A Session:

Mark Zitter, Moderator: I’d like to turn to the bigger issue that people have brought up and that you raised about single payer health care. I’m not going to ask the question that you already answered. I know the administration is not in favor of it. I do find that many people confuse single payer health care with universal coverage – not the same thing. Many countries have both – not the same thing. So clearly the administration is not in favor of a single payer approach; what’s the Trump administration’s feeling about everybody having health care coverage.

Seema Verma: I think we’ve always said that we want to make sure that people have access to coverage. That’s always been a goal of the administration. I just don’t think the government is the one to make decisions for each and every American. People need to make decisions about health care on their own. They need to have choices and options and they need to make the decisions that are going to work best for them. We don’t think the the government should be making decisions about individual families and for people about their health care. That should come from the individual.

Mark Zitter: And when you say “access to coverage,” is that the same as coverage?

(Audience laughter)

Seema Verma: We want people to have access to coverage, and I don’t…I think we’ve been very clear about making sure that, you know, that there’s access in a lot of different ways. What we’ve had through Obamacare is a type of plan – a very expensive plan that lots of people can’t afford. Different people want different types of plans, and I think they should be able to make the choices – decide what’s going to work best for them.

Mark Zitter: So we have through the Affordable Care Act about half the number of uninsured in America. We still have eight or nine percent, whatever that might be, and granted the coverage for everyone is not optimal, so just being covered is not all that we need. However we still have eight or nine percent, more in some states, less in others; what’s the Trump administration’s plans to get that number up pretty close to one hundred.

Seema Verma: So a couple things that we’ve done…What we’re seeing in the exchanges is that the coverage has become very expensive, and for people that are subsidized, they’re not necessarily experiencing issues in terms of getting access to the coverage; they still may having a lot of problems in affording the out-of-pocket expenses and the very high deductibles. But a lot of people cannot afford the coverage; they are not able to get subsidies. And so one of the things that we’re trying to do is to make certain that there is different types of options available, providing more flexibility – short term limited duration plans; we put out a rule for association health plans. The idea is to create more flexibility and more options for consumers to be able to have different choices, because I don’t think that everybody can afford the one-size-fits-all Obamacare approach – a very expensive plan that’s leaving out millions of Americans.

Mark Zitter: We just heard over the past week in terms of the association health plans – there have been some new rules there. One of the groups that was most in favor of it didn’t feel like the new rules were sufficient for it to pursue. So are there other plans to do something else in that regard?

Seema Verma: We’re always going to be continuing to drive towards getting Americans options. I think the way Obamacare is structured, it’s a one-size-fits-all approach, and so you’re going to see action by the agency, and I think that’s what the president, in terms of his executive order, wants to make sure there is different types of plans available, that people have choices about their care.

Mark Zitter: One of the statements that the president has made that has gotten a lot of excitement on the right, and increasing interest on the left, is the notion of giving states much more flexibility in how they administer health care to their residents. There’s concern on the left that maybe states won’t do what they want overall, but of course you’ve talked about experimentation… Here in California, as you probably heard, we have a gubernatorial race. Most candidates are running on some kind of platform about single payer health care on a statewide basis. Plenty of challenge to that, but I guess my question to you is that should that platform go forward it would require, I suppose, waivers from the federal government so the money that currently flows through your department would be put into the California single payer pool. Should that happen… should that be requested, what would be your feeling about granting California that flexibility?

Seema Verma: I don’t think a single payer system is going to work, number one. I think that a lot of the analyses show us that it’s unaffordable, and that it would actually put many people in the situation where the government is making decisions about their health care. We’ve been consistent that we support flexibility, but when we look at proposals, we evaluate them to see are they fiscally sustainable, are they fiscally sustainable for the federal government as well as the states, and when we’re evaluating proposals that’s what we’re looking at, we’re looking to see whether the proposal falls within the confines of the law. But it doesn’t make sense for us to waste time on something that is not going to work.

Mark Zitter: So that’ll be a no.

Seema Verma: Like I said, our parameters are that it has to be fiscally sustainable for the federal government.

https://www.commonwealthclub.org…

YouTube video (1 hour, 7 minutes):
https://m.youtube.com…

Transcript of prepared speech:
https://www.cms.gov…

***

Comment:

By Don McCanne, M.D.

This speech was primarily the rhetorical spin that this administration has been spewing out – much conservative and libertarian ideology with a paucity of health policy recommendations that are largely ineffective and often detrimental. Medicare for All advocates should be particularly concerned about what she has to say.

To no surprise, she dismisses Medicare for All with what she believes to be an inflammatory label: “socialized.” She then accuses advocates of not understanding Medicare. She says that that Medicare for all would risk removing resources from current Medicare beneficiaries, which of course is the opposite of the truth since it would expand benefits. She insists that it is unaffordable, ignoring the fact that increased government spending would be offset by the reduction in private health care spending.

Confirming that her speech is rhetorical, lacking in any beneficial policy substance, she concludes by saying, “Medicare for All would become Medicare for None.”

The conservatives have long supported giving the states a much greater role in regulation and financing of health care, contending that the states are in a better position to make decisions about health care for their people. Yet showing that she is much more driven by ideology than by policy, she insists that a single payer system is not going to work regardless, that it would be unaffordable, which all studies show is absolutely untrue when looking at total health care spending. She says that though she supports flexibility, she is not going to “waste time on something that is not going to work.”

As the moderator Mark Zitter says, “So that’ll be a no.”

I found it very painful to listen to this speech. I left out of the transcript that I typed her little joke about world peace, which to me only compounded the pain – joking about peace, of all things. (The audience didn’t laugh either.)

These people will never understand the ethics and morality of an egalitarian health care system that brings health care justice to all. We need to replace them with people who do understand and who care.

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

Medicare is turning 53. Here’s the best way to celebrate

By George Bohmfalk, M.D.
The Charlotte Observer, July 26, 2018

Monday is the 53rd birthday of Medicare, the program that added several years to seniors’ lives and elevated millions out of poverty. Many physicians, including my father, fought it tooth and nail, only to find that their incomes grew as their patients’ health improved. Doctors saw that they could practice as they had before, but now get paid for what previously was charity elder care. Their worries about it being socialized medicine ceased.

Medicare is an extremely successful and popular government program, a very good thing for 15 percent of our citizens. As private, for-profit health insurance continues to squeeze enrollees into narrower provider networks and unaffordable cost-sharing, many Americans under 65 are desperate for relief. Most business leaders do not realize that around one-third of every healthcare dollar goes to administration, rather than healthcare. We pay around twice per person what every other country pays for healthcare, the largest share of GDP. Despite being the biggest market, we pay the world’s highest prescription drug prices. Our health outcomes, including life expectancy, rank near the bottom.

Except in the Medicare population. Once people have access to healthcare, their health dramatically improves. Medicare has a secret for the rest of the country: We can expand Medicare to cover everyone, improve it to cover prescription drugs and eliminate deductibles and co-payments, and save money in the process. The secret lies in Medicare’s 2-3 percent administrative overhead, a fraction of private insurance companies’. Politicians commonly campaign on eliminating waste, but their promises rarely materialize. With Improved Medicare for All, we can convert hundreds of billions in administrative waste to actual, life-saving healthcare.

Improving Medicare can be a fairly straightforward process, as described in the House bill HR 676. The taxes to fund it would be less than current healthcare spending for 95 percent of households — a clear win-win for the vast majority of us. Employers would no longer be burdened with providing health insurance and could better compete globally. Everyone truly could choose and keep their doctors, if not their current expensive and restrictive insurance plans.

But as widespread support for Medicare for All has grown, deceptive lookalike proposals have appeared. With names like Medicare Extra for All, Medicare Part E, and Medicare-X, these plans retain private, for-profit insurance companies with their paper-shuffling, treatment denials and cost-sharing. They all threaten real progress in healthcare by preserving the wasteful but profitable status quo.

If those plans prevail, Medicare may not have many more birthdays. The best celebration of Medicare’s 53rd birthday would be to improve it and offer it to everyone. Tell your congressional representatives that’s the birthday gift you want, for yourself, your loved ones, and for the country.

Dr. Bohmfalk, a retired neurosurgeon, chairs the Education Committee of Health Care Justice North Carolina, the Charlotte chapter of Physicians for a National Health Program. He may be reached at HCJusticeNC@gmail.com.

https://www.charlotteobserver.com…

Taking health care reform to the election booth

KFF Health Tracking Poll

Conducted July 17-22, 2018

Thinking about the upcoming election, is a candidate’s position on “passing a national health plan in which all Americans would get their insurance from a single government plan, or Medicare-for-all” the single most important factor in your vote, very important but not the most important factor, one of many factors you’ll consider, or not an important factor in your vote?

12% – Single most important factor
37% – Very important, but not the most important factor
29% – One of the many factors you’ll consider
21% – Not an important factor in your vote
2% – Don’t know/Refused

http://files.kff.org…

***

Morning Consult + POLITICO National Tracking Poll

Conducted July 19-23, 2018

How important of a priority should each of the following be for Congress? Passing a healthcare reform bill

55% – A top priority
25% – An important, but lower priority
6% – Not too important a priority
5% – Should not be done
9% – Don’t know/No opinion

https://www.politico.com…

***

Comment:

By Don McCanne, M.D.

In the Kaiser poll over three-fourths say that a single government plan or Medicare-for-all should be considered or is very important or the single most important factor in the upcoming election. In the Morning Consult/POLITICO poll three-fourths say that passing a health care reform bill is an important or top priority, with over half saying it is a top priority.

As a topmost priority, generic health care reform seems to have greater support than a single government plan or Medicare for all, but both concepts do have three-fourths majority support. That’s enough to make legitimate health care reform a litmus test in the coming election, and what could be more legitimate than an improved Medicare for all? Let’s get the word out.

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

Locking patients out of Medigap plans

In All But Four States, Seniors on Medicare Can Be Denied a Medigap Policy Due to Pre-existing Conditions, Except During Specified Windows of Opportunity

KFF, Newsroom, July 11, 2018

In all but four states, insurance companies can deny private Medigap insurance policies to seniors after their initial enrollment in Medicare because of a pre-existing medical condition, such as diabetes or heart disease, except under limited, qualifying circumstances, a Kaiser Family Foundation analysis finds.

Medigap policies provide supplemental health insurance to help cover the deductibles and coinsurance for Medicare covered services. One in four people in traditional Medicare had a Medigap policy in 2015.

This new analysis of federal law and state regulations shows that only Connecticut, Maine, Massachusetts, and New York require Medigap insurers to sell policies to all Medicare beneficiaries ages 65 and older either continuously during the year or for at least one month per year. In all other states and the District of Columbia, insurers may deny a Medigap policy to seniors, except during their initial open enrollment period when they start on Medicare, or when applicants have other specified qualifying events, such as the loss of retiree health coverage.

Depending on their state, Medicare beneficiaries who miss these windows of opportunity may unwittingly forgo the chance to purchase a Medigap policy later in life if their needs or priorities change, or if they choose to switch to traditional Medicare after several years of being in a Medicare Advantage plan.

The brief provides new national and state-by-state data on Medigap enrollment, and describes federal and state-level consumer protections that can affect seniors’ access to Medigap.

https://www.kff.org…

***

Medigap Enrollment and Consumer Protections Vary Across States

By Cristina Boccuti, Gretchen Jacobson, Kendal Orgera, and Tricia Neuman
KFF, Issue Brief, July 11, 2018

Discussion

Medigap plays a major role in providing supplemental coverage for people in traditional Medicare, particularly among those who do not have an employer-sponsored retiree plan or do not qualify for cost-sharing assistance under Medicaid. Medigap helps beneficiaries budget for out-of-pocket expenses under traditional Medicare. Medigap also limits the financial exposure that beneficiaries would otherwise face due to the absence of an out-of-pocket limit under traditional Medicare.

Nonetheless, Medigap is not subject to the same federal guaranteed issue protections that apply to Medicare Advantage and Part D plans, with an annual open enrollment period. As a result, in most states, medical underwriting is permitted which means that beneficiaries with pre-existing conditions may be denied a Medigap policy due to their health status, except under limited circumstances.

Federal law requires Medigap guaranteed issue protections for people age 65 and older during the first six months of their Medicare Part B enrollment and during a “trial” Medicare Advantage enrollment period. Medicare beneficiaries who miss these windows of opportunity may unwittingly forgo the chance to purchase a Medigap policy later in life if their needs or priorities change. This constraint potentially affects the nearly 9 million beneficiaries in traditional Medicare with no supplemental coverage; it may also affect millions of Medicare Advantage plan enrollees who may incorrectly assume they will be able to purchase supplemental coverage if they choose to switch to traditional Medicare at some point during their many years on Medicare.

Only four states (CT, MA, NY, ME) require Medigap policies to be issued, either continuously or for one month per year for all Medicare beneficiaries age 65 and older. Policymakers could consider a number of other policy options to broaden access to Medigap. One approach could be to require annual Medigap open enrollment periods, as is the case with Medicare Advantage and Part D plans, making Medigap available to all applicants without regard to medical history during this period. Another option would be to make voluntary disenrollment from a Medicare Advantage plan a qualifying event with guaranteed issue rights for Medigap, recognizing the presence of beneficiaries’ previous “creditable” coverage. For Medicare beneficiaries younger than age 65, policymakers could consider adopting federal guaranteed issue protections, building on rules already established by the majority of states.

On the one hand, these expanded guaranteed issue protections would increase beneficiaries’ access to Medigap, especially for people with pre-existing medical conditions. They would also treat Medigap similarly to Medicare Advantage in this regard, and make it easier for older adults to switch between Medicare Advantage and traditional Medicare if their Medicare Advantage plan is not serving their needs in later life. On the other hand, broader guaranteed issue policies could result in some beneficiaries waiting until they have a serious health problem before purchasing Medigap coverage, which would likely increase premiums for all Medigap policyholders. A different approach altogether would be to minimize the need for supplemental coverage in Medicare by adding an out-of-pocket limit to traditional Medicare.

Ongoing policy discussions affecting Medicare and its benefit design could provide an opportunity to consider various ways to enhance federal consumer protections for supplemental coverage or manage beneficiary exposure to high out-of-pocket costs. As older adults age on to Medicare, they would be well-advised to understand the Medigap rules where they live, and the trade-offs involved when making coverage decisions.

https://www.kff.org…

***

Comment:

By Don McCanne, M.D.

Although most individuals are relieved when they are finally eligible for Medicare, the traditional program leaves them exposed to excessive out-of-pocket costs and so they often seek additional coverage.

If they are fortunate enough to have an employer-sponsored retiree plan, they will usually select that. If they have very low incomes, they may be eligible for dual coverage with Medicaid. Medigap plans are offered to supplement traditional Medicare, but they are quite expensive and many feel that they cannot afford them. Some decide that they will risk going without any other coverage, but others will select private Medicare Advantage plans usually because the benefits are more generous whereas the premiums are generally quite low, and may be zero.

The Medicare Advantage plans have become quite popular because of their marketing appeal, but some individuals find that their use of provider networks limits their access to other physicians and hospitals that they would prefer, plus they sometimes feel that they are being deprived of care that they feel they should have such as an expensive cancer drug that has been excluded from the plan formulary or placed on a financially inaccessible tier.

When their care becomes complex they sometimes decide that they would prefer to shift to the traditional Medicare program that does not limit them to provider networks, and purchase a Medigap plan to protect themselves against catastrophic losses. At this point they are usually out of luck. If they elected not to enroll in a Medigap plan during the initial enrollment period when they first became eligible for Medicare, with rare exceptions they will find that guaranteed issue no longer applies and that they likely will be denied coverage. The initial marketing appeal of the Medicare Advantage plan comes back to bite them since they are then locked out of the Medigap plans.

There is something unjust here. Congress and the administrations of the past couple of decades have been granting the private Medicare Advantage plans all kinds of concessions while paying them more that what comparable patients would cost in the traditional Medicare program. Yet they have failed to enact the improvements that the traditional Medicare program needs to make benefits comparable to the private plans. That is why Medigap plans exist. They are necessary to cover the financial exposure that exists in traditional Medicare, especially the risk of catastrophic loss.

But why should someone in the traditional plan have to buy an expensive supplemental Medigap plan when we, as taxpayers, are also contributing generously to the private Medicare Advantage insurers (30 percent of what they receive goes to administrative costs, profits, and extra benefits such as Silver Sneakers). Shouldn’t taxpayer support for all Medicare beneficiaries be equitable, whether in the private or public plans?

If the traditional Medicare program were funded at the same risk-based level as the private Medicare Advantage plans, we could roll all of the Medigap benefits into traditional Medicare and then there would be no need to purchase a separate Medigap plan. Furthermore, there would be no reason to consider a private Medicare Advantage plan unless you were willing to give up your choice of physicians and hospitals in exchange for a Silver Sneakers membership, or if you preferred to receive your care through an integrated health care delivery system such as Kaiser Permanente.

Better, of course, would be to establish a single payer program – an improved Medicare for all. One of the more important improvements would be to roll Plan F Medigap benefits into Medicare. However, Congress decided that in 2020 Plan F benefits will no longer be offered to new enrollees – just one more measure to chisel away at the traditional Medicare program while furthering the cause of privatization by nurturing the private Medicare Advantage plans. In fact, a new administration proposal this month will further expand benefits in the private Medicare Advantage plans while denying them to patients in the traditional program.

How about health care justice for all? We can have that by enacting and implementing an expanded and improved Medicare for all.

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