Project 2025 Mandate for Leadership: The Conservative Promise, April 2024, The Heritage Foundation & partner organizations, Chapter 14: Department of Health and Human Services

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Medicaid Reform Proposals (pp. 466-472)
[HJM bolding of narrative]

Reform Financing: Allow states to have a more flexible, accountable, predictable, transparent, and efficient financing mechanism to deliver medical services. This system should include a more balanced or blended match rate, block grants, aggregate caps, or per capita caps. Any financial system should be designed to encourage and incentivize innovation and the efficient delivery of health care services. Federal and state financial participation in the Medicaid program should be rational, predictable, and reasonable.

Direct Dollars to Beneficiaries More Effectively and Responsibly: End state financing loopholes. Reform payments to hospitals for uncompensated care. Replace the enhanced match rate with a fairer and more rational match rate. Restructure basic financing and put the program on a more fiscally predictable budget.

Strengthen Program Integrity: Incentivize states to decrease waste, fraud, and abuse. Improve Medicaid eligibility standards to protect those in need. Conduct oversight and reform of managed care.

Incentivize Personal Responsibility: Ensure that Medicaid recipients have a stake in their personal health care and a say in decisions related to the Medicaid program. Implement work requirements and match Medicaid benefits to beneficiary needs.

Allow Private Health Insurance: Enable states to contribute to a private insurance benefit for all family members in a flexible account that rewards healthy behaviors.

Increase Flexible Benefit Redesign Without Waivers: Eliminate obsolete mandatory and optional benefit requirements for able-bodied recipients. Redesign eligibility, financing, and service delivery of long-term care.

Eliminate Current Waiver and State Plan Processes: Allow providers to make payment reforms without cumbersome waivers or state plan amendment processes. Shift the balance of responsibility for Medicaid program management to states.

Prohibit Planned Parenthood from Receiving Medicaid Funds: End taxpayer funding of Planned Parenthood and all other abortion providers. Redirect funding to health centers that provide comprehensive health care for women.

Withdraw Medicaid funds for states that require abortion insurance: Cut 10 percent of Medicaid funds

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Comment:

By Jim Kahn, M.D., M.P.H.

In my previous post, I introduced Project 2025 and the threats that it presents overall. Today is the first focused post – detailing the attack on Medicaid, our primary health insurance for the poor.*

As for understanding Project 2025’s Medicaid policy agenda, let me cut to the chase. The proposed changes, despite being couched in bureaucratic buzzwords, have a straightforward and nefarious intent: Reduce health insurance coverage for the poor, by restricting both eligibility and benefits. And, equally worrisome, use Medicaid to suppress access to abortion.

Here’s the translation of Project 2025 policy jargon:

A “balanced or blended match rate” means less federal money (currently the majority of Medicaid funding), imposing a larger financial toll on states and thus lowering overall funding. “Block grants” and “caps” means fixed funding, regardless of the size of eligible populations and their medical needs, and slow or no growth over time. “End state financing loopholes”, “reform payments”, and (again) “replace enhanced match rate” all mean: lower federal contributions. All this compromises providing care, see analyses here, here, and here.

“Improve Medicaid eligibility standards to protect those in need” means: cover only the very poorest and sickest, leaving out many who currently qualify and who, in today’s fragile health insurance environment, desperately need Medicaid.

“Incentivize personal responsibility” means – impose often onerous preconditions on getting Medicaid benefits. The example, “implement work requirements” — which don’t work.

“Allow private insurance” means abandoning the Medicaid public structure in favor of private insurance, which results in widespread under-insurance – especially dangerous for the poor.

“Eliminate … benefit requirements” means, well, removing requirements for specific medical services, thereby increasing risk. “Redesign … long-term care” means – undercut the mainstay of long-term care funding for the poor and middle class.

Layered onto this broad reduction in medical benefits is a full-bore attack on abortion services. I don’t think I need to translate the language excerpted above, which is atypically clear and direct. More on this topic in an upcoming post.

What’s amazing about Project 2025 is the ability to rhetorically cast dangerous policies as being about efficiency, generosity to the sickest, and personal virtue. In contrast, we know that true efficiency and generosity are available in true universal health insurance – single payer. The security of excellent health care access will go a long way toward increasing societal virtue.

* As I’ve written previously, I very much look forward to the day when the phrase “health insurance for the poor” no longer has meaning. Meantime … we must maintain the program that provides for the medical needs of the economically vulnerable.

https://healthjusticemonitor.org…

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Project 2025’s “Mandate for Leadership: The Conservative Promise,” released in April, threatens to replace modern American values with a retrograde vision. This 900-page action plan proposes a rapid, broad, and enduring transformation. It lays out sweeping policy shifts that favor the wealthy and undermine support for the poor, middle class, and minorities. Its detailed specification of practical implementation steps is chilling.

The Project 2025 policy scope is wide. On the economic side, it would make permanent the 2017 tax cuts for rich individuals and corporations, promote anti-union “right to work” laws, and reduce the power of public sector unions. In health, it would undermine the effectiveness of both public and private insurance, which we’ll explore thoroughly in subsequent posts. It would compromise pandemic response and end protections for abortion and reproductive health, as well as for LGBTQ rights.

Project 2025 would also fundamentally change how government and voting work, gutting the checks and balances built into our system. Specifically, it attacks the mechanisms that assure balance and continuity in how elected officials are chosen and how they must govern. In the area of voting, it promotes requirements for photo IDs and tighter absentee voting rules, both of which disadvantage minorities, the poor, and students. This would further weaken the voting power of these groups.

Its most insidiously consequential change concerns how the government operates. Project 2025 proposes use of a bureaucratic maneuver – “Schedule F” – to reclassify tens of thousands federal senior civil service employees (with job protections) into political appointees (who serve at the pleasure of the President). This means that the most technically skilled senior managers, who know the law and how to follow it, would be replaced with inexperienced and politically pliant newcomers who would be guided by presidential whims regardless of existing law. This undermines nearly a century of accumulated law, regulations, and professional governance.

HJM sees Project 2025 as a fundamental threat to progressive health policy. Thus, we’ll be writing about it regularly in coming weeks. Our focus will be on health policy – insurance, reproductive health, equity. But we’ll also veer into other topics.

Please let me (Jim) know if you have specific questions for us to address.

https://healthjusticemonitor.org…

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Even Doctors Like Me Are Falling Into This Medical Bill Trap, The New York Times, Op-Ed, June 17, 2024, by Danielle Ofri

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Last July, my daughter was still limping a week after a bike injury and we needed a quick X-ray to rule out a fracture. As a doctor, I knew we didn’t need an expensive emergency room for something this straightforward. We found an urgent care at the end of a strip mall in Chicago, and 20 minutes later we received the good news that there was only a sprain.

But this is health care in America. Two weeks later a bill arrived: The radiology charge from NorthShore University HealthSystem for the ankle and wrist X-rays was $1,168, a price that seemed way out of range for something that usually costs around $100 for each X-ray. When I examined the bill more closely, I saw that the radiology portion came not from the urgent care center but from a hospital, so we were billed for hospital-based X-rays. When I inquired about the bill, I was told that the center was hospital-affiliated and as such, is allowed to charge hospital prices.

It turns out that I’d stumbled into a lucrative corner of the health care market called hospital outpatient departments, or HOPDs. They do some of the same outpatient care — colonoscopies, X-rays, medication injections — just as doctors’ offices and clinics do. But because they are considered part of a hospital, they get to charge hospital-level prices for these outpatient procedures, even though the patients aren’t as sick as inpatients. Since these facilities don’t necessarily look like hospitals, patients can be easily deceived and end up with hefty financial surprises. I’m a doctor who works in a hospital every day, and I was fooled.

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Following is just a comparatively brief sampling of excerpts from a couple thousand NYT readers’ comments:

“You don’t have a health care system in the US. You have a health care industry. Your industry is designed to serve a wide range of 3rd party sharks who add huge costs to medical care without actually adding any value to the process. Now, many of your medical clinics and hospitals have been purchased by private equity which ensures that your health care will diminish and your costs will rise.”

“Now everyone from doctors to patients are asking for single payer.”

“The runaway costs of medical care will only be contained when we have Medicare for All.”

“I live in Canada. I demand my right to pay taxes. Taxes help pay for our medical system. The procedures are covered, and I won’t get billed for them.”

“Taiwan has one of the best universal healthcare systems on the planet.  For profit healthcare is an affront to basic human rights.”

“Single payer Medicare for all yesterday, today and tomorrow!”

“Get the profit out of our medical system. Eliminate the middlemen and the bloat.  One national system.  Period.”

“I’m a physician, and it’s time for universal healthcare for this country!”

“The bottom line is that it doesn’t have to be this way: different examples of single payer systems are throughout the world to glean from.”

“How desperately we need a single payer system.”

“I lived in a major Canadian city for almost a decade, and even with a substantially higher tax rate, my paychecks went a lot farther. Taxes pay for good stuff, America, if you let them.”

“We really need universal healthcare so doctors can do what they need to do, in the appropriate facility where they need to do it, without insurance companies second guessing everything.”

“In the long term, America needs a public healthcare system, one in which citizens’ health and patient care, not financial returns, are the goals.”

“Solution for patients and caregivers alike: Improved Medicare for all, AKA single payer financing of healthcare.”

“It is way beyond time that the United States adopted a single-payer health care system.”

“Just another reason we urgently need a real National Health Service that covers all medical procedures.”

“A majority of Americans have for decades favored a national healthcare system. Everybody gets over their socialism phobia as soon as they are eligible for Medicare.”

“We will get the needed change when the voters put the right people into office–the right people who put the health of the community first.”

“The only answer is nationalized health care.”

“I turned 65 and got Medicare. What a revelation – I can finally afford medical care. Everyone in this country should have this. I don’t like taxes but for universal health care I would pay more taxes.”

“I’d love to have single-payer health care. This is one of those things, like roads or managing air space, that the government does better than a for-profit corporation can do.”

“Why can’t we as citizens of the richest nation in the world agree that ALL of us deserve to have a decent roof over our heads, healthy food on the table and universal healthcare?”

“The time for a single payer system is long overdue.”

“The only conceivable solution is evolution to a single payer, single insurer system, well regulated by the government.”

“We need Medicare for all, and I do not mean profit-driven insurance company owned misleadingly-advertised Medicare Advantage.”

“Medicare for all. Get capitalism out of health care.”

“How many of you complainers have contacted your Congressional representatives to voice your opinion? One can easily find online their Washington phone numbers and emails, as well as their local offices. Medicare for all!”

“Here in Canada, never a bill from Emergency or Clinic.”

“Healthcare costs are out of control. We need national health care.”

“How to fix it?  Medicare for all.”

“Single payer health care system.”

“Single payer government funded healthcare would prevent the financial rip off that Dr Ofri describes.”

“America needs a single payer system which removes profit motivations and the costly parasites that enrich themselves at patients’ and society’s expense.It’s done well elsewhere, why can we not find the will to do it for ourselves?”

“National health is the solution.”

“Another excellent argument for universal government health care.”

“It’s time to give the current approach an unceremonious burial and replace it with a truly universal single payer system.  The American model of health care is a demonstrable failure.”

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Comment:

By Don McCanne, M.D.

Within just a few hours, this New York Times article on inflated medical bills precipitated a couple thousand reader responses which overwhelmed the editors of the Comments section so they closed it off to further responses. The readers’ message was loud and clear. Not only do they understand why our health care financing system is so overpriced while underperforming, as the sampling of excerpts above demonstrates they also know what to do about it: enact and implement single payer Medicare for All.

In just a few months, the rest of us will have an opportunity to express the same sentiment when we exercise our right to vote in the upcoming election. It’s crucial to understand where the candidates stand on health care justice, including the potential for a single-payer financing system, as well as other policies to make the United States a better nation for all of us. Show your support for health justice!

https://healthjusticemonitor.org…

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Supply-Side Healthcare?, Phenomenal World, May 9, 2025, by Adam Gaffney

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The politics of hospital care and construction

As some pundits tell it … “supply-side” competition-based expansion is exactly the medicine our healthcare system needs. The root cause of constrained access and rising healthcare costs, the argument goes, is public regulation giving the provider side of the market more leverage, allowing it to extract higher payments from insurers. Greater competition will lead to expanding supply, leveling the playing field between providers and insurers without altering the nature of ownership or public responsibility in the sector. “Call it supply-side economics, but for healthcare,” Matthew Yglesias wrote in Bloomberg, advising that we “focus less on the way insurance works than on expanding care to increase competition and reduce prices.” The Nikansen Center echoes the sentiment and generalizes it across those service industries at the core of American life. In healthcare, higher education and housing, this bipartisan consensus argues, supply expansion is the solution to rising costs.

Hospital supply expansion surely is needed in many places in the United States; decades of disadvantage, discrimination, and disinvestment have left many communities—particularly those with low-income and minority populations—deprived of needed healthcare facilities and resources. The problem is that the new “supply-side” gambit won’t succeed in securing access to healthcare for these populations. Nothing in the existing marketplace ensures that new construction will go where it’s needed. All evidence suggests that it will, rather, be put in the service of gaining market share in already lucrative areas. …

“Supply-side economics, but for healthcare” misdiagnoses the basic problem, which is not the performance of competition but rather the nature of financing and ownership. US hospitals are increasingly dominated by corporate behemoths and private equity firms who usher in skyrocketing prices and inequities while degrading the quality of care. Any effort to expand supply within the existing US healthcare scene will only accelerate this galloping corporate takeover, making us worse off in the process. Moreover, the nature of healthcare—a service with unique characteristics distinct from other commodities—poses profound consequences for the supply-side strategy of harnessing entrepreneurial spirits to expand provision efficiently. Unlike other services, the supply of healthcare induces its own demand, for every human body ultimately fails. Hospital beds, doctors’ hours, and machines can generally be put to some use. …

Multiple recent econometric analyses have found that when a shift of demand affects the use of care by one population—for instance, due to gain (or loss) of insurance coverage—the change in utilization of care by that population tends to be offset by slightly less (or more) care provided to populations whose coverage does not change. … My research with colleagues has come to similar conclusions. We analyzed health survey microdata before and after implementation of Medicare in 1966 and the Affordable Care Act in 2014, finding little evidence for an aggregate increase in society-wide healthcare use despite a substantial expansion of insurance (i.e. of demand), with some redistribution in use towards newly insured populations. Reviewing published utilization effects of some thirteen universal coverage expansions in capitalist nations over the past century, we found generally similar trends. …

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Comment:

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

As single-payer advocates, much of our focus is on healthcare access, particularly cost barriers stemming from uninsurance and underinsurance. That stands to reason: most of us fight for a better healthcare system primarily because we want to see everyone get the high-quality medical care they need when they need it. We care, more than anything, about health. Single-payer would mean that our demand for care (in economist-speak) would depend not on our insurance or wealth, but rather on our medical needs — it would, that is to say, expand and equalize “demand” by removing cost barriers that suppress use of care for the less fortunate.

But how we think about healthcare supply is important as well. Some conservative and even liberal thinkers argue that rather than focus on expanding coverage (i.e. demand), we should expand supply: i.e. more clinicians, more hospitals, and so forth, and thereby drive down the cost of care by fostering market competition. This article (by me) begins as an exploration of these “supply-wide” proposals, and argues that they wouldn’t accomplish what proponents think they would — indeed, they would cause costs to rise. It ends by making a broader argument about how the essence of medical care is time spent by human beings — time that can be redistributed but not expanded.

Supply expansion would fail as a cost control measure — even if it is needed for some services, like primary care, or for disadvantaged communities that have been left behind in our system — for a variety of reasons, as I trace, including the inefficiencies and redundancies that competition generates. Additionally, in medicine, supply often creates its own demand: ICU beds tend to be used when available, and our clinic schedules can invariably be filled.

That being said, some also envision a world where a supply-side transformation — e.g. from technological advances like AI – reduces the labor inputs needed to provide care (and other services). But in healthcare, I argue, there is zero historical or theoretical reason to believe that this will happen. Indeed, over the last century, as healthcare has been more capital intensive it has also in a sense become more labor intensive. There are more dollars of physical hospital capital assets per hospital bed than ever before, even as the number of nursing FTEs per hospital bed day has risen with the rising technological complexity of care, to give one example. On a more fundamental level, even with new tools and technologies, the time we need as healthcare providers to interview patients, evaluate reems of data, respond to concerns and questions, advocate for services, and formulate treatment plans will not fall — if anything, it will only rise. There will be no magical technological productivity fix to our healthcare woes.

We do need supply-side changes, to be clear, just not the ones that neoliberals envision. As healthcare delivery is gobbled up by corporations, cost and waste will rise even as quality deteriorates; we should think about public and community healthcare ownership along with public financing. Moreover, the simplicities of single-payer financing allow for major reductions in administrative costs, shaving off hundreds of billions of unproductive healthcare spending annually, as advocates frequently note.

At the same time, though, we should recognize that the value of some things we need, and healthcare is a prime example, is very much tied to the time that a human being puts into them. Versions of these services that contain less time – shorter visit lengths or higher patient to nurse ratios in the hospital – often have less fundamental value. Less time is being devoted to our care and health. Such time cannot be manufactured like commodities, it can only be more fairly distributed in society.

https://healthjusticemonitor.org…

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The State of Medical Debt in the U.S., (2-hour video with ten experts), Lown Institute, May 20, 2024, Website article by Noelle Serino

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Medical debt has reached epidemic levels in the United States, impacting millions of Americans and creating barriers to good health. “This is a mammoth problem that is seriously impairing the mental health, the physical health, and the productivity of our country”, said Dr. Vikas Saini, President of the Lown Institute.

“We need to enact some sort of universal, publicly-funded national single-payer plan that is administered at the state and local levels with comprehensive, lifetime benefits, dental, vision, mental health care, and so forth” said Berneta Haynes, Senior Attorney, National Consumer Law Center.

The link provides access to a two-hour video of a panel of experts covering the topics of 1) scope of the problem, 2) drivers of medical debt, 3) insights from new research, and 4) opportunities and challenges for change.

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Comment:

By Don McCanne, M.D.

Our nation continues to demonstrate how our reliance on private health insurance has been a mistake, especially when considering the financial burden that it places on lower-income individuals. For national statistics on medical debt prevalence and consequences, see here and other HJM posts.

What is difficult to understand is that we know that adoption of a national single payer program would not only prevent such financial hardships, but it would also ensure affordable access to a high-performance health care delivery system for absolutely everyone.

What on earth is preventing us from moving forward with the enactment and implementation of such a program? We certainly have the supporting data, but where is our will?

https://healthjusticemonitor.org…

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Commentary:

By Ed Weisbart, M.D., PNHP National Board Secretary

Our health is just an innocent bystander in the wake of damage the corporate insurance industry is inflicting on Americans, and Medicare Advantage (MA) extends their greedy grasp to seniors and people with disabilities. As the new report, Taking Advantage, from Physicians for a National Health Program (PNHP) concludes, “MA represents the worst of private insurance coming to take over the best system of health care that America has to offer.” The findings were presented and discussed at a webinar on June 3.

This report reveals that the damages inflicted on us by MA are far worse and more pervasive than most had realized. Nearly twelve million people in MA are in networks that exclude more than 70% of the physicians in their county. More than seven million have such high out-of-pocket costs that they have no choice but to avoid medically necessary care. Prior Authorizations and other egregious HMO-style tools are rampant. Virtually none of these things happen in Traditional Medicare, and few people joining MA are aware that they are making this life-threatening gamble.

That’s right, it’s life-threatening. These MA programs are not just inconveniences or annoyances: they have been shown to kill us.

As an example, one of the dozens of studies cited in the PNHP report determined that people in MA are twice as likely to die after pancreatic cancer surgery than are people in Traditional Medicare.

Despite an overwhelming mountain of similar evidence, the insurance industry has the audacity to claim that they are the solution to America’s problem with inequities in healthcare. They justify this claim by the fact that people of color along with others with limited financial resources are more likely to sign up for MA than the rest of the country. But is that proof that they help, or is that not actually proof that MA is one of the drivers of health inequity?

Medicare itself is far from perfect; an unacceptably high 25% of white and 27% of Blacks in Traditional Medicare cite cost-related problems accessing care if they are in fair or poor health. The racial difference skyrockets in MA, where 35% of white Americans and 50% of Black Americans have this problem. MA is not a solution to inequities; it’s one of the drivers. People with more financial means reject the inferior insurance that is Medicare Dis-Advantage.

The PNHP report also cites studies demonstrating geographic disparities. 42% of physicians in metropolitan areas, and 65% of physicians in rural areas, are not in MA networks. Given the paucity of physicians in rural areas, this translates into prohibitively long commutes for a simple blood pressure visit. No one warns rural Americans of this when they opt into MA.

Insurance corporations have stopped hiding this from their shareholders. Tom Cowhey, chief financial officer of CVS, declared that that they are looking at pulling out of communities where they make less profits, cutting back on benefits like hearing and vision care, and maybe even more. As Cowhey put it, “the goal is margin over membership… Lose up to 10% of our Medicare members? That’s okay.”  CVS isn’t alone; Humana, Centene, and others are being just as honest about their indifference to the harms they cause in the name of their profiteering.

Compare CVS’ corporate mantra of “margin over membership” with a couple of the advocacy community’s flagship messages, “Patients Over Profits” and “Care Over Cost”. Our allies at People’s Action have a campaign centered on the mirror-image inverse of the insurance industry’s misguided philosophy and inescapable subordination to profits before people, regardless of the harm they cause.

The bottom line here, as spelled out in PNHP’s report and webinar, is that we are all being cheated by MA. Their industry was created with the promise that they could improve our health and lower costs by coordinating, informing, and managing care. Instead, the insurance industry has clearly learned that they make more profits by delaying, denying, and interrupting healthcare. They are not doing what they are paid (overpaid!) to do. It’s time we stopped them from taking advantage of us.

Despite the overwhelming evidence of harm, it would be a mistake to call for an isolated end to MA and add another disruption to healthcare for the millions of seniors and people with disabilities who are currently in MA. Many are there today because they are unable to purchase a Medicare supplemental policy and can’t dare risk the financial ruin of Traditional Medicare’s copays and deductibles. Many are in MA because of the promise of extra benefits (hearing, vision, dental, pharmacy, etc.) that go beyond what’s included in Traditional Medicare today, though we know few actually use those extra benefits and most find them to be grossly inadequate shadows of real benefits.

And, frankly, the data in PNHP’s report is national data about the industry as a whole, but there likely are some MA plans that are better than the patterns seen when data is averaged across the nation. Unfortunately, as pointed out in the webinar, there is virtually no public data for comparing those individual plans. To paraphrase Alex Lawson of Social Security Works, that’s like having the FAA tell us that one airline’s planes are frequently crashing, but not telling us which airline that is. Just let the free market sort it out.

We must continue to fight for improvements to Traditional Medicare, coordinated and synchronous with the elimination of MA subsidies, so that savings from MA can be used to help fund the improved benefits across all of Medicare.

Watch the webinar, and then take the actions suggested there. We win when we’re organized…

https://healthjusticemonitor.org…

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Former U.S. Surgeon General: We’re Not Ready as a Nation for Single-Payer Healthcare; High Medical Debt ‘Obliterating Our Country’s Future’, MedPage Today, June 4-5, 2024, by Jeremy Faust

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Question: People in the comments section of your article did say, “Well, wouldn’t Bernie Sanders’ approach be better? Wouldn’t single-payer be the way?” And I always answer this question by saying, “I don’t know. I know it works in other countries, but I’m not sure this country is set up for that.” What do you think about that?

Jerome Adams: “You also can’t go to a system where you’re giving universal access to healthcare and single-payer until you can agree upon what that actually means.

“A real example: you go to Canada or the U.K. right now, and you’ll have no shortage of people who will tell you that they’re waiting 6 to 8 months for their elective surgery [A]. In the United States, if you take someone who comes in to their doctor in pain or with a diagnosis and they get told that they’re going to have to wait 6 to 8 months for their elective surgery, they will lose their minds and they’ll be on the phone with their lawyer or their local news station right away.

“We have a different expectation for what universal access to healthcare and a single-payer system would look like here versus other countries. Until we’re ready to have a very mature and nuanced conversation about that and about the fact that we can do this, but if we do this it means that you’re not going to be able to get what you want when you want [B] just because that’s the cultural expectation here. I think there’s a lot of nuance here.

“So at the end of the day, to answer your question, I don’t think that we are quite ready as a nation to really go there even though it sounds good. But I also think that we don’t have to. Switzerland, for instance, has a system where they provide access to a certain level of care for everyone in the country [C]. If you want more, you can buy it off of the market.

“I think there are hybrid systems that we can and should be thinking about that are predicated on giving people a baseline level of care, guaranteed, that do work and still allow a free market to exist.” …

Question: [T]alking about the high-deductible healthcare plans. I want to take the devil’s advocate [position] here and say, isn’t that the point of a high deductible?

Adams: … This is about the fact that 66% of bankruptcies in the United States are driven by medical debt. So regardless of whether you feel like it’s a person’s fault or not, we have a broader societal issue when … bankruptcies are being driven by this kind of debt [D]. That’s number one.

Number two, as I mentioned earlier about the Affordable Care Act [ACA], we’re now in a place where almost 60% of people with employer-provided health insurance — the ‘good insurance’ — are forced onto high-deductible health plans [E]. It’s not that they made a choice, it’s that that was the only option that they were given, or the plans are priced such that that’s the only one where I can afford the premium to go on. So it’s not like people out there are making the choice that they want this high-deductible health plan, they’re being pushed in that direction.

The final point I’d make about the high-deductible health plan … the whole premise of the high-deductible health plan was also to include HSAs, where you contribute to these HSAs on a monthly basis so you’ve got something in the kitty in case you have an emergency. … But also we know that many people, particularly from marginalized communities like Black and Brown individuals and individuals from under-resourced communities, often are uneducated about their HSA or don’t contribute to their HSA [F].

So you have a system set up that’s dysfunctional because people aren’t educated and they aren’t contributing to it. Even when they do everything right — like I do, I max out my HSA — you still could get hit with a bill in January [G] as opposed to December. Mayo Clinic, in this instance, isn’t waiting until December to get their money. They want their money now. and so I’ve got to come up with it now.

… Nobody thinks that they’re going to need emergency medical care! Heck, I didn’t think that I was going to pass out at a medical meeting after a hike. …

No one’s talking about this on the campaign trail. [H] You don’t hear Biden or Trump talking about this on the campaign trail. You don’t hear people running for Congress talking about this on the campaign trail, but it is 66% of bankruptcies. It’s literally just obliterating our country’s future in terms of putting people in medical debt. …

Again, I raised this because I want people to really understand that this is hitting all of us and it is not sustainable.

[W]e highlight the need for increased transparency and pricing. [I] … we also need to look at state policies to help people avoid surprise medical bills, not just for out of network, but again, from January surprises and all sorts of different ways that people run into surprise medical bills. …

We need collaboration between providers, insurers, and healthcare systems, to really figure out how we unstick this broken system.

Then, we need to improve high-deductible health plans. I think that it’s still workable, [J] but my situation showed that high-deductible health plans are actually setting a lot of people up for medical bankruptcies and the burden of medical debt.

[ HJM comments keyed to bracketed letters ]

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Comment:

By Jim Kahn, M.D., M.P.H.

Dr. Adams engages in policy analysis by anecdote. This is hazardous; omitting relevant evidence leads to faulty conclusions. He thus dismisses single payer in cavalier fashion. Below is a point-by-point critique (with, I should note, quite a few points of agreement):

[A] “They’re waiting 6 to 8 months for elective surgery” in Canada and the UK. These numbers aren’t relevant to US single payer. For starters, the UK NHS is under assault by the Tories. More generally, the OECD record for elective surgery wait times is quite good, with medians of 4-7 weeks in the best-performing countries … and we’d be starting with higher spending and more surgeons than any of them. Of course, elective surgery isn’t urgent, by definition. On other measures of access, such as for primary care, the US lags far behind other OECD nations.

[B] “If we do [single payer] it means you’re not going to get what you want just because that’s the cultural expectation here.” Hmm. Is the US cultural expectation to skip or delay care for financial reasons? To experience 2-3 years’ lower lifespan? Today, while the best-insured may get the medical care they want right away, most have to wait or can’t get it at all.

[C] “Switzerland, for instance, has a system where they provide access to a certain level of care for everyone in the country.” That “certain level of care” is standard and comprehensive. Only 8.5% of spending is voluntary health insurance.

[D] “66% of bankruptcies in the United States are driven by medical debt.” Got that right!

[E] “about the Affordable Care Act, we’re now in a place where almost 60% of people with employer-provided health insurance — the ‘good insurance’ — are forced onto high-deductible health plans.” Yup – forced into high deductibles. Not a choice.

[F] “we know that many people, particularly from marginalized communities like Black and Brown individuals and individuals from under-resourced communities, often are uneducated about their HSA or don’t contribute to their HAS.” Right – likely can’t afford to contribute. HSAs are regressive, benefiting the healthy and wealthy. They worsen inequality.

[G] “you still could get hit with a bill in January.” Right again … several thousand dollars within the deductible, all at once, with no financial reserves.

[H] “No one’s talking about this (medical debt & bankruptcies) on the campaign trail.” True. Biden mentions lower prescription drug costs for seniors, which help a bit. Trump discusses ending the ACA. Some progressive Congressional candidates discuss single payer.

[I] “we also need to look at state policies to help people avoid surprise medical bills.” We’ve tried that, and federal policies too. It doesn’t work – too complex and gameable, and even if it did succeed it would leave unresolved 25 other major problems with our fragmented insurance.

[J] “we need to improve high-deductible health plans. I think that it’s still workable.” Not really. The problem with high deductibles is that they leave individuals & families financially vulnerable. Other wealthy nations don’t use high deductibles. With good reason – they impair access to care, impoverish people, punish the poor, and don’t control health care costs

Come on, Dr. Adams – endorse a real solution, one proven in dozens of other countries. It’s nice to hear from a former Surgeon General on problems with our insurance. How wonderful would it be for him to endorse the effective and enduring policy solution – single payer.

Financial Burden of Health Care in the Privately Insured US Population, JAMA Internal Medicine, May 28, 2024, by Sukreth A. Shashikumer, et al.

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Improving health care affordability is a national priority, including for nearly 180 million individuals with private insurance coverage who have experienced increased premiums and decreased benefits (eg, increasing copayments and deductibles). This issue is particularly salient for those with low incomes, who are more susceptible to debt, bankruptcy, and worse outcomes due to poverty.

This cross-sectional study used 2007 to 2019 Medicare Expenditure Panel Survey data for respondents and family members younger than 65 years with private insurance. Families’ total health care spending was calculated as contributions to premiums plus out-of-pocket medical and prescription drug spending. We assessed families’ annual financial medical burden by dividing their total health care spending by their postsubsistence income (income less estimated food costs).

The unweighted sample included 96075 families. Among low-income families, mean total health care spending was $3163 in 2007 and $3247 in 2019. Low-income families’ medical burden was 23.5% in 2007 and 26.4% in 2019.  Among higher-income families, mean total health care spending increased from $4071 in 2007 to $5239 in 2019. Higher-income families’ medical burden was 5.4% in 2007 and 6.5% in 2019.

In this national cross-sectional study of privately insured US families, inflation-adjusted health care spending increased from 2007 to 2019, largely owing to increasing contributions to premiums. Annual financial burden increased significantly, both overall and among low-income and higher-income families. Mean financial medical burden was more than 26% of post subsistence income for low-income families, compared with approximately 6% for higher-income families.

Our findings highlight the need to strengthen financial safeguards for low-income families, including those who do not meet the enhanced state definitions of Medicaid eligibility and are considered well-resourced enough to rely on private insurance. Furthermore, these results suggest that, without stronger emphasis on regulating premiums, controlling out-of-pocket costs is necessary but not sufficient to alleviate the burden of health care.

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Comment:

By Don McCanne, M.D.

Our political leaders who are quite satisfied with our health care system based heavily on private insurance plans (employer-sponsored plans, ACA plans, privately purchased plans, etc.) should make themselves aware of the findings in this relatively simple study. The financial burden of private insurance plans has continued and will continue to creep upward throughout the years, further threatening the affordability of health care, making it an imperative that we do something to stem the tide of increasing private insurance costs, especially for lower-income individuals who are being priced out of health care, experiencing significant medical debt, and suffering medical bankruptcy.

It’s not as if we didn’t understand that there is a way around this dilemma. There are many other defects with the private insurance model, but the most important is that it has been designed to draw off our health care dollars to create wealth for the investors and other intermediaries. Rather, our health care system needs to be financed based on the ability to pay with the funds distributed based on medical need and not for purposes of wealth accumulation.

Of course, that model is the single payer or Medicare for All model of health care financing. Since it would be financed by equitable, progressive taxes, there would no longer be any concern about adjustments in premiums or other cost sharing that would adversely impact lower income individuals. Although the accountants of the extremely wealthy would deal with larger numbers, the amounts would not have a negative impact on their lifestyles.

Instead of listening to the billionaires, Congress should listen to the American Public Health Association:

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American Public Health Association, Policy Number 20219, Excerpt

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Single payer is the best option to ensure equity, fairness, and priorities aligned with medical needs. This approach benefits public health, as everyone will have universal access to needed care, with treatment plans based on what works best for the patient. Clinics and hospitals will be free to provide appropriate treatments based on need.

https://healthjusticemonitor.org…

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