PNHP

Medicare for All amid a pandemic

Medicare for All amid a pandemic

By George Bohmfalk, M.D.
The Charlotte Observer, Letters, July 27, 2020

Regarding “Experts: NC must make wise choices so cases don’t spike,” (July 25):

This article quotes a S.C. professor saying “rationing care has already become a reality in some hospitals.“

Until now, rationing has only been a scare tactic in criticisms of Medicare for All. Our free-market, capitalistic, for-profit health care system promised to spare us from socialist disasters like rationing. It appears that a pandemic has brought it to its knees.

Medicare for All cannot prevent pandemics. However, universal coverage and coordinated health planning, with early testing and treatment not rationed by ability to pay, would go a long way to limit hospitalizations and deaths in future pandemics.

The present system is clearly failing. It’s time to demand Medicare For All.

Health savings accounts are often redundant

Use of Health Savings Accounts Among US Adults Enrolled in High-Deductible Health Plans

By Jeffrey T. Kullgren, MD, MS, MPH; Elizabeth Q. Cliff, PhD; Christopher Krenz, BA; Brady T. West, PhD; Helen Levy, PhD; Mark Fendrick, MD; Angela Fagerlin, PhD
JAMA Network Open, July 17, 2020

Abstract

Importance: Health savings accounts (HSAs) can be used by enrollees in high-deductible health plans (HDHPs) to save for health care expenses before taxes. Expansion of and encouraging contributions to HSAs have been centerpieces of recent federal legislation. Little is known about how US residents who may be eligible for HSAs are using them to save for health care.

Objective: To determine which patients who may be eligible for an HSA do not have one and what decisions patients with HSAs make about contributing to them.

Design, Setting, and Participants: This cross-sectional national survey assessed an online survey panel representative of the US adult population. Adults aged 18 to 64 years and enrolled in an HDHP for at least 12 months were eligible to participate. Data were collected from August 26 to September 19, 2016, and analyzed from November 1, 2019, to April 30, 2020.

Main Outcomes and Measures: Prevalence of not having an HSA or not making HSA contributions in the last 12 months and reasons for not making the HSA contributions.

Results: Based on data from 1637 individuals (American Association of Public Opinion Research response rate 4, 54.8%), half (50.6% [95% CI, 47.7%-53.6%]) of US adults in HDHPs were female, and most were aged 36 to 51 (35.7% [95% CI, 32.8%-38.6%]) or 52 to 64 (36.8% [95% CI, 34.1%-39.5%]) years. Approximately 1 in 3 (32.5% [95% CI, 29.8%-35.3%]) did not have an HSA. Those who obtained their health insurance through an exchange were more likely to lack an HSA (70.3% [95% CI, 61.9%-78.6%]) than those who worked for an employer that offered only 1 health insurance plan (36.5% [95% CI, 30.9%-42.1%]; P < .001). More than half of individuals with an HSA (55.0% [95% CI, 51.1%-58.8%]) had not contributed money into it in the last 12 months. Among HDHP enrollees with an HSA, those with at least a master’s degree (46.1% [95% CI, 38.3%-53.9%]; P = .02) or a high level of health insurance literacy (47.3% [95% CI, 40.7%-54.0%]; P = .03) were less likely to have made no HAS contributions. Common reasons for not contributing to an HSA included not considering it (36.8% [95% CI, 30.8%-42.8%]) and being unable to afford saving for health care (31.9% [95% CI, 26.2%-37.6%]).

Conclusions and Relevance: These findings suggest that many US adults enrolled in an HDHP lack an HSA, and few with an HSA saved for health care in the last year. Targeted interventions should be explored by employers, health plans, and health systems to encourage HSA uptake and contributions among individuals who could benefit from their use.

https://jamanetwork.com…

Comment:

By Don McCanne, M.D.

High-deductible health insurance plans have become more popular primarily because the plans are less expensive. The insurers are able to spend less on health care for two reasons. The risk of first dollar coverage is transferred from the insurer to the insured, and, with high-deductible plans, that may amount to a few thousand dollars per patient. The second reason is that patients might find that first dollar coverage may present enough of a financial hardship such that they may forgo care that they really should have – forgone care that the insurers don’t have to pay for.

Health savings accounts (HSAs) were established to make available funds that could be used so that the patient would not forgo beneficial health care services that fell under the deductible. Services that did not seem to provide adequate health care value could be rejected by the patient. Thus HSAs were designed to put the health care shopper in charge of their own spending since the HSA funds were their own funds anyway. HSA funds are tax-advantaged which benefits those with higher incomes, but does nothing for those whose incomes are too low to pay taxes.

The study by Kullgren, et al shows that many individuals who have HSA-eligible high-deductible health plans have not established a health savings account, and the majority of those who do have HSAs are not contributing funds to them. The majority of patients are at risk of facing financial hardship from the deductibles simply because the HSAs are not funded or do not even exist, thus patients may end up forgoing beneficial health care services. Also they add more administrative complexity to our health care financing system which is already overburdened with costly administrative excesses. Bad policy all the way around.

Under a well designed, single payer, improved Medicare for All, first dollar coverage is provided which eliminates financial barriers to beneficial health care services. The single payer model uses other more patient-friendly tools to prevent excessive health care spending. The patient has enough decisions to make without insisting that they must also make decisions on how health care dollars are spent. Many other nations provide health care at an average of half the per capita cost of what we spend, and they don’t require patients to become informed shoppers to do it. High-deductibles and HSAs should be replaced with first dollar coverage under single payer Medicare for All.

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Many U.S. Homes Too Cramped to Stop COVID-19’s Spread

By Amy Norton
HealthDay, July 24, 2020

People with COVID-19 are told to keep their distance from family members to protect them from infection. But a new study finds that one-fifth of U.S. homes are too small for that to happen.

Researchers found that more than 20% of households nationwide lacked enough bedrooms and bathrooms to allow a person with COVID-19 to isolate. That covers roughly one-quarter of the population.

And as with the pandemic in general, minority and low-income Americans are most affected. Among Hispanic adults, close to 40% live in a home with too few bedrooms or bathrooms.

Experts said housing conditions are likely one reason that Black and Hispanic Americans have been especially hard-hit during the COVID-19 pandemic.

“This is not affecting everyone in the same way,” said Dr. Talia Swartz, an infectious disease specialist at Mount Sinai Hospital in New York City.

It’s hard for any family to keep coronavirus from spreading in the household, said Swartz, who is also a spokeswoman for the Infectious Diseases Society of America.

“It’s that much harder if you’re living in crowded conditions,” she added.

Health experts’ advice to isolate sick family members makes sense, Swartz noted. But it can be frustrating for people without the space to do so.

“The guidance is catered to people who are able to do those things,” she said. “I think we need to be more thoughtful in our recommendations.”

Dr. Ashwini Sehgal, a professor of medicine at Case Western Reserve University in Cleveland, led the study.

“The issue of quarantining at home hasn’t gotten the same attention as mask wearing and social distancing,” he said. “And I think we need to do more.”

One option, Sehgal said, could be to offer hotel rooms to people who need to quarantine — under medical supervision, and with free meal delivery. The tactic has been used in several Asian countries, he noted.

New York City, which was the epicenter of the U.S. pandemic in the spring, did launch a hotel program, as did some other big cities. But Sehgal said he’s not aware of any coordinated effort to make that option widely available.

And cramped housing is not limited to big cities, said Paulette Cha, a research associate with the Public Policy Institute of California in San Francisco.

In California, where high housing costs are a longstanding issue, overcrowding is widespread, she said.

Compounding the problem, many people in cramped housing are also essential workers who don’t have the option of staying at home. Looking at California’s numbers, Cha’s team found that 29% of food service workers lived in crowded conditions, for example. The same was true for 31% of farm workers.

“If you’re out in the world and at risk of being exposed to the virus, and then unable to manage your risk [of transmission] at home, everything is amplified,” Cha said.

Swartz agreed that all those factors coming together puts families in a tough spot. And that includes the anxiety essential workers can feel about potentially bringing the virus home, she noted.

When a family member has COVID-19 and cannot isolate within the home, Swartz said other measures — though challenging — can still be taken. They include maintaining 6-feet of physical distance, hand-washing and regularly cleaning household surfaces.

There’s also the bigger picture, Cha said. The pandemic has thrown a light on inequities that have existed in the United States for many years — and housing is among them.

“These issues are all tied together,” she said. “And during the pandemic, all the chickens have been coming home to roost. The question is: Are we going to acknowledge this and invest in these communities?”

The findings, recently published online in the Annals of Internal Medicine, are based on responses to a 2017 federal housing survey. Of white respondents, 16% lived in housing without enough bedrooms or bathrooms to quarantine. That rose to 24% among both Black and Asian respondents; 34% among Native Americans; and 38.5% of Hispanic respondents.

https://consumer.healthday.com…

More information:

The U.S. Centers for Disease Control and Prevention has advice for people living in close quarters.

SOURCES: Ashwini Sehgal, MD, professor, medicine, and director, Center for Reducing Health Disparities, Case Western Reserve University School of Medicine, Cleveland; Talia Swartz, MD, PhD, assistant professor, medicine, Icahn School of Medicine at Mount Sinai, New York City, and spokeswoman, Infectious Diseases Society of America; Paulette Cha, PhD, research fellow, Public Policy Institute of California, San Francisco; Annals of Internal Medicine, July 21, 2020, online

Near term political prospects for Medicare for All

‘Medicare For All’ Gets Nod In Democratic Platform For First Time Ever

By Amanda Terkel and Tara Golshan
HuffPost, July 22, 2020

For the first time, the Democratic Party platform mentions “Medicare for All,” according to a draft version released this week. It’s a victory for progressives who worked to make the transformation of the health care system a central issue in the presidential campaign.

“Generations of Democrats have been united in the fight for universal health care. We are proud our party welcomes advocates who want to build on and strengthen the Affordable Care Act and those who support a Medicare for All approach; all are critical to ensuring that health care is a human right,” the document reads.

Former Vice President Joe Biden, the party’s presumptive nominee for president, does not back Medicare for All, a policy that was central to the rival presidential campaign of Sen. Bernie Sanders (I-Vt.). So the platform does not endorse the idea, and the reference to it is brief. But supporters say it’s still a win to have their progress acknowledged ― and to have the idea enshrined in an official party document in a positive way.

“If this pandemic has taught us anything, it’s that health care is a human right and that the greed and cruelty of health insurance corporations must end,” said Josh Orton, a senior adviser to Sanders who was on the committee. “A majority of Democrats in the U.S. House support a Medicare for All system, and it shows real progress that our movement is now a part of the DNC platform itself.”

https://www.huffpost.com…

Comment:

By Don McCanne, M.D.

Although the current draft of the Democratic Party platform doesn’t endorse Medicare for All, it does welcome both advocates of the Affordable Care Act and advocates of Medicare for All, acknowledging the support of both concepts within the ranks of the party. It is a first in that previous efforts to include single payer in the party platform have been rejected. So the mere mention of Medicare for All in the platform does represent progress.

The presumptive Democratic candidate for president – Joe Biden – has made it clear that he does not support Medicare for All and has implied that he would veto it if it came to his desk. The presumptive Republican candidate – President Donald Trump – has shown no interest in supporting Medicare for All.

So where does that leave us? As FDR said when special interests sought his support for another unrelated agenda, “Make me do it.”

That’s quite a task, having to pump up the politics such that the president can’t refuse, but that’s what we have to do.

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Persuading opponents to support Medicare for All

On the belief that beliefs should change according to evidence: Implications for conspiratorial, moral, paranormal, political, religious, and science beliefs

By Gordon Pennycook, James Allan Cheyne, Derek J. Koehler, and Jonathan A. Fugelsang
PsyArXiv, Preprint, Last edited June 24, 2020

Abstract

Does one’s stance toward evidence evaluation and belief revision have relevance for actual beliefs? We investigate the role of having an actively open-minded thinking style about evidence (AOT-E) on a wide range of beliefs, values, and opinions. Participants indicated the extent to which they think beliefs (Study 1) or opinions (Studies 2 and 3) ought to change according to evidence on an 8-item scale. Across three studies with 1,692 participants from two different sources (Mechanical Turk and Lucid for Academics), we find that our short AOT-E scale correlates negatively with beliefs about topics ranging from extrasensory perception, to respect for tradition, to abortion, to God; and positively with topics ranging from anthropogenic global warming to support for free speech on college campuses. More broadly, the belief that beliefs should change according to evidence was robustly associated with political liberalism, the rejection of traditional moral values, the acceptance of science, and skepticism about religious, paranormal, and conspiratorial claims. However, we also find that AOT-E is more strongly predictive for political liberals (Democrats) than conservatives (Republicans). We conclude that socio-cognitive theories of belief (both specific and general) should take into account people’s beliefs about when and how beliefs should change – that is, meta-beliefs – but that further work is required to understand how meta-beliefs about evidence interact with political ideology.

Conclusion

Our 8-item actively open-minded thinking about evidence (AOT-E) scale was strongly predictive of a wide range of beliefs, values, and opinions. People who reported believing that beliefs and opinions should change according to evidence were less likely to be religious, less likely to hold paranormal and conspiratorial beliefs, more likely to believe in a variety of scientific claims, and were more political liberal (in terms of overall ideology, partisan affiliation, moral values, and a variety of specific political opinions). Moreover, the effect sizes for these correlations was often large or very large, based on established norms (Funder & Ozer, 2019; Gignac & Szodorai, 2016). The size and diversity of AOT-E correlates strongly supports one major, if broad, conclusion: Socio-cognitive theories of belief (both specific and general) should take into account what people believe about when and how beliefs and opinions should change (i.e., meta-beliefs). That is, we should not assume that evidence is equally important for everyone. Furthermore, our findings provide clear support for the perspective that reasoning facilitates sound judgment, thereby undermining the idea that intuition commonly dominates reasoning. We also found essentially no support for motivated reasoning. Regardless future work is required to more clearly delineate why AOT-E is more predictive for political liberals than conservatives.

https://psyarxiv.com…

Comment:

By Don McCanne, M.D.

This study revealed that people are sharply divided on open-minded thinking about evidence (AOT-E); that is, they are divided on believing whether or not beliefs and opinions should change according to evidence. More specifically, they find that AOT-E is more strongly predictive for political liberals (Democrats) than conservatives (Republicans). Since these differences are relative rather than absolute, we shouldn’t try to reach for a theory of all things here, but we can use this to try to understand why there is resistance to supporting Medicare for All when the evidence is overwhelming that it is a vastly superior model of health care financing when compared to the highly dysfunctional system under which we are suffering.

So now that we know that the political opponents to Medicare for All by and large do not believe that the evidence supporting the superiority of the model should be used to change their beliefs or opinions which cause them to reject the model, what should we do? We have expounded on the benefits of Medicare for All until we’re blue in the face, yet we don’t seem to budge their side. Should we abandon trying to present the evidence? If so, then what else can we do? Do we simply wait until they have an epiphany? That doesn’t seem to be working either. Should we ask them what we can do to help sway them? But if they already reject the evidence, then they certainly are not looking for other ways to be swayed.

Donald Trump just shifted from ridiculing face masks during the COVID-19 pandemic to recommending that people use them, based on the evidence. Evidence? Has anyone presented him with the evidence favoring Medicare for All? Wouldn’t it be worth a try?

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What will Medicare for All really cost?

A Review of Reports on the Cost and Funding of Medicare-for-All

By Gordon Mosser
SSRN, May 12, 2020

Abstract

In the US, 30 million people have no health insurance, and the per capita cost of health care is far higher than it is in other countries. To address these problems, many have advocated establishing Medicare-for-All (M4A). This paper reviews seven reports on the costs of M4A that were written by scholars of health economics in universities or private foundations that study health care. Two of these reports also describe in detail how the program might be funded. Senators Bernie Sanders and Elizabeth Warren have also made suggestions for funding.

Judged from the conclusions of the seven reports, it appears that M4A would result in a net decrease in overall US healthcare costs of 5.7% on average. Under M4A, US health care would cost approximately $46,000 billion over 10 years. Over the same period, approximately $23,500 billion in new federal revenue would be needed in place of present-day payments from other sources.

This revenue could be raised in many different ways. In this review, 11 possible taxes and fees are highlighted in an example of how the necessary revenue could be raised. Under this example, it would not be necessary to impose a federal sales tax or any new taxes directly on low or middle income households, but high income households and wealthy Americans would likely pay higher taxes.

Published Reports on the Cost of Health Care under Medicare-for-All:

  • Thorpe
  • Blahaus
  • PERI
  • Friedman
  • Urban Institute
  • RAND
  • Yale

See full report for the following:

  • Cost: Factors That Could Change Healthcare Costs
  • Cost: Conclusions and Assumptions of the Seven Reports
  • Cost: Arriving at Overall Conclusions on Cost and Revenue Needed
  • Funding: Proposals That Have Been Made for Raising the Necessary Revenue
  • Funding: An Example of How the Necessary Federal Revenue Could be Raised

All of the reports project a large increase in spending by the federal government, as would be expected. Under M4A, a substantial portion of existing spending would be shifted into the federal budget. This represents new federal spending but not an increase in healthcare costs. Some political commentators have represented the dollar-volume of this shift as the cost of M4A, thus making the overall cost of health care in the US appear to increase enormously with M4A, more than 50%. This characterization is obviously misleading, perhaps intentionally so.

Concluding Comments

In discussions of Medicare-for-All, including Presidential debates, inevitably someone says, “This plan sounds all right, but how much will it cost?” The short and accurate answer is: “Nothing.” We are already paying for it. In fact, we estimate that we are overpaying by 5.7%, maybe more. Moreover, we are providing insurance coverage for fewer people than would be covered under Medicare-for-All, and those people who now have coverage are receiving fewer benefits than they would under Medicare-for-All.

We would need new federal revenue to fund the program, but this would not be new money. Most of it would be re-directed money. Currently this money flows from individuals, families, and businesses to insurance companies, and then to hospitals, physicians and other providers. Under Medicare-for-All, it would flow instead to the federal government before being transferred to providers, and the total amount transferred would be reduced.

Thus, the cost of health care under M4A should not be a barrier to its adoption. The principal barriers are instead fear of the unknown and the threat of disruption. The change to Medicare-for-All would be a monumental change, and the politics of making this change are not considered in this paper. It is clear that thinking about this change is perplexing and even frightening. We should, however, cease debating the cost and turn our attention to how to implement such a system, one that would both reduce the cost of health care in the US and generate substantial health benefits for those Americans who are currently uninsured or underinsured. To establish Medicare-for-All, the body politic will need to summon the will to enact change and to face the challenge of managing the transition.

Gordon Mosser, M.D., is a Senior Fellow in the Division of Health Policy and Management at the University of Minnesota School of Public Health.

https://papers.ssrn.com…

Comment:

By Don McCanne, M.D.

Understandably, since single payer Medicare for All is a serious proposal which is supported by a majority of Americans, people would like to know what it would cost. Since final, definitive legislation has not been produced, precise estimates cannot be made at this time. However, based on analyses of the general concepts by Thorpe, Blahaus, PERI, Friedman, Urban Institute, RAND, and Yale, fairly reliable generalizations can be made. Gordon Mosser has compiled these estimates and has come up with a “golden mean” on what the major features of spending on single payer Medicare for All might be.

  • Our current national health expenditures are already more than enough to pay for comprehensive health care for everyone through a well designed single payer model of an improved Medicare for All. Our total national health expenditures may actually decrease under such a model.
  • Medicare benefits would be improved, providing more comprehensive coverage.
  • Medicare eligibility would be expanded to include everyone.
  • The efficiency of the single payer model of Medicare would dramatically reduce administrative waste, plus efficiencies in purchasing would recover enough funds to pay for much of the improved benefits and expanded coverage of Medicare for All.
  • Since the system would be funded through the tax system, taxes will increase, but the additional amount paid in taxes by most individuals will be more than offset by the elimination of private spending for health care. On average, only the wealthy will pay more than they currently do.
  • Since the taxes will be progressive, funding of health care will be more equitable, based on ability to pay, and thus affordable for each of us.
  • What will the system cost? Nothing, since we are already spending enough to pay for it. To claim that the tax increases are increases in costs is either naive or outright dishonest.

So when someone asks, “How are we going to pay for Medicare for All?” The answer is, “We’re already paying enough, but we’re going to pay for it more fairly through equitable tax policies. For all but the very wealthy, average health care spending will decrease.”

Just as a reminder, PLOS Medicine on January 15, 2020 published “Projected costs of single-payer healthcare financing in the United States: A systematic review of economic analyses,” by Christopher Cai, James Kahn, et al. They surveyed an even greater number of single payer cost analyses, and their results were essentially the same: “There is near-consensus in these analyses that single-payer would reduce health expenditures while providing high-quality insurance to all US residents.”

PLOS Medicine:
https://journals.plos.org…

Quote of the Day – Projected costs of single payer in the United States:
https://pnhp.org…

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81 million Americans live in homes that lack enough space and bathrooms to follow COVID-19 quarantine and isolation recommendations

Inadequate room for quarantine/isolation much more common among minorities hardest hit by pandemic, worsening spread within families

FOR IMMEDIATE RELEASE, July 21, 2020

Contact: Ashwini Sehgal, M.D., sehgal@case.edu
Steffie Woolhandler, M.D., M.P.H., co-founder, Physicians for a National Health Program, swoolhan@hunter.cuny.edu or Steffie_Woolhandler@hms.harvard.edu
Clare Fauke, communications specialist, Physicians for a National Health Program, clare@pnhp.org

An article published today in the Annals of Internal Medicine reports that 25 million dwellings that house 81 million Americans lack adequate space or plumbing to allow compliance with recommendations that a person who may have COVID-19 maintain physical separation from others in their household.

The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) advise those who are infected with or have been exposed to COVID-19 stay at home, confining themselves to a separate bedroom and bathroom if possible. Researchers from Case Western Reserve University and the City University of New York at Hunter College used data from the American Housing Survey to determine the feasibility of providing separate bedrooms and bathrooms in U.S. dwellings. They found that more than 1 in 5 homes — housing about one quarter of all Americans — lack sufficient space and plumbing facilities to comply with the WHO and CDC recommendations.

The proportion of homes unsuitable for isolation or quarantine is particularly high among minority and low-income households, which have experienced high rates of COVID-19 illness and death. About 46% of Latinx people, 43% of Native Americans, and 32% of Black Americans live in dwellings where separation is not feasible, compared to less than 20% of non-Hispanic whites. Crowding is worst for apartment dwellers, particularly in the Northeast.

Dr. Ashwini Sehgal, a Professor of Medicine at the Case Western Reserve University School of Medicine and lead author of the study commented, “To help contain family spread we should immediately offer free masks, gloves, and disinfection supplies to all families of potentially contagious persons. But we need to go further than that. To protect their loved ones, many doctors and nurses caring for COVID-19 patients have been put up in hotel rooms that lie vacant because of the pandemic. We need to offer that option to potentially infectious patients. Similar strategies have helped contain the pandemic in several Asian countries.”

“Poverty and overt discrimination force many people of color into crowded and unsafe housing, fueling the spread of the pandemic,” noted study co-author Dr. Steffie Woolhandler, a Distinguished Professor of Public Health at the City University of New York at Hunter College and Lecturer in Medicine at Harvard. “We need to implement emergency measures to minimize household spread. But we also need to assure that that all Americans can afford decent housing, and to finally begin enforcing the 1968 Fair Housing Act that too many landlords and realtors continue to flout.”

“Feasibility of Separate Rooms for Home Isolation and Quarantine for COVID-19 in the United States,” Ashwini R. Sehgal, M.D.; David U. Himmelstein, M.D.; Steffie Woolhandler, M.D., M.P.H., Annals of Internal Medicine, published online ahead of print July 21, 2020. DOI: https://doi.org/10.7326/M20-4331

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization whose more than 23,000 members support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.

Hacker and Pierson: ‘Let Them Eat Tweets’

How the Right Rules in an Age of Extreme Inequality

By Jacob S. Hacker (Yale University), Paul Pierson (University of California, Berkeley)

Introduction

This is not a book about Donald Trump.

Instead, it is about an immense shift that preceded Trump’s rise, has profoundly shaped his political party and its priorities, and poses a threat to our democracy that is certain to outlast his presidency.

That shift is the rise of plutocracy – government of, by, and for the rich.

Chapter 1 – The Conservative Dilemma

Plutocratic populism is rather new; the political dilemma that gives rise to it is very old. What happens when an economic system that concentrates wealth in the hands of the few coexists with a political system that gives the ballot to the many?

Whenever economic elites have grossly disproportionate power and come to see their economic interests as opposed to those of ordinary citizens, they are likely to promote social divisions. They are also likely to come to fear a fair democratic process in which those citizens have significant clout. These elite responses to extreme inequality enter into politics mainly through conservative parties, which must navigate the tension between unequal influence and democratic competition. The Conservative Dilemma is not a problem of a particular moment. It is a problem inherent in democratic politics in contexts of extreme inequality.

Chapter 2 – Republicans Embrace Plutocracy

Extreme inequality creates three fundamental threats to healthy democratic politics: divergent elite interests, disproportionate elite power, and diminished elite commitment to democracy itself.

Chapter 3 – Organizing through Outrage

If finding groups Republicans could rely on to navigate the Conservative Dilemma took time, it was time well spent. For the groups that aligned with the GOP proved unusually skilled at creating durable shared identities that motivated citizens, and then getting those citizens to show up, not just on election day, but whenever big shows of strength were needed. These were groups, in short, that could rally their troops, creating sharp lines between friend and foe and instilling a sense of threat. And what best rallied those troops, they discovered, was outrage.

Chapter 4 – Identity and Plutocracy

If Republicans had weakened their embrace of plutocracy, they would have adopted economic priorities closer to those of less affluent GOP voters and diminished their reliance on divisive appeals. And if they had moderated their economic stances and softened their cultural appeals, they could have brought more nonwhite voters into the fold. They did neither – that they cultivated voter identities that were so intense, exclusive, and divisive; that they ramped up white backlash even as American society as a whole was becoming more tolerant – wasn’t because voters gave them no other options. Ultimately, it was because they chose plutocrats over everyone else.

Chapter 5 – A Very Civil War

In the new GOP, public officials either bent their knee to Trump, retired from the scene, or were demolished.

Yet if the past few years have witnessed a Republican civil war, it has been a very civil war, in which the side allegedly losing has made gains it could have scarcely contemplated just a few years before. Among the biggest winners were the right-wing plutocrats who had been at the heart of the establishment. When Trump took power, he handed much of the power to people loyal to the plutocrats, or to the plutocrats themselves. They brought their long-standing policy ambitions into the federal government and carried them out with a vengeance.

The plutocrats have gotten huge tax cuts. They have reaped the benefits of an unprecedented attack on regulations that police big corporations and protect consumers, workers, and the environment. And they have seen the nation’s powerful courts tilt even further in favor of elite economic interests.

Chapter 6 – Tyranny of the (Wealthy and Extreme) Minority

Although Republicans decisively lost the House of Representatives in 2018, they did not turn to moderation.

They recognized the widening gap between their priorities and those of the broader electorate. But they saw this growing divergence not as a problem with their priorities, but as a problem with their strategies. To these intense and focused factions, electoral and policy setbacks did not mean that Republicans had to attract wider support. They meant Republicans had to figure out how to win without it.

Conclusion

Moderation from economic elites is most likely to emerge in response to growing pressure from below.

Where, exactly, will that pressure come from?

(No spoiler here.)

https://wwnorton.com…

Comment:

By Don McCanne, M.D.

Many of us who have been working so hard and so long on single payer reform – an improved Medicare for All – have had difficulty in understanding why an obviously vastly superior health care financing model has not been enacted and implemented long before now. Such a system would benefit all of us, although the very wealthy would pay more taxes (but not enough to be detectable without a careful perusal of their tax statements). With polling demonstrating popular support and with a model that should have strong appeal for almost everyone, it seems that it should have been put in place long ago.

In “Let Them Eat Tweets,” Jacob Hacker and Paul Pierson explain why that has not occurred. Simply, the very wealthy control the government; that is, we have a plutocracy. The plutocrats are opposed to the government taxation and regulation that would be required to establish a universal, equitable, publicly-administered and publicly-financed health care system; so we don’t have it.

The Constitution was designed to prevent a small group from gaining control of the government, yet it has happened even though the vast majority of U.S. citizens are worse off for it. The authors explain how this came to be. They do not attribute it to Donald Trump – its onset was decades before Trump entered the scene – but they do use the Trump administration to illustrate the adverse consequences of a plutocracy, including how only a relatively few individuals can have such great control over our government. As an example, at a time we desperately need a redistribution to partially ameliorate the injustices of profound income and wealth inequality, instead we got a massive tax reduction for the plutocrats and an increase in government deficit spending for the rest of us and our progeny, thus worsening the inequality.

If there is good news here, it is that “moderation from economic elites is most likely to emerge in response to growing pressure from below.” Even though our democracy has suffered damage under the plutocrats (details are in the book) we do still have a democracy that we can repair and use to align the interests of the plutocrats with the will of the people. Any keen observer of our politics will realize how difficult that will be, but we can do it.

Maybe we could start with single payer Medicare for All.

PNHP does not endorse any political party nor any candidate for office.

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Gov. Andy Beshear wants to give Black Kentucky residents health coverage — but there’s a catch

The effort is already underway, Beshear told Salon. State Rep. Attica Scott says it's just a "short-term Band-aid"

By Igor Derysh
Salon, July 18, 2020

Kentucky Gov. Andy Beshear is working to make good on his promise to expand health coverage to all Black residents amid the coronavirus pandemic, but the emergency measure comes with an expiration date.

Black Americans have been disproportionately impacted by the health crisis. In Kentucky, where Black people make up just over 8% of the population, they represent more than 16% of the state’s coronavirus deaths.

Beshear, a first-term Democrat who won a narrow election in deep-red state, sought to address that disparity in June.

“We are going to begin an effort to cover 100 percent of our individuals in our Black and African-American communities,” the governor said last month. “We’re going to be putting dollars behind it.”

Six weeks later, Beshear told Salon that the effort is underway.

“My commitment when I ran for office is to ensure that every Kentuckian had some form of health care coverage and what COVID-19 has laid bare is a systematic racism in our health care system that has led to African Americans of Kentucky dying at twice the rate they make up of the population,” Beshear said in an interview.

“And so that, along with these calls for justice and equity around the country, really brought into focus the fact that what’s what’s being asked for is finally some priority in our African American communities. So while our goal is to sign everyone up for some form of health care coverage, we are starting with our Black communities.”

Beshear told Salon that the state has identified about 20,000 Black residents who lack health care coverage.

“The easiest means to, at least initially, provide that coverage … is through the pandemic Medicaid program,” he said. “That right now in COVID-19 is a one-page form, and that’s the way to get people into the system.”

The pandemic Medicaid program is a temporary measure intended to provide free health care to eligible applicants. The state plans to reach out to churches and community leaders to help with the sign-ups and has approved a budget for a direct marketing campaign to reach residents who lack coverage. The marketing will also target the state’s Hispanic residents, who have also been disproportionately affected.

But after the emergency program expires, residents may once again be left without coverage.

Beshear said the state aims to “transition” residents into “whatever people qualify for, whether it’s the [Obamacare] exchange where they can get private insurance,” “expanded Medicaid,” or “through some other means or manner.”

“I believe that there is a health care product, whether it’s public or private, that everyone qualifies for,” he said.

The expanded Medicaid and private exchange options are already available, however. While Kentucky’s Medicaid expansion has greatly helped to reduce the number of uninsured people, many who do not qualify also lack the resources to purchase a private plan.

Pressed on potential coverage gaps when the temporary pandemic program expires, Beshear argued that the state’s Medicaid expansion and health exchange subsidies would provide affordable options for all Black residents.

“We believe that right now in Kentucky, because of how we expanded Medicaid, that there will be a product out there for everyone that is affordable,” he said. “And if we find various gaps, we want to address them first for our African American population. But second for everyone.”

It’s unclear how those gaps would be addressed. Kentucky’s policy could “draw legal challenges that allege discrimination against other populations that also lack health insurance,” Politico noted.

It’s also unclear how Beshear would be able to get funding for any sort of health care expansion from the Republican-dominated state legislature.

“At the moment, we are able to use COVID funding, CARES Act funding,” he said.

Many in Kentucky say they want Beshear to go further.

The disparity facing Black residents is “clearly immoral” but expanding coverage to uninsured Black residents is only “the beginning” because the number of all uninsured residents in the state has swelled, said Kay Tillow, a longtime nursing union organizer who chairs the group Kentuckians for Single Payer Health Care, which called on Beshear to endorse a Medicare for All system.

In an interview, Tillow described Medicaid as offering a “lower tier” of care than private plans, and said many Medicaid recipients, particularly in rural areas, have trouble finding hospitals and specialists. That leaves many with only private insurance options amid an economic crisis.

“We don’t think that the structure of our current health care system is going to make it possible for him to do this, when you have to buy the insurance,” she said. “And when we have 931,000 people laid off in just the past few months, I mean, there’s no way. … We don’t have a structure that is going to make it possible to do this. So we’re challenging the governor to say, ‘OK, let’s follow through.’ Help us to get a national health care plan that really makes it possible to make this a human right and to cover every single person.”

Rep. Attica Scott, the only Black woman in the Kentucky state legislature, said Beshear’s plan was just a “short-term Band-aid.”

“I don’t see it as an actual longterm solution,” Scott said in an interview. “To me, this felt like a quick rush to say, ‘I’m doing something for Black people.’ … But it is definitely not a longterm systemic solution to this crisis that Black people are facing because the crisis is attacking us at every single level.”

Scott argued that Beshear should have sought the advice of more Black lawmakers before rolling out the plan.

“I’m not sure what members of our Kentucky Legislative Black Caucus he spoke to before deciding that this was what was best for Black people,” she said. “Had he spoken to some of us, I know that I would have said we also need to look at, for example, the implicit bias in health care, because Black women are three to four times more likely to die in childbirth than white women,” she said. Scott introduced a bill to address that disparity in the most recent legislative session, she said. “And neither he nor his lieutenant governor, who just had a baby this year, ever mentioned that bill, [they] didn’t support it.”

Implicit bias in health care “not only impacts maternal health, but all of our health as Black people,” she said.

“Many Black folks across the Commonwealth need the governor to have a more expansive understanding of what impacts our health and that it’s not only health insurance, it is access to health care,” she said. “It is dismantling a system that is steeped in racism [and] historical trauma. Implicit bias means that as soon as we walk through the door, we’re judged based on our educational level, our socioeconomic status and our zip code.”

Black people have been disproportionately impacted by the coronavirus, Scott said, because of the “economic and social factors that we find ourselves living under, and the inequities that we experience every day.

“If the governor really wants to address our health and our economic security as Black folks, then he’s got to make sure that he is pushing the legislature to address issues like education and access to higher education and making higher education affordable,” she said. “Making sure that we have jobs that are located in our neighborhoods, making sure that we’re paying people living wages, all of those issues have to be addressed. It’s not just one thing. It’s not only access to health insurance, which many of us actually have. It’s also looking at how institutional systemic racism impacts even the health care field, that makes us not even want to go get health care when we’re ill or when we think something’s wrong.”

Beshear said the health care plan was one part of his ongoing focus on addressing racial disparities.

“One of my first acts was restoring voting rights to over 170,000 Kentuckians that are disproportionately African American that had lost those voting rights,” he said. “We rescinded a Medicaid waiver that would have disproportionately affected our African American communities. We have taken increasing steps in being intentional about diversity within our own cabinet. Our top two appointed officials in Kentucky for the first time ever are both African-American individuals.”

When the pandemic hit, “it laid bare what inequality in health care does,” he said. The subsequent protests over the police killing of Breonna Taylor in Louisville and broader issues systemic racism “greatly” affected the administration’s priority on addressing inequality, Beshear said.

“I think what it has done is create more urgency and, frankly, we should have had more urgency before. It shouldn’t have taken COVID-19, it shouldn’t have taken the protests and demonstrations,” he said. “But what you hear is people being tired of either no change or change that doesn’t occur fast enough. And when you see what’s happened with COVID, you understand that change has to happen faster. It has to happen now. Martin Luther King Jr. had a quote about health care being one of the worst inequalities. We should have done a heck of a lot more since then.”

Scott said there were many other problems facing Black residents, such as environmental concerns related to chemical companies based in black neighborhoods like the West End of Louisville, along with widespread economic inequities.

“Where I live, people can’t get to the doctor because of lack of public transportation. We can have all the health care in the world, but I can’t get to a dentist. I can’t get to a primary care physician. I can’t get to a gynecologist,” she said. “We’ve got to address access to employment opportunities because, of course, when people struggle to make ends meet, whether it’s paycheck to paycheck or no check to no check, that’s going to impact both their physical and mental health. So those are all issues that the governor and his administration has to work with our Legislative Black Caucus to address, because we’re the people who are deeply rooted in community. We live these issues every single day.”

Another pressing matter facing Kentucky’s Black residents is the looming eviction cliff, when thousands will face potential homelessness after state and federal eviction moratoriums expire.

“Admittedly we have a challenge,” Beshear said. “We need people to have a home to be able to stay in, to be healthy and to defeat COVID-19. And the cost of someone being evicted can be great. It can be the difference of life and death.”

But Beshear argued that the eviction policy will have to be reviewed because some people are taking advantage of the moratorium.

“We do have some instances where people who can and should be paying their rent are not paying their rent because of orders we’ve put out,” he said. “So our goal moving forward is to find a way to make sure that those that need extra time because of COVID have it [and] are not evicted, but also making sure that there aren’t some out there just gaming the system. It’s not easy to find that perfect solution, but that’s what we’re looking for.”

Scott questioned the governor’s focus on those “gaming the system,” arguing, “If folks say they need help having secure housing, we need to help people.”

“I’m a renter so that’s a tough statement for me to hear,” she added, “because who makes the determination about someone’s situation and what they can and cannot afford to pay? That’s such a judgment call at a time when people are living in crisis… People are back home or at home more than ever, so they’re using up more utilities, eating more food … So that expense has increased. So who’s making this judgment call? I think that’s a real tough sell for me. I believe we just need to take care of people.”

Kentucky is facing a $1.1 billion budget shortfall, like many other cash-strapped states that saw tax revenue dry up amid statewide stay-at-home orders, which will greatly affect its future ability to address these crises.

“We desperately need … another round of CARES Act [funding] to specifically help with our state budget,” Beshear said. The current shortfall “would result in the largest budget cuts in modern history” and cuts to “all of these programs that are so critical.”

Sen. Mitch McConnell, R-Ky., the Senate majority leader, has pushed back against calls to provide aid to state and local governments, which he termed “blue state bailouts” even as his own state faces a dire budget crisis.

Beshear said he “pushed hard” for state aid in recent conversations with McConnell.

“Obviously he’s not made any commitments. My hope is that he understands that this is a must, not a maybe,” he said. “So while I am optimistic … I’m worried, because what happens when you’ve got to cut a billion dollars from a budget? Those that need us most suffer. And our biggest part of our budgets are education and health care.”

Scott argued that McConnell’s comments about the state aid show that he “could care less about those of us in Kentucky who are struggling to make it every day.”

“People like Sen. McConnell and many of the folks who are making those kinds of misguided decisions live quite well, quite comfortably,” she said, “while the rest of us struggle to make ends meet. So, quite frankly, I’m not interested in their misguided opinions on what it means to try to survive every single day, let alone thrive. If the senator cared at all about the people in Kentucky, then he would do everything in his power to make sure that housing and utilities and food and medicine and medical care are highly accessible to every single person living in the Commonwealth of Kentucky.

“I have been concerned about what that’s going to mean for people like my daughter, who is a pharmacy tech, because those are often seen as the frontline workers who can go first” in the event of budget cuts, Scott said. “We already disgracefully underfund public education as it is. So I’m not sure what more you can take away from us with public education. But I see frontline workers … being laid off first. That, to me, is something that the federal government, led by Sen. McConnell, needs to look at and say, ‘How do we make sure that we prevent this from happening?’ I’m not convinced that Sen. McConnell or his colleagues are doing everything in their power to protect the people in the United States.”

https://www.salon.com…

John Lewis

“Do not get lost in a sea of despair. Be hopeful, be optimistic. Our struggle is not the struggle of a day, a week, a month, or a year, it is the struggle of a lifetime. Never, ever be afraid to make some noise and get in good trouble, necessary trouble.”

John Lewis
February 21, 1940 – July 17, 2020

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Perceived discrimination under Medicaid

Insurance Types, Usual Sources of Health Care, and Perceived Discrimination

By Héctor E. Alcalá, Amanda E. Ng, Sujoy Gayen, and Alexander N. Ortega
The Journal of the American Board of Family Medicine, July 2020

Abstract

Introduction: Discrimination can compromise access to and utilization of health care and lead to poorer health. As such, it is important to understand the factors associated with experiences of discrimination in health care.

Methods: Using data from the 2015 to 2017 California Health Interview Survey (n = 63,100), this study examined whether insurance types and sites of usual sources of care were associated with reasons for perceived discrimination in health care and whether the reasons were associated with delaying health care. Odds of study outcomes were calculated among insured adults using logistic regressions. Insurance coverage types and sites of usual sources of care were the main independent variables. Six reasons for lifetime discrimination in health care were examined: 1) dissatisfaction with the health care system, 2) race or skin color, 3) age, 4) way the participant speaks English or other barrier to communication, 5) insurance status or type, and 6) income or education.

Results: Adults with Medicaid perceived more discrimination due to race or skin color relative to those with employer-sponsored coverage. This association does not vary by race/ethnicity. Perceived discrimination due to 1) dissatisfaction with the health care system, 2) insurance status or type, and 3) barriers to communication were each associated with increased delays in getting needed medical care.

Conclusions: Findings highlight potential insurance types and sources of care that could contribute to perceptions of being discriminated.

From the Discussion

This study observed that insurance type and sources of care are associated with lifetime perceptions of discrimination in health care. Perceived discrimination in health care was higher for those whose regular source of care is the ED relative to those whose regular source of care is a doctor’s office or HMO, but it did not vary substantially once specific reasons for discrimination were considered. In addition, participants receiving Medicaid were more likely to perceive discrimination in health care, with race or skin color being the only specific reason, when compared with their counterparts with employer-sponsored coverage. This supports prior work that observed that Medicaid patients reported lower satisfaction when compared with individuals with other types of insurance. The present study built on prior research that focused solely on racial and ethnic discrimination and showed that individuals with Medicaid were more likely to report perceiving racial or ethnic discrimination in health care.

Conclusions

This study observed that, even considering substantial health care reform, the experiences patients have in the health care setting vary systematically. Because this seems to be conditioned, at least in part, on the type of insurance a person has and where he or she receives health care, future reforms to the health care system are needed that provide a stronger overhaul of health care quality and must be better at addressing the effects of patients’ prior experiences with health care. In particular, because patients with several different public insurance coverage options experienced a higher burden of discrimination, not addressing these problems will disproportionally affect populations that are poorer and experience worse social determinants of health (eg, Medicaid enrollees). Furthermore, while perceived discrimination has a negative effect on health care utilization, our study suggests that the health care system needs to improve its ability to address certain types of discrimination to promote better population health.

https://www.jabfm.org…

Comment:

By Don McCanne, M.D.

The Medicaid program works well from the standpoint that the benefits are comprehensive and the out-of-pocket exposure is minimal, providing relatively good financial protection in the event of medical need.

However, Medicaid is a welfare program and, as such, faces certain stigmas. People on the program are certainly aware of that and thus may be on guard for fear that they may be considered by others to somehow be less worthy, which could show up in the quality of care they receive or the enthusiasm with which it is rendered. In fact, the majority are now enrolled in Medicaid managed care programs which have reputations for stinting on care because of the low reimbursement rates they receive. For those receiving care outside of managed care organizations, it is generally known that reimbursement rates are very low and it may be difficult to know if providers are truly altruistic or if they are accepting Medicaid patients by default. At any rate, there is little political support for funding Medicaid at rates comparable to the private sector.

This uncertainty may cause patients to be on the watch for discrimination in their care. This may be particularly true for individuals who are already accustomed to discrimination because of their racial or ethnic backgrounds.

Unfortunately, this study adds to previous studies that confirm that racial and ethnic minorities indeed do perceive discrimination in the care they receive under the Medicaid program.

If we were to replace all current sources of health care funding with a single payer model of an improved Medicare for All, we would automatically eliminate discrimination that is based on the financing source, such as we see with Medicaid. Certainly other sources of discrimination would continue to require further remedies, but Medicare for All would provide a giant step forward toward social solidarity by virtue of an egalitarian health care financing system.

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BENES Act would reduce complexity of Medicare Part B enrollment but ignore Parts A, C, D, and Medigap

House Committee Approves Bill to Ease Medicare Part B Enrollment

By Susan Jaffe
MedPage Today, July 15, 2020

A House committee unanimously approved legislation Wednesday that would make changes for the first time in 50 years to the complex rules for enrolling in Medicare’s Part B, which covers doctor visits and other outpatient care.

Currently, seniors who don’t get Part B when they first become eligible for Medicare pay permanent, recurring late enrollment penalties and can only sign up during the first 3 months of the year for coverage that begins July 1, unless they qualify for an exception. To make matters worse, they cannot buy other health insurance during their months-long wait.

Patients often find out they need Part B only after their provider or insurance company sends them a bill for services. That’s because only Social Security beneficiaries currently receive a notice when they become eligible for Medicare.

If the measure, known as the “BENES” Act (Beneficiary Enrollment Notification and Eligibility Simplification Act), becomes law, the Centers for Medicare & Medicaid Services (CMS) and the Social Security Administration would be required to notify people before they turn 63, 64, and 65 that they may be eligible for Medicare at age 65. It would eliminate the waiting period by ensuring that coverage begins on the first of the month after they sign up.

Currently, far too many people make honest mistakes when trying to understand and navigate this confusing system. The consequences of such missteps are significant — including late enrollment penalties, higher out-of-pocket health care costs, gaps in coverage, and barriers to accessing needed service. In 2019, 764,000 Medicare beneficiaries paid a penalty for late Part B enrollment, increasing their monthly premiums by an average 28%, according to a May report by the Congressional Research Service.

The House of Representatives is expected to pass the bill sometime this year but its prospects in the Senate are still uncertain.

https://www.medpagetoday.com…

BENES Act:
https://www.aging.senate.gov…

Medicare Part A and B Eligibility and Enrollment:
https://www.cms.gov…

Comment:

By Don McCanne, M.D.

The eligibility, processes and rules for enrolling in Medicare are relatively complex and vary for Part A – hospital, Part B – physician and outpatient, Part C – private Medicare Advantage, Part D – drug, and Medigap – private supplemental coverage. Original Medicare is Part A and Part B, but enrollment is such that individuals may end up with gaps in coverage or paying significant penalties if the enrollment process for Part B is not followed carefully. The BENES Act would reduce this risk, though not eliminate it.

If you read the CMS eligibility and enrollment instructions for Part A and Part B (link above), you will see that they are unreasonably complex for a program that should be (but is not) automatic for everyone. Although the BENES Act would help, some complexities would remain, not to mention the problems with Part C, Part D, and especially with the Medigap plans. Medigap is particularly important for those who want to remain in the Original Medicare program, but the rules are such that enrollment may have underwriting penalties or coverage can be refused if the initial enrollment period was missed. In the push to privatize Medicare, they have made enrollment in the Medicare Advantage plans easier, but there are still rules to be followed, not to mention that you are limited to the insurers’ provider networks and you lose your almost unlimited choice of providers in the Original Medicare program.

Compare this to single payer improved Medicare for All. Every resident is eligible and is automatically enrolled, forever. Benefits are comprehensive, including drugs, and since care is free at the time of service, there is no reason to have separate private or supplemental plans. There is no Part A, Part B, Part C, Part D, nor Medigap; there is only Medicare for All.

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