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Medicare For All: If Not Now, When?

Medicare For All: If Not Now, When?

By Adam Gaffney, M.D., M.P.H.
Health Affairs Blog, March 9, 2020

The rise of Medicare for All has triggered mixed reactions. Supporters see it as a cause for hope — the culmination of decades of research, education, and advocacy. President Donald Trump, on the other hand, is dyspeptic, fuming in his recent State of the Union that single-payer would “bankrupt our nation,” and vowing not to “let socialism destroy American healthcare.” A third group expresses sympathy for the goals of Medicare for All, and even acknowledges its policy merits, but sees the political obstacles as insurmountable — and advises that advocacy for such reform should be abandoned because it risks undermining beneficial, and more realistic approaches.

A clear-eyed assessment of institutional realities that will face the next presidential administration, Billy Wynn recently argued in the Health Affairs blog, should temper Democrats’ demands. He cautioned that Democratic victories in federal elections are far from secure; that Medicare for All may not be passable via budget reconciliation even if Democrats take the Senate with only a simple majority; and that Democratic legislators are, in any event, hardly unified in support of Medicare for All. Similarly, John E. McDonough recently warned that comprehensive healthcare reform has, in the past, required an elusive “super-majority Trifecta” — Democratic control of the House, Senate (with 60-seats), and Presidency. Even under such favorable conditions, he contends, our political capital might be better invested elsewhere.

While the hurdles are certainly formidable, steep political odds hardly compel us to abandon Medicare for All. Indeed, advice to drop the push for such reform rests on a misunderstanding of the dynamics of political change. History suggests that movements organized around ambitious demands can, over time, create the conditions for their passage — and that demands for radical change often advance, rather than undermine, the prospects for more incremental progress in the interim. As important, the life-and-death urgency of single-payer healthcare reform – too often underemphasized by its critics – has the potential to bring together a coalition of supporters across cultural, geographic and even class lines. It may, in other words, trigger a movement that could accomplish the unexpected.

1. The Dynamics of Political Change: Lessons from History

The institutional barriers that critics describe are real enough, and cannot be waved away. But they are also not immutable: throughout history, energizing issues have changed political contexts.

Consider, for instance, the passage of Medicare and Medicaid in 1965. Democrats had been stymied since the Truman administration in their efforts to pass a public national health insurance plan, obstructed in part by members of Congress intent on accommodating the insurance industry. John McDonough is right to emphasize that, from a narrow perspective, a super-majority Trifecta made Medicare achievable. 1964 saw a historic electoral shift, that, as Ted Marmor has noted, all but “guaranteed the passage of legislation on medical care for the aged.” But the achievement was only possible because people had been laying the groundwork for Medicare for years prior to the pivotal election. Senior citizen groups, progressive activists, organized labor, and allies in the civil rights movement forced it onto the national political agenda, holding politicians feet to the fire year after year — a point made by Natalie Shure in the Nation. Moreover, it required years of legislative efforts and coalition building to ready the ground for the final push. Had supporters not done so — had everyone waited to design and advocate for Medicare until the political chess pieces were in perfect position — the window would have opened, the window would have closed, and Medicare might very well not have come to be.

The same can be said for almost every sweeping political change in US history. The abolition of slavery, the reforms of the New Deal era, the civil rights legislation of the 1960s, and the legalization of gay marriage — none would have happened if reformers had patiently waited for the proper political alignment in the halls of Congress before envisioning, designing, and demanding change. The 2020 elections may or may not cause a political earthquake on par with 1964, but it hardly follows from this that we ought to lower our sights. After all, nobody can accurately predict when the pivotal shift will come. We do know, however, that if we wait for it happen, we will already be too late.

2. The Urgency of National Health Insurance

Dismissing Medicare for All as impractical also neglects the moral urgency of reform.

That uninsurance is deadly is no longer up for debate. Quasi-experimental studies of multiple coverage expansions have demonstrated that insurance reduces mortality (confirming earlier observational work), including: the Massachusetts health reform (number needed to insure [NNI] to prevent one death a year: 830); pre-ACA state Medicaid expansions (NNI: 239-316); and now the ACA Medicaid expansions (NNI: ~714 for adults 19-64). Two of these estimates are remarkably close to that of the randomized Oregon Medicaid Experiment (NNI: 769), although that effect estimate was not statistically significant. Most recently, however, another randomized study — of an intervention by the Internal Revenue Service — provided powerful experimental evidence that health insurance is life-saving. Regardless of which NNI estimate one uses, basic arithmetic makes clear that — with 30 million uninsured — tens of thousands of people are dying annually for lack of coverage. Notably, such deaths from lack of medical care are occurring everywhere, not only in states that have not expanded Medicaid. While non-expansion states have higher uninsurance rates, the number of uninsured in expansion states — for instance, 2.8 million in California and 1.0 million in New York — mean that hundreds or thousands are dying from lack of medical care a year in most states.

Critics might respond, however, by noting that Medicare for All is not the only way to address this challenge — that there might be other, and easier, ways to realize universal coverage. That being said, most other alternative health reform proposals would fail to achieve this end. Democratic presidential candidate Joseph Biden’s public option proposal, for instance, would leave some 3% of Americans (or approximately 10 million individuals) uninsured according to his campaign’s own estimates. A recent analysis by RAND researchers of a Medicare “buy-in” for those age 50-64 found that it would have “little to no effect on total health insurance enrollment.” An estimate from the Congressional Budget Office similarly found that a public option made available on the ACA exchanges would have “minimal effects on … the number of people who would be uninsured.” And a recent analysis from the Urban Institute found that a package of reforms that included a public option could leave as many as 21.3 million uninsured. In fairness, other more expansive proposals might cover everyone. Nonetheless, in addition to achieving universal coverage, Medicare for All is uniquely designed to do something else: achieve a universal improvement of coverage.

Rising copays and deductibles are causing more and more patients to go without needed care, or to face harsh financial consequences when they do. Underinsurance is, today, as much a problem as uninsurance — and, according to estimates from the Commonwealth Fund, is growing most rapidly among those with employer-sponsored coverage. Exhibit 1 provides rates of uninsurance (including those with lapses of coverage) and underinsurance in 2018. Overall, about 1 in 3 Americans — or more than 100 million individuals — fall into one of these categories, and can be classified as having deficient health coverage.

Exhibit 1: Deficient health coverage in the United States, 2018

Source: 2018 National Health Interview Survey; 2018 Commonwealth Fund Biennial Health Insurance Survey; Commonwealth Fund analysis of 2012 Medicare Current Beneficiary Survey extrapolated to 2018 (see notes).

Notes:

  1. These are individuals who were insured at the time of survey but uninsured within the last year; the category does not overlap with those who are currently uninsured or underinsured in the Commonwealth Fund report I draw it from. Of note, that analysis reported only 24 million uninsured, but this excludes children and seniors. Adding the estimated 4.1 million uninsured children in 2018 to the Commonwealth figure produces a similar number of total currently uninsured as the National Health Interview Survey estimate I use here.
  2. Defined by the Commonwealth Fund investigators as having deductibles >= 5% of income or annual out-of-pocket spending in last year >= 10% of income (or >5% of income for those with low incomes).
  3. In 2016, according to Commonwealth Fund estimates, 24% of Medicare beneficiaries were underinsured (defined as annual out-of-pocket spending >= 10% of income year, a narrower definition than used for the age 19-64 group). Applied to the 2018 elderly population of 52 million, this translates to 12.6 million individuals.
  4. The Commonwealth Fund investigators report a lower total of the “inadequately insured” of 87 million. However, this estimate excludes both children and seniors who are uninsured and underinsured. My estimate also excludes underinsured children, as I am unaware of recent estimates of underinsurance for this group.

Similar to uninsurance, underinsurance has staggering adverse effects on health. Exhibit 2 presents evidence, drawn exclusively from randomized or quasi-experimental studies, on the health consequences of copays or deductibles for patients with six conditions: high blood pressure, heart attacks, diabetes, breast cancer, multiple sclerosis, and rheumatoid arthritis. For those with each of these diseases, cost-sharing deters the use of needed medications and care and, in many instances, causes demonstrable clinical harm.

Exhibit 2: Health consequences of copays and deductibles for those with select diseases

Source: Author’s analysis of reports of randomized trials and quasi-experimental studies

  1. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2752366
  2. https://www.ncbi.nlm.nih.gov/pubmed/28564682
  3. https://www.ncbi.nlm.nih.gov/pubmed/29847485
  4. https://jamanetwork.com/journals/jama/article-abstract/400929
  5. https://www.nejm.org/doi/full/10.1056/NEJM198312083092305
  6. https://www.nejm.org/doi/full/10.1056/NEJMsa1107913
  7. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2013.0654
  8. https://annals.org/aim/article-abstract/2716078/high-deductible-insurance-delay-care-macrovascular-complications-diabetes
  9. https://www.ncbi.nlm.nih.gov/pubmed/29382660
  10. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.05026?journalCode=hlthaff
  11. https://www.ncbi.nlm.nih.gov/pubmed/28736929
  12. https://www.ncbi.nlm.nih.gov/pubmed/28736929

Medicare for All — unlike other reforms — would alleviate such widespread and unnecessary suffering not merely by covering the uninsured, but by eliminating financial barriers to care. Rising costs from higher care utilization will be offset by large savings from simplifying administration. Indeed, a recent systematic review found that some 19 out of 22 economic analyses of Medicare for All predicted overall savings in the first year as a result of such efficiencies. Transforming healthcare financing is what makes such an unprecedented coverage expansion economically — and hence politically — feasible.

The policy advantages of Medicare for All, in other words, aren’t mere minutiae: they are part of the force for political change.

Medicare for All: The Link Between Policy and Politics

Yet policy and politics are linked in another, more fundamental way. The experience of illness and of medical care is almost universal. This means that in the United States, encounters with our dysfunctional healthcare financing system are also near universal. How many have never had a spell of being uninsured, dealt with an onerous copay or deductible, contended with a medical bill or collections agency, gone without needed care because of cost, or faced a denial of care from their insurer? It is not merely uninsured Americans who have much to gain from single-payer reform, in in other words, but also those with chronic conditions who pay a tax for their illness in the form of cost-sharing; those with Medicare coverage who lack dental and long-term care benefits; those with Medicaid who must hurdle administrative barriers to remain covered and face frequent “churn” out of the program, and who sometimes have inferior access to care. Indeed, even those satisfied with their employer-sponsored coverage know that they are but one sickness — and consequent job loss — away from losing it.

All of which is to say that at the end of the day, the vast majority of the nation could benefit from single-payer reform — and that fact makes it winnable. Above all, however, we can be sure of one thing: not bothering to push for Medicare for All today will guarantee that it doesn’t happen tomorrow.

Author’s Note: The author serves as President of Physicians for a National Health Program (PNHP), a non-profit organization that favors coverage expansion through a single payer program. He does not receive compensation from that group, although some of his travel on behalf of the organization is reimbursed by it. He wishes to thank Phillip Rocco, Natalie Shure, David Himmelstein, and Steffie Woolhandler for their review of drafts of this article and helpful suggestions for revision; any errors are the author’s alone.

https://www.healthaffairs.org…

Support Medicare for all

By Kathleen Healey, M.D.
San Francisco Chronicle, March 9, 2020

Americans are threatened by a COVID-19 pandemic and over 27 million of us have no health insurance. What could possibly go wrong? During an outbreak of a communicable disease we are all safer if everyone around us has access to health care.

Many people delay medical evaluations and care because of cost, which would be disastrous in a public health emergency. Lack of insurance prematurely kills 45,000 of us every year, and causes hospital closures.

For the insured, medical debt and surprise bills could be the second wave of a crisis. Our neighbor Canada and most European countries enjoy national insurance systems that cover everyone from birth to death, at half the cost of what we pay per person. Our private insurances are expensive for families and businesses and additional costs are passed on to us in copays and deductibles.

Money is removed from the health care dollar for profit, advertising, and complex administrative systems. All of us need health care and health care is local. We don’t need the expensive middleman. Support single payer/Medicare for all for public health and the common good. It is affordable and it works.

https://www.sfchronicle.com…

Medicare For All: If Not Now, When?

By Adam Gaffney, M.D., M.P.H.
Health Affairs Blog, March 9, 2020

The rise of Medicare for All has triggered mixed reactions. Supporters see it as a cause for hope — the culmination of decades of research, education, and advocacy. President Donald Trump, on the other hand, is dyspeptic, fuming in his recent State of the Union that single-payer would “bankrupt our nation,” and vowing not to “let socialism destroy American healthcare.” A third group expresses sympathy for the goals of Medicare for All, and even acknowledges its policy merits, but sees the political obstacles as insurmountable — and advises that advocacy for such reform should be abandoned because it risks undermining beneficial, and more realistic approaches.

A clear-eyed assessment of institutional realities that will face the next presidential administration, Billy Wynn recently argued in the Health Affairs blog, should temper Democrats’ demands. He cautioned that Democratic victories in federal elections are far from secure; that Medicare for All may not be passable via budget reconciliation even if Democrats take the Senate with only a simple majority; and that Democratic legislators are, in any event, hardly unified in support of Medicare for All. Similarly, John E. McDonough recently warned that comprehensive healthcare reform has, in the past, required an elusive “super-majority Trifecta” — Democratic control of the House, Senate (with 60-seats), and Presidency. Even under such favorable conditions, he contends, our political capital might be better invested elsewhere.

While the hurdles are certainly formidable, steep political odds hardly compel us to abandon Medicare for All. Indeed, advice to drop the push for such reform rests on a misunderstanding of the dynamics of political change. History suggests that movements organized around ambitious demands can, over time, create the conditions for their passage — and that demands for radical change often advance, rather than undermine, the prospects for more incremental progress in the interim. As important, the life-and-death urgency of single-payer healthcare reform – too often underemphasized by its critics – has the potential to bring together a coalition of supporters across cultural, geographic and even class lines. It may, in other words, trigger a movement that could accomplish the unexpected.

The Dynamics of Political Change: Lessons from History

The institutional barriers that critics describe are real enough, and cannot be waved away. But they are also not immutable: throughout history, energizing issues have changed political contexts.

Consider, for instance, the passage of Medicare and Medicaid in 1965. Democrats had been stymied since the Truman administration in their efforts to pass a public national health insurance plan, obstructed in part by members of Congress intent on accommodating the insurance industry. John McDonough is right to emphasize that, from a narrow perspective, a super-majority Trifecta made Medicare achievable. 1964 saw a historic electoral shift, that, as Ted Marmor has noted, all but “guaranteed the passage of legislation on medical care for the aged.” But the achievement was only possible because people had been laying the groundwork for Medicare for years prior to the pivotal election. Senior citizen groups, progressive activists, organized labor, and allies in the civil rights movement forced it onto the national political agenda, holding politicians feet to the fire year after year — a point made by Natalie Shure in the Nation. Moreover, it required years of legislative efforts and coalition building to ready the ground for the final push. Had supporters not done so — had everyone waited to design and advocate for Medicare until the political chess pieces were in perfect position — the window would have opened, the window would have closed, and Medicare might very well not have come to be.

The same can be said for almost every sweeping political change in US history. The abolition of slavery, the reforms of the New Deal era, the civil rights legislation of the 1960s, and the legalization of gay marriage — none would have happened if reformers had patiently waited for the proper political alignment in the halls of Congress before envisioning, designing, and demanding change. The 2020 elections may or may not cause a political earthquake on par with 1964, but it hardly follows from this that we ought to lower our sights. After all, nobody can accurately predict when the pivotal shift will come. We do know, however, that if we wait for it happen, we will already be too late.

The Urgency of National Health Insurance

(Use the link below to access this important section of the article.)

Medicare for All — unlike other reforms — would alleviate such widespread and unnecessary suffering not merely by covering the uninsured, but by eliminating financial barriers to care. Rising costs from higher care utilization will be offset by large savings from simplifying administration. Indeed, a recent systematic review found that some 19 out of 22 economic analyses of Medicare for All predicted overall savings in the first year as a result of such efficiencies. Transforming healthcare financing is what makes such an unprecedented coverage expansion economically— and hence politically — feasible.

The policy advantages of Medicare for All, in other words, aren’t mere minutiae: they are part of the force for political change.

Medicare for All: The Link Between Policy and Politics

Yet policy and politics are linked in another, more fundamental way. The experience of illness and of medical care is almost universal. This means that in the United States, encounters with our dysfunctional healthcare financing system are also near universal. How many have never had a spell of being uninsured, dealt with an onerous copay or deductible, contended with a medical bill or collections agency, gone without needed care because of cost, or faced a denial of care from their insurer? It is not merely uninsured Americans who have much to gain from single-payer reform, but also those with chronic conditions who pay a tax for their illness in the form of cost-sharing; those with Medicare coverage who lack dental and long-term care benefits; those with Medicaid who must hurdle administrative barriers to remain covered and face frequent “churn” out of the program, and who sometimes have inferior access to care. Indeed, even those satisfied with their employer-sponsored coverage know that they are but one sickness — and consequent job loss — away from losing it.

All of which is to say that at the end of the day, the vast majority of the nation could benefit from single-payer reform — and that fact makes it winnable. Above all, however, we can be sure of one thing: not bothering to push for Medicare for All today will guarantee that it doesn’t happen tomorrow.

The author serves as President of Physicians for a National Health Program (PNHP), a non-profit organization that favors coverage expansion through a single payer program.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

Once again, policy that prevents financial hardship, physical suffering, and even death must prevail over politics. History has shown that we can advance beneficial policies in spite of political barriers.

So let’s get busy. Let’s pound on the politics! We have to bring an end to preventable suffering and death.

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

Americans need a fully funded health care program

By Judith L. Albert, M.D.
Pittsburgh Post-Gazette, March 9, 2020

The coronavirus has arrived in the U.S. and it’s only a matter of time before it reaches Western Pennsylvania. The American public copes with fear of infection by stockpiling hand sanitizer, rather than considering how this epidemic demonstrates the unavoidable connection we have with one another and with all living things on the planet.

Viruses are everywhere; they do not distinguish human populations by income, race, sexual orientation, class, immigration status or health insurance coverage. If the 70 million uninsured/​underinsured residents in this country cannot afford to pay for a doctor visit, emergency room visit or coronavirus test, then we all suffer the consequences, because we are all in this together.

Uninsured and underinsured folks are everywhere: They prepare and grow our food, they are health care workers, technology contract workers, caregivers and custodians. This epidemic is for all of us.

We can blame the Chinese for failing to contain the spread, or the Centers for Disease Control and Prevention for fumbling the first batch of tests for COVID-19, or various other national and international strategies to control transmission, but none of these failures really matter when we do not agree that health care is a human right.

Because the coronavirus is not the only threat to human health we face, we need a publicly financed, nonprofit, single-payer national health program that would fully cover medical care for all Americans.

Dr. Judith L. Albert is a co-founder of Physicians for a National Health Program of Western Pennsylvania.

https://www.post-gazette.com…

Surprise medical bills, coronavirus and bad insurance: 3 arguments for Medicare for All

Americans aren't just worried about contracting the coronavirus. They're worried about how they'd pay for it and other unexpected health expenses.

By Philip A. Verhoef, M.D.
USA Today, March 9, 2020

Congress is grappling with the problem of surprise medical bills, but will its Band-Aid approaches make a difference? As a physician, I’m trained to look beyond superficial symptoms to diagnose the underlying ailment. When patients pay thousands of dollars each year for “good” private insurance, how does a health care system allow them to walk away from a single hospital visit with debilitating medical debt? These concerns have become even more pressing with the spread of the new coronavirus and the costs associated with prevention, testing and treatment.

Most Americans assume that a commercial insurance card in their wallet protects them from unexpected medical bills. They pay their premiums and deductibles, scour the pages of insurance fine print and keep up with the revolving door of “in-network” doctors and hospitals.

However, going to the “in-network” hospital is no guarantee that the emergency room doctor, radiologist or anesthesiologist will be “in-network.” Today, many hospitals no longer directly employ physicians but instead contract with physician staffing firms such as TeamHealth, which employs more than 16,000 clinicians at 3,300 medical facilities.

Caught unaware in a medical crisis

These agencies are extremely profitable, which is why private equity firms are so hungry to buy them. Contract physicians operate outside of insurance coverage agreements — they’re not part of any “network” — and can act like free agents, billing patients directly for services not covered by insurance, called “balance billing.”

What does this mean for patients? Imagine you’re having a heart attack and call 911. Paramedics transport you to the nearest emergency room, which may or may not be in your insurer’s network. And because that hospital — or the ER doctor on duty —  does not have a contractual relationship with your insurer, they can essentially name their price and “balance bill” you for the amount the insurance company won’t cover.

Here in Hawaii, many critically ill patients must use air ambulances for transportation from their home island to one that can provide emergency specialty services. For one of my patients, an air ambulance was a life-or-death necessity but deemed “out of network” by their insurance. Weeks later, the family received a balance bill for more than $25,000. They were forced to file bankruptcy and then enroll in Medicaid to cover subsequent health care costs — all with an insurance card in their wallet.

If this hasn’t happened to you, it’s just a matter of time. Over 40% of privately insured patients face surprise medical bills after visiting emergency rooms or getting admitted to hospitals. These bills punch a major hole in most family budgets: The average surprise hospital bill is $628 for emergency care and $2,040 for inpatient admission. That’s on top of the more than $20,000families pay in premiums and deductibles each year just for the insurance policy.

If faced with a surprise $500 medical bill, half of Americans would either have to borrow money, go into debt or wouldn’t be able to pay it at all. Medical bills are a key contributor in two-thirds of personal bankruptcies, and yet the vast majority of households filing for medical bankruptcy have insurance.

Medicare for All is the only solution

What is the value of commercial insurance if it can’t protect us from financial ruin?

Lawmakers are considering a number of policies that would prohibit balance billing, cap the amount patients pay at out-of-network facilities and implement baseball-style arbitration when providers and insurance companies can’t agree on a payment. But surprise bills are not the real problem — they are merely one symptom of a dysfunctional system based on private insurance. And insurance companies only turn a profit by restricting patient choice, denying claims and passing costs onto enrollees.

The only policy that can end this scourge for good is single-payer Medicare for All, which would cover everyone in the nation for all medically necessary care. Medicare for All would eliminate out-of-network bills, because every doctor and hospital would be covered. Patients would never see a medical bill again, because Medicare for All would pay doctors and hospitals directly, with no deductibles, co-pays or insurance paperwork to get in the way.

Right now the current Medicare system is covering the costs of coronavirus testing, protecting patients just as it was designed to do. This health emergency is another argument for expanding such protections to all Americans.

Working in various hospitals across the country, I have met so many patients who delay or avoid needed care for fear of surprise bills and financial catastrophe. That’s risky for them and, in the face of a threat like coronavirus, for all of us. It doesn’t have to be this way. As a doctor, I prescribe Medicare for All.

Dr. Philip A. Verhoef is an intensive care unit physician in Honolulu, Hawaii. Follow him on Twitter: @DrPhilipVerhoef.

https://www.usatoday.com…

Cost realities of the health care status quo

By Elizabeth Andes, M.D.
The Kansas City Star, Letters, March 8, 2020

Voters have an opportunity to cast votes for presidential candidates with very different solutions to the American health care crisis. Poll after poll show that most voters’ top priority in this election is the cost of health care. This makes sense, given that American health care costs twice that of nations with universal care, while health insurance, pharmaceutical and hospital companies reap huge profits.

The Affordable Care Act included many important improvements, but sidestepped the fundamental drivers of our crisis. Prescription drug coverage through Medicare Part D has been a bonanza for Big Pharma, but it included no provisions for reining in costs and profits.

At a time when 68,000 American lives are lost every year from a lack of health care, we can no longer support outrageous corporate profits over people. Opponents of “Medicare for all” ask how we can afford it. A recent study in The Lancet revealed that such a program would reduce costs by 13%.

We can’t afford our current wasteful system of overhead, profit and greed. Only universal coverage can ensure that the United States doesn’t continue to rank dead last among 17 industrialized nations in life expectancy and other health outcomes.

Dr. Elizabeth Andes is the chair of the Kansas City Metro Chapter of Physicians for a National Health Program.

Canadians are happy with their single-payer system

By Jay D. Brock, M.D.
The Free Lance-Star (Fredericksburg, Va.), March 7, 2020

There’s a reason why Canadians love their Single Payer Health Insurance System more than hockey, while our health insurance industry is about as popular as the telemarketing industry.

We all see the costs increase beyond our control, and wonder where and how it will end. We all hear or worry about the denials of care. Or seethe when our health insurance company takes away our choice of physician.

What’s going on?

Blame the health insurance industry upon which our health insurance system is based. Its business model is to take in as many of our healthcare dollars as possible, but spend as few of them on our healthcare as it can get away with—the classic definition of a wasteful middleman. This is a system built with the health of the insurance industry— not our health—in mind.

No wonder Single Payer Medicare for All, gaining in popularity, has health insurance CEO’s so worried.

Especially since “Waste” should be our system’s middle name. Our healthcare costs become increasingly unaffordable because the system manages to spend hundreds of billions of our healthcare dollars on administrative and other costs that have nothing to do with our health and everything to do with building a bigger medical bureaucracy.

The waste is staggering indeed—a top medical journal, “The Lancet”, just published a major article revealing that a Single Payer Medicare for All would not only cover everyone and do it without any additional out of pocket costs for us, it would also save $450 billion and 68,000 lives a year—lives now lost because too many of us cannot afford timely medical care.

Critics who complain that the Canadian system, like any system,  has its problems, ignore that it spends much less than we do. Sadly, these critics neglect to mention that when we switch to a Single Payer, money now wasted on those administrative costs would go to our healthcare, and there would then be enough money to cover everyone’s care—and do it without any additional out of pocket costs— while covering some aspects of care Canadians can only dream about, including medications and even nursing home care.

Please note that Single Payer Medicare for All doesn’t change our healthcare delivery system—rightly the envy of the world—it changes how we fund and pay for it. So increased wait times for getting appointments, especially elective procedures, largely a function of how much money is in the system, and not the system itself, should not be a problem. (If some of the hundreds of billions saved with M4A is spent on educating more doctors and nurses, wait times for all should even improve compared to now.)

Despite what critics claim, the average American will see their take-home pay go up—and their healthcare costs go down. Economists have told us that the vast majority of Americans, perhaps as many as 95% of us, would come out ahead.

Can the country afford M4A?

Absolutely.

We already put enough money into healthcare to pay for it, but with all the waste we just don’t spend it wisely.

What we can cannot afford is the current system, with its waste of money—and lives—that should be an affront to the family values of every American.

As every other modern nation spends half of what we spend while providing robust insurance to their entire country it offends my sense of pride in the United States to hear someone throw up their hands, abandon the American Dream, and claim that we are not able to do at least as well as they can. And our proof point is Medicare. For more than 50 years, Medicare has rescued American seniors from poverty, extended their lives, and provided them with access to nearly every physician and hospital.

Medicare for All seeks to improve Medicare, make it truly affordable, and extend it to all.

In the end, the decision will be about what’s more important—maintaining our family’s health with a truly fair and affordable Single Payer Medicare for All, or maintaining the current system.

I choose my family.

I hope you do too.

Dr. Jay D. Brock, a family medicine physician, lives in Fredericksburg.

https://www.fredericksburg.com…

Doctors and dark money: A bad prescription for health care reform

By Augie W. Lindmark, M.D., Micah A. Johnson, and Alec M. Feuerbach
Medscape, March 6, 2020

As Democratic presidential candidates continue to debate health reform, a multi-million dollar advertising campaign aims to sway voters against any expansion of Medicare. Behind that campaign is a coalition of 115 health care industry groups including insurers, hospitals, drug companies – and physicians.

The ads that have run during Democratic debates are paid for by the Partnership for America’s Health Care Future, a group formed in 2018 with a seemingly benign goal: “improve what’s working in health care and fix what’s not.” Leaked documents, however, reveal the Partnership is focused on the more specific goal of blocking Medicare for All, Medicare Buy-In, and public option plans.

The American Medical Association was a notable founding member of the Partnership, and as physicians and medical students, we were troubled that medicine’s largest professional body would join a dark money lobbying group. Others in the profession shared our concern and organized protests at the AMA annual meeting last summer in Chicago. After mounting pressure—and just two months after the summer protests—the AMA did the right thing: it quit the Partnership. Doctors, we hoped, would play an honest and constructive role in the next wave of health reform debates.

Unfortunately, the AMA was not the only physician group in the Partnership. Other members listed on the group’s website include the American College of Radiology, the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, and the Virginia Orthopaedic Society. We believe these organizations should follow the AMA and exit the Partnership—and all doctors’ groups should avoid such deceptive efforts in the future.

It is inevitable that doctors will hold diverse views about health care reform, but physicians should adhere to professional standards such as disclosing financial conflicts of interest and presenting evidence truthfully. Simply put, we believe the tactics of the Partnership for America’s Health Care Future are incompatible with these standards.

To understand the problem of the Partnership, it helps to examine both their interests and actions. To block Medicare expansion, the group has launched a multi-year strategy (containing at least 17 initiatives) aimed at influencing the national health reform debate, including their deep-pocketed advertising campaign.

One ad aired during the South Carolina Democratic debate showed a mother at her child’s basketball practice warning about “new government-controlled health insurance.” Another ad warns that a “one-size-fits-all” government health insurance program could force 55% of rural hospitals to close.

When the public hears a message denouncing the expansion of public health insurance, they deserve to know that a private insurance trade group sponsors that message. But from Facebook ads to YouTube videos to television ads, the Partnership relies on its nondescript name and does not disclose the identity of its member groups. This provides a convenient avenue for industry groups to simultaneously influence public opinion and obscure their own financial interests.

This was evident when the group spent nearly $300,000 in South Carolina in advance of that state’s primary, and more than $900,000 in Virginia leading up to Super Tuesday on March 3. Last summer, the Partnership bought half of all political advertising in Iowa—re-upping their investment to $1.2 million before the Iowa caucuses. As a dark money organization the Partnership does not disclose its funding sources, but its member groups are clearly big spenders: they spent $143 million lobbying Congress in 2018.

And it’s not just advertisements. In December, the Washington Post reported a series of email exchanges that suggest lobbyists affiliated with the Partnership had drafted significant portions of op-eds published by state lawmakers attacking proposals to expand Medicare. Upon publication, there was no mention of the Partnership, leaving readers unaware of the industry role in crafting these messages.

The Partnership also actively promotes misinformation. For instance, one advertisement states that “Medicare for All, Medicare Buy-In, and a public option all mean the same thing: you’d pay more to wait longer for worse care.”

This message is misleading in numerous ways. First, a public option is vastly different from Medicare for All: one proposal could add a public plan to the Affordable Care Act Marketplace while leaving the rest of the insurance system intact and the other would transition all Americans into a version of Medicare.

Furthermore, the Partnership’s claim that Americans would “pay more” under these reforms is contradicted by Congressional Budget Office (CBO) findings that a public option would have lower premiums than private insurance. Similarly, when asked about Medicare for All during a Congressional hearing, the Deputy Director of the CBO indicated that many middle- and low-income people could pay less for Medicare for All than they currently pay for their employer-sponsored insurance, largely because a public insurance system can be financed progressively.

Instead of pouring money into such campaigns of misinformation, doctors should present evidence truthfully. But the American College of Radiology “has committed extensive resources to the Partnership’s goal,” including a $300,000 grant to the Partnership around the time of its inception. Supporting misinformation campaigns seems to violate not only an established norm of the medical profession, but also the ACR’s own bylaws that state: “Members should not publicize themselves through any medium or forum of public communication in an untruthful, misleading, or deceptive manner.”

Physicians should play an honest and constructive role in the health reform debate, and uphold the values of the medical profession when entering the public arena. Physician groups should not participate in a dark-money lobbying organization that promotes misleading information and obscures significant conflicts of interest. The Partnership for America’s Health Care Future is a bad prescription for health reform, and doctors should stay away.

https://www.medscape.com…

HHS’s zero tolerance for children (er, something like that)

Communication and Management Challenges Impeded HHS's Response to the Zero-Tolerance Policy

U.S. Department of Health and Human Services, Office of Inspector General, March 2020

Why we did this study

In spring 2018, the Department of Justice and Department of Homeland Security (DHS) adopted a zero-tolerance policy under which large numbers of families entering the United States without authorization were separated by DHS. Typically, adults were held in Federal detention while their children were placed in Department of Health and Human Services (HHS) custody and provided care through the Unaccompanied Alien Children (UAC) Program. A Federal district court subsequently ordered the Federal Government to reunify separated families who met certain criteria. Given the impact of the zero-tolerance policy on vulnerable children and families, OIG conducted this review to examine challenges that HHS faced in responding to the zero-tolerance policy and carrying out the reunification effort.

How we did this study

This report synthesizes information from interviews with, and written responses from, senior HHS officials and HHS staff; interviews with staff at 45 HHS-funded care provider facilities under the UAC Program; case reviews for a purposive sample of separated children; and more than 5,000 documents obtained through requests to the Department, from facility staff, and from interview respondents. We analyzed interview and documentary data to identify significant challenges that HHS and facilities faced in responding to the zero-tolerance policy and reunifying separated children, as well as factors that contributed to those challenges.

What we found

Interagency channels for coordinating immigration policy across Federal departments were not used to notify HHS of the zero-tolerance policy in advance. Meanwhile, key senior HHS officials did not act on staff’s repeated warnings that family separations were occurring and might increase. HHS’s lack of planning for the possibility of larger-scale family separation left the Department unable to provide prompt and appropriate care for separated children when the zero-tolerance policy was implemented. Further, because no procedures or systems had been established to track separated families across HHS and DHS for later reunification, HHS struggled to identify separated children. Additionally, care provider facilities faced significant operational challenges at every stage of the reunification process, complicated by poorly-communicated guidance from HHS. Finally, HHS has taken steps to improve tracking of separated children, but the procedures include manual processes that are vulnerable to error.

What we recommend

HHS should take steps to ensure that children’s interests are prioritized and represented in decisions affecting the UAC Program, both internally and when engaging with interagency partners. HHS should also modify or pursue formal agreements with DHS and DOJ to ensure that it is receiving information that supports its operation of and ability to provide care for children in the UAC Program. Additionally, HHS should improve communication to care provider facilities regarding interim guidance, operational directives, and other instructions that are not immediately available in published policy documents. Finally, HHS should further improve its ability to identify and track separated children by reducing reliance on manual processes.

https://oig.hhs.gov…

Complete report (70 pages):
https://oig.hhs.gov…

HHS was unprepared for Trump family separation policy, watchdog says

By Nathaniel Weixel
The Hill, March 5, 2020

Poor communication and internal management decisions left the Department of Health and Human Services (HHS) ill-prepared to respond to the Trump administration’s “zero tolerance” policy of family separations, according to an internal watchdog report released Thursday.

The report from HHS’s Office of Inspector General paints a picture of an agency caught off guard and struggling to catch up with its response. The lack of preparation hurt the agency’s ability to identify, care for and ultimately reunite children who had been separated from their parents.

According to the inspector general, senior HHS officials had no idea the family separation policy was being implemented by the departments of Justice and Homeland Security until they learned about it from media reports.

The lack of planning for large-scale separations also resulted in the agency being unable to provide “prompt and appropriate care” for separated children.

It created a lack of available bed space, leaving hundreds of children inappropriately detained in Department of Homeland Security (DHS) custody, instead of with HHS.

And at the same time, the report found that warnings from staff were ignored. Key senior officials with HHS’s Administration for Children and Families (ACF) “did not act on staff’s repeated warnings that family separations were occurring and might increase,” the report said.

According to the report, “no procedures or systems had been established to track separated families across HHS and DHS for later reunification.”

The official policy resulted in about 2,700 children being separated from their parents over a six-week period in the spring of 2018.

Last fall, the ACLU said that an additional 1,500 children were separated than previously disclosed, bringing the tally to more than 4,000 from the roughly 2,700 children previously known to have been separated that year.

https://thehill.com…

Comment:

By Don McCanne, M.D.

No, this report is not about single payer Medicare for All, but rather it is about a program initiated by a government that the people elected to implement important public programs.

In this instance, after Donald Trump was elected president, he instituted aggressive immigration policies that included forcibly separating immigrant children from their parents. Without adequate preparation or management, the children were transferred from the Department of Homeland Security to the Department of Health and Human Services – an agency that should certainly be sensitive to the physical and emotional needs of children. The report does indicate that they were successful in inducing protracted periods of crying amongst the children – therapeutic emotional venting, I suppose.

We have observed this administration’s management of other government health programs, including its attack on the provisions of the Affordable Care Act. Can you imagine what their approach might be if we already had a single payer model of Medicare for All up and running? Elections do matter.

As a democracy, we can change the political culture by becoming well informed on the policies supported by the various political candidates, and then by carefully casting our votes appropriately. But instead of selecting a candidate who is empirically perceived as having the best chance of displacing a bogeyman, we should choose a candidate based on support of public policies that would serve America best.

In the meantime, to help bring an end to our nation’s cruel immigration policies, we should consider placing Stephen Miller in a cage for the duration of Trump’s term, maybe along with the humane gesture of supplying him with a crying towel.

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

Transitional job churn is a benefit of Medicare for All

Fundamental health reform like ‘Medicare for All’ would help the labor market

Job loss claims are misleading, and substantial boosts to job quality are often overlooked

By Josh Bivens
Economic Policy Institute, March 5, 2020

Fundamental health reform like “Medicare for All” would be a hugely ambitious policy undertaking with profound effects on the economy and the economic security of households in America. But despite oft-repeated claims of large-scale job losses, a national program that would guarantee health insurance for every American would not profoundly affect the total number of jobs in the U.S. economy. In fact, such reform could boost wages and jobs and lead to more efficient labor markets that better match jobs and workers. Specifically, it could:

  • Boost wages and salaries by allowing employers to redirect money they are spending on health care costs to their workers’ wages.
  • Increase job quality by ensuring that every job now comes bundled with a guarantee of health care—with the boost to job quality even greater among women workers, who are less likely to have employer-sponsored health care.
  • Lessen the stress and economic shock of losing a job or moving between jobs by eliminating the loss of health care that now accompanies job losses and transitions.
  • Support self-employment and small business development—which is currently super low in the U.S. relative to other rich countries—by eliminating the daunting loss of/cost of health care from startup costs.
  • Inject new dynamism and adaptability into the overall economy by reducing “job lock”—with workers going where their skills and preferences best fit the job, not just to workplaces (usually large ones) that have affordable health plans.
  • Produce a net increase in jobs as public spending boosts aggregate demand, with job losses in health insurance and billing administration being outweighed by job gains in provision of health care, including the expansion of long-term care.

The upshot: M4A creates a small amount of manageable churn but increases the overall demand for labor and boosts job quality.

The job challenge relating to a fundamental health reform is managing a relatively small increase in job churn during an initial phase-in period. Most Medicare for All plans explicitly recognize and account for the costs of providing these workers the elements of a just transition. This sort of just transition is far easier when health care is universally provided.

Besides this challenge, the effect of fundamental reform like M4A on the labor market would be nearly uniformly positive. The effect of a fundamental reform like M4A on aggregate demand is almost certainly positive and will therefore boost the demand for labor. The number of jobs spurred by increased demand for new health care spending (including long-term care) will certainly be larger than the number displaced by realizing efficiencies in the health insurance and billing administration sectors.

Finally, the introduction of fundamental health reform like M4A—particularly reform that substantially delinks health care provision from specific jobs—would greatly aid how the labor market functions for typical working Americans. Take-home cash pay would increase, job quality would improve, labor market transitions could be eased for employers and made less damaging to workers, and a greater range of job opportunities could be considered by workers. The increased flexibility to leave jobs should lead to more productive “matches” between workers and employers, and small businesses and self-employment could increase.

Fundamental health reform would benefit typical American families in all sorts of ways. Importantly, contrary to claims that such reform might be bad for jobs, this reform could substantially improve how labor markets function for these families.

https://www.epi.org…

Full report (13 page PDF):
https://www.epi.org…

Comment:

By Don McCanne, M.D.

We frequently hear about the economic catastrophe that would occur if we wiped out employment in the private health insurance industry. But is that true?

This important report by Josh Bevins of the Economic Policy Institute describes the tremendous societal benefit from moving those jobs to more productive sectors while eliminating job-lock, giving individuals much more freedom in choosing their occupations, including more options for self-employment and small business development. The gain in employment in the health care delivery system should provide greater job satisfaction because you are helping people with their health care needs rather than being stuck in an administrative occupation in an industry that profits by reducing patient access to health care – not exactly a job that generates pride in your work.

This report should be downloaded to be used in your advocacy work for health care reform. The health insurance industry job loss that people worry about is far more than offset by the beneficial impacts of this transitional job churn. Not only would everyone have affordable health care though single payer Medicare for All, society will also benefit from the positive effects on the labor market.

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

Dr. James Cowan on “Health Insurance 101”

PNHP Rhode Island vice president Dr. James Cowan gave a “Health Insurance 101” talk at the Lifelong Learning Collaborative’s Spring 2020 Convocation on March 5, 2020. He argued that our current health care financing arrangements funnel massive amounts of both capital and labor into unproductive sinkholes, to the detriment of the entire U.S. economy.

Dr. Steffie Woolhandler on “Democracy Now”

PNHP co-founder Dr. Steffie Woolhandler appeared on “Democracy Now” on March 5, 2020. She discussed coronavirus as a prime example of why the United States needs a single-payer national health program. Improved Medicare for All would eliminate many of the barriers that prevent people from seeking medical care, including lack of insurance and high copayments.