Member Resource – Page 116

Please, someone destroy the insurance companies — before they destroy me

By Rebecca Levy-Gantt, D.O.
Napa Valley (Calif.) Register, July 28, 2020

You would think as a physician and owner of a small private solo medical practice I would be against a Medicare For All, Single-Payer plan since that approach would have doctors earning a salary and not allow earning more for doing additional procedures and visits.

Well, I say, bring it on.

The private insurance system is unsustainable. Without major change, I will not be in private practice much longer.

The last six years of running a private practice has been my education in private health insurance. If I contract with a particular insurance plan, we take that insurance. If a patient has a Preferred Provider Organization (PPO) plan like United Healthcare or Cigna, we can likely see them since I have contracted with those plans.

A significant drawback of health maintenance organizations (HMOs) and PPOs is both limit patient freedom to choose. I am contracted with many insurance companies, but a contract does not guarantee a particular company will pay for my services.

Each company is different. One will pay for preventive care, but another will not. The guidelines are rarely clear. If I am planning a biopsy in my office, and if we have called the patient’s insurance company for authorization, getting that authorization does not guarantee the insurance company will pay the cost of the biopsy.

This is our process: we call for authorization, get approval for a procedure, and bill the insurance company, but half the time the insurance company then decides not to pay or the patient must pay a larger portion. We often have to appeal or resubmit bills or remain on hold for hours to discuss the authorization with an insurance representative.

In what world would this be acceptable? Can you imagine telling your plumber after your pipes were fixed that you would pay nothing or only 40 percent of the cost? Then you make your plumber wait three months for payment?

We physicians have no automatic explanation of benefits that pops up when patients give us their insurance card. Contracts are confusing, vague, and contradictory. This is so even for my staff of insurance experts.

We do not know if something will be covered sometimes until after the service has been authorized and provided. We bill the insurance company, only to receive a notice: “This is not a covered service.”

This occurs even when the exact service was covered last year with the same insurance company.

I recently delivered a baby. In the sixth month of pregnancy, my office called the patient’s insurance company to ask about coverage for the delivery. She was informed that “the patient’s delivery will be covered at 80 percent of the contracted delivery rate.” We then know the patient will be responsible for 20 percent.

After the delivery, the bill went to the insurance company. We expected to receive 80 percent of the contracted fee from the company. We did not. The insurance notice said “This is not a covered service. No payment is forthcoming. The patient is responsible.”

My biller spent over two hours on the phone trying to understand what had happened. A second insurance representative recommended “resubmitting the bill.” We did so.

We are still waiting.

In what world would this be an acceptable practice? Two months have now passed. Once three months go by the insurance company can refuse to pay because of a “delay in billing.”

More time on the phone. More money uncollected.

If I want to care for their patients, I must sign the contract the insurance company presents. If I do not, I cannot care for patients with their insurance.

I cannot negotiate. I have tried. The contract is “take it or leave it.”

This is anti-small business. Our country was founded on the idea that individuals and small businesses were the backbone of our nation.

The only reliable coverage is Medicare. If a rep says ‘yes,’ they mean ‘yes.’ An approach where the government pays the bills seems to be the answer. We would be removing barriers standing between patients and health care providers.

When people say some love their insurance, it is not their insurance they love but their providers. Single-payer health care has a proven track record.

We look to Canada, Taiwan, and South Korea where the population lives longer and has a lower maternal death rate.

If the health insurance industry remains as is, I fear that small private practices such as mine will no longer be an option. The dream I worked so hard and so long for will die, and I will have to start the slow process of closing down my practice before the insurance companies help to close it down on me.

https://napavalleyregister.com…

Social Determinants of Death: Addressing Institutional Racism in American Healthcare

Structural racism calls for more than another New Deal

The New Deal allowed racial inequities to grow

Without having an honest conversation about how we got here, we will never be able to move on and heal.

By Susan Rogers, M.D.
Crain’s Chicago Business, Letters to the Editor, July 10, 2020

On reading the article “Why isn’t there a New Deal 2.0 in the mix?” (Crain’s Forum on Transportation, June 8), I found it surprising how the author lauded the New Deal as if it solved so many of the financial problems that the nation faced in recovering from the Great Depression without looking at the problems that it created.

It did solve many financial problems but at the expense of disenfranchising Blacks who lived here. Social Security, one of the major projects of this bill, intentionally excluded farmers and domestics, two of the few areas of the economy where Blacks could find employment. When it created Aid to Dependent Children, the beneficiaries were almost only white women. When it expanded several years later to include Black women, it then became known as an “entitlement.”

Other federal programs such as the GI Bill did not benefit Black GIs. They received less than 1 percent of the school loans, mortgages, job trainings, etc. Racial segregation, encouraged, allowed and condoned by federal and local government, created the fertile ground on which these inequities thrived. So the New Deal is so often looked at as a great success, but in reality it is exactly what allowed the racial inequities that already existed to continue to grow into what we see today.

Recent COVID policies continue to disenfranchise poor people and minorities. Small Black businesses were left out of the CARES Act. Low-wage workers who have no health or sick leave benefits yet are labeled as essential workers are disproportionately Black and are most impacted by the COVID pandemic. They are placed in a situation where there is no good choice. They must go to work and risk exposure to COVID or stay home and risk hunger and homelessness. Is it by accident that the essential workers of today are treated as if they live in modern-day slavery? The police brutality that has always been here has now been made so clear and finally reached a tipping point that no one can continue to deny.

We need to address the structural racial inequities that these prior and current programs created and encourage. History makes it clear that it is not by accident that poor people are disproportionately minorities and immigrants. We need to teach this history rather than continue to live in this sterile bubble that has been created. Without having an honest conversation about how we got here, we will never be able to move on and heal. Doing more of the same will continue to get us more of what we already have.

Dr. Susan Rogers is president-elect of Physicians for a National Health Program.

https://www.chicagobusiness.com…

Comment:

By Don McCanne, M.D.

For those of us who think that we’ve already addressed most of the problems in racism, we need to get real. For us single payer Medicare for All advocates, enacting and implementing an equitable, universal system of health care financing will be an important step forward, but we’ll still have so much more work to do.

PNHP members, as activist physicians and other healthcare professionals, are particularly qualified to speak up on behalf of health care justice for all, but in supporting single payer health care reform, we have been a single issue advocacy organization. We need to be part of the greater movement wherein our single issue is social justice for all – that means everyone.

But we have to guard against compromising social solidarity by acts such as paring down today’s message in the streets by saying simply, “All lives matter.” Seemingly equitable solutions cannot be allowed to gloss over the deep rooted problems that need our uncompromising attention.

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As COVID-19 Spread in April, Work Absence due to Illness was Highest on Record: New JAMA-IM Study

More than 2 million workers missed work in mid-April — the highest absence rate since 1976 — suggesting that COVID-19 was more widespread than official illness count, with immigrant workers most affected

July 27, 2020

Contact:
Adam Gaffney, MD MPH, Harvard Medical School, agaffney@cha.harvard.edu
Steffie Woolhandler, MD MPH, City University of New York (CUNY) at Hunter College, steffie_woolhandler@hms.harvard.edu

In mid-April, as the COVID-19 epidemic roared through the nation, 2,017,105 jobholders were absent from work because they were ill. The April figure was the highest number since at least 1976, and more than double the rate from mid-April 2019, according to a new study from researchers at Harvard Medical School and CUNY’s Hunter College. The findings suggest that the official counts of COVID-19 cases greatly understate the number of people sickened by the virus.

The surge in sickness-related work absences was largest for immigrant workers, a group that includes many essential workers at high risk of coronavirus exposure; immigrant jobholders’ absence rate rose almost five-fold from 12 months earlier, when their absenteeism rate had been 37% lower than that of native-born jobholders. Workers 55 and older, and those with less education also had larger than average year-over-year increases in sickness-related absences. The research appears Monday, June 27 in the Journal of the American Medical Association (JAMA): Internal Medicine.

Researchers analyzed the Census Bureau’s monthly Current Population Survey which tracks U.S. employment. Because the survey asked only about work absence during a single week in mid-April, the figures likely understate the number of jobholders who were out sick during the course of the month.

The share of workers who were out sick was virtually identical in the first two months of 2019 and 2020. As in most years, work absences began dropping in the early spring of 2019, falling to 0.58% of the workforce by April. In contrast, in 2020 the number who were out sick began rising in March as COVID-19 illnesses began spreading, and soared in April, when 1.51% of all job holders were out sick, nearly triple the percentage from a year earlier.

“I’ve seen firsthand COVID-19’s impact on the critically ill patients in our ICU, and we’ve known that many more were also ill at home,” noted lead author Dr. Adam Gaffney, a pulmonary and critical care specialist at Harvard Medical School and the Cambridge Health Alliance, a safety-net hospital system at an epicenter of the pandemic in eastern Massachusetts. “But our study indicates that the pandemic has sickened many more people than we had realized, especially vulnerable employees like immigrants.”

“Millions of immigrants and people of color have put themselves in harm’s way to keep vital services running during the COVID-19 crisis,” said Dr. Steffie Woolhandler, a primary care doctor, Distinguished Professor of Public Health at CUNY’s Hunter College, and Lecturer in Medicine at Harvard. Many are uninsured and have no income if they miss work. The least we can do to protect them is to assure paid sick leave and universal health care, benefits that workers in every other wealthy nation already enjoy.”

“Illness-Related Work Absence in Mid-April Was Highest on Record,” by Adam W. Gaffney, MD, MPH, David U. Himmelstein, MD, and Steffie Woolhandler, MD, MPH, JAMA Internal Medicine, July 27, 2020. DOI: 10.1001/jamainternmed.2020.2926

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.

https://www.charlotteobserver.com…

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:
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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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Without having an honest conversation about how we got here, we will never be able to move on and heal.

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