Member Resource – Page 120

Inequality Set in Concrete

Physical Resources Available for Care at Hospitals Serving People of Color and Other U.S. Hospitals

This study, authored by Gracie Himmelstein, M.A. and Kathryn EW Himmelstein, M.S.Ed., M.D. is in press at the International Journal of Health Services.

Abstract

Racial inequities in health outcomes are widely acknowledged. This study seeks to determine whether hospitals serving people of color in the United States have lesser physical assets than other hospitals. With data on 4,476 Medicare-participating hospitals in the U.S., we defined those in the top decile of the share of Black and Hispanic Medicare inpatients, as “Black-serving” and “Hispanic-serving” respectively. Using 2017 Medicare cost reports and American Hospital Association data, we compared the capital assets (value of land, buildings and equipment), and the availability of capital-intensive services at these hospitals and other hospitals, adjusted for other hospital characteristics. Hospitals serving people of color had lower capital assets, e.g. $5,197/patient-day at Black-serving hospitals, $5,763 at Hispanic-serving hospitals, and $8,325 at other hospitals (p<.0001 for both comparisons). New asset purchases 2013-2017 averaged $1,242, $1,738, and $3,092/patient-day at Black-serving, Hispanic-serving and other hospitals respectively (p<.0001). In adjusted models, hospitals serving people of color had lower capital assets (-$215,121/bed, p<.0001) and recent purchases (-$83,608/bed, p<.0001). They were also less likely to offer 19 of 27 specific capital-intensive services. Our results show that hospitals that serve people of color are substantially poorer in assets than other hospitals, and suggest that equalizing investments in hospital facilities in the U.S. might attenuate racial inequities in care.

Racial inequities in health and health care have been extensively documented (1). However, the mechanisms generating these inequities are not fully understood. Evidence suggests that the differential quality of hospitals visited by white patients and patients of color, rather than differential care quality within a given hospital, accounts for a significant portion of inequities in the outcomes of inpatient care (2-4). Despite the official desegregation of hospitals required by Title VI of the 1964 Civil Rights Act (5), hospital segregation by race persists (6). In 2004, 5% of hospitals cared for 44% of Black Medicare patients (7), and in 2010-2011 three-quarters of all Black infants in the U.S. were born in just one-quarter of U.S. hospitals (8).

Studies have documented significant differences in hospitals’ quality metrics according to the racial composition of their patients. Facilities treating a higher proportion of non-white patients have lower nurse-to-census ratios (7), score worse on patient safety indicators (9) and indicators of quality of obstetric care (10), and have higher 30-day readmission rates following surgical procedures (11). Studies also suggest that hospitals serving people of color have higher mortality rates for several conditions (12-14). Differences in hospital quality persist after controlling for numerous potential explanatory variables, such as patient case-mix, hospital volume and geographic region.

One potential contributor to quality differences between hospitals serving people of color and other hospitals is inequity in the physical resources available for care, which may be quantified as the dollar value of hospitals’ investments in their plant and equipment, or “capital”. Some analyses suggest that the level of hospital capital investment is a significant determinant of hospital quality (15, 16), and that inequities in physical resources may contribute to racial inequities in health outcomes. For example, Hsia et al. found that that differences in emergency department overcrowding contribute to racial inequities in mortality following acute myocardial infarction (17). However, we could identify no comprehensive studies of racial inequities in hospitals’ physical resources. Using data on virtually all hospitals that care for Medicare patients, we assessed the relationship between hospitals’ service to inpatients of color and their physical assets as measured by capital investments.

Methods

Data

We obtained data on the race and ethnicity of Medicare fee-for-service enrollees hospitalized at acute care hospitals in 2016. This data, compiled from Medicare Part A “100% files” and provided to us by Dr. Ashish Jha, is the most recent available, and is described elsewhere (7). We linked this data to three sources of information on hospital characteristics: Medicare Hospital Cost Reports for fiscal years 2013 through 2017 (the most recent year for which cost reports for most hospitals were available as of December 13, 2019), Medicare’s Case Mix files for 2017, and the American Hospital Association (AHA) Annual Survey Database for 2017. When similar data were available from Medicare cost reports and AHA survey, we used the source with the fewest missing observations.

Medicare Hospital Cost Reports, which hospitals must file annually with The Centers for Medicare and Medicaid Services (CMS), include data on hospitals’ teaching and ownership status, which we categorized as government, non-profit or for-profit; urban or rural location; and total discharges. Worksheet A-7, Part 1 of the Cost Reports provides data on the value of capital assets, defined by Medicare as: Land, Land Improvements, Buildings and Fixtures, Building Improvements, Fixed Equipment, Movable Equipment, and Health Information Technology Designated Assets, as well as a reconciled value for total capital assets. The cost reports include data on the value of each type of asset at the end of the fiscal year, as well as changes in assets during the fiscal year due to purchases, donations, and “disposals and retirements.”

The AHA database includes survey-derived data on each hospital’s average daily census, licensed beds, bed size category, state (which we categorized into the four regions defined by the U.S. Census Bureau – Northeast, South, Midwest and West), several specific services and technologies available at the hospital, and the gross square footage of the physical plant. The AHA data also includes figures for the total value of hospital assets. These correlated closely (r=.96) with the Medicare figures, which had fewer missing observations and were hence used for analyses.

The Centers for Medicare and Medicaid Services (CMS) compiles Medicare’s Case Mix file from claims for each patient’s Diagnosis Related Group (DRG) that hospitals submit in order to receive payment. DRG’s are specifically designed to estimate the resource use necessary for care of the average patient with a given DRG.

Analysis

For each hospital, we used the racial/ethnic categories provided in the Medicare data to calculate Black and Hispanic patients’ share of all Medicare inpatients in 2016, which we use as a proxy for the racial composition of each hospital’s total inpatient population. (No nationwide data is available on patient race for non-Medicare inpatients). Although many scholars now prefer the term “Latinx” to refer to individuals with ancestors from Central/South America or the Spanish-speaking Caribbean, we use the term “Hispanic” to be consistent with the terminology in the source data. Few Medicare patients were discharged from pediatric hospitals, which were excluded from all analyses.

As is standard in the literature on hospital segregation, we categorized the 10% of hospitals with the highest share of Black patients (over 22.5%) as Black-serving, and the 10% of hospitals with the highest share of Hispanic patients (over 4.4%) as Hispanic-serving (9, 13). We defined a hospital as “serving people of color” if it met our definition for either Black-serving or Hispanic-serving. To assess whether the results were sensitive to the definitions of Black- and Hispanic-serving hospitals, we repeated the main analyses using the 95th percentile (34.4% for Black patients and 9.0% for Hispanic patients) and 75th percentile (9.3% for Black patients and 1.1% for Hispanic patients) of the proportion of Black and Hispanic patients as cut points for designating hospitals serving people of color.

Because hospitals sometimes file part-year or amended annual Medicare Cost Reports, we deleted duplicate reports (retaining the most recent) and those reporting less than 340 days of data. For each hospital, we determined hospital characteristics, and the gross square footage and capital assets available per-licensed bed, per-discharge and per-patient (inpatient) day in 2017.

For our principal analyses of total capital assets we summed the values of assets at the start of the fiscal year, purchases and donations during the year, and fully depreciated assets still in use, then subtracted asset disposals and retirements during the year. We also performed sensitivity analyses using two alternative measures of total capital assets: one that excluded fully depreciated assets still in use; and one that included fully depreciated assets still in use but excluded the value of land, which might be influenced by local land values.

Because new asset acquisition may vary greatly from year-to-year, we analyzed new asset purchases and donations over the five-year period 2013-2017 to provide a more stable assessment of new capital acquisition. We assumed that hospitals reporting no new capital purchases had non-missing zero dollars of new capital investments.

For all analyses of the ratios of capital asset values and square footage to discharges, patient days and beds, we excluded the top and bottom 1% of observations to eliminate implausible outliers (e.g. hospitals reporting negative capital values).

We used two-sided t-tests for bivariate comparisons of Black- and Hispanic-serving hospitals to other hospitals. We used multivariate linear models to assess whether inequities in capital assets between hospitals serving people of color and other hospitals are attributable to other hospital characteristics. Our main models estimated the relationship between serving people of color and capital assets and square footage after controlling for region, teaching status, urban/rural location, ownership (for-profit, public or non-profit) and bed size (categorized by the AHA as 6-24, 25-49, 50-99, 100-199, 200-299, 300-399, 400-499 or 500+ beds). We considered p values < .05 significant.

We also performed two sensitivity analyses, one that included an additional control for the percentage of Medicaid discharges amongst total facility discharges, and another that included an additional control for Medicare Case Mix Index. Additionally, because our data on hospitals’ racial/ethnic mix of patients were for 2016, while the data we used to assess capital assets covered fiscal year 2017 (which includes data for parts of calendar 2016 and 2017), we repeated all analyses using 2016 Medicare cost reports. These analyses yielded virtually identical results and are not reported further.

Finally, to assess the clinical implications of differences in capital assets we analyzed differences between hospitals serving people of color and other hospitals in the availability of 27 capital-intensive services included in the AHA data: eleven diagnostic imaging technologies (diagnostic radioisotope facility, electron beam computed tomography, full field digital mammography, magnetic resonance imaging [MRI], intra-operative MRI, magnetoencephalography, multi-slice computed tomography [CT] of less than 64 slices, multi-slice CT of 64 slices or greater, positron emission tomography [PET], PET-CT, and single proton emission CT [SPECT]); four radiation therapy modalities (image-guided radiation therapy, intensity modulated radiation therapy, proton beam therapy and a shaped beam radiation system); three surgical technologies (stereotactic radiosurgery, robotic surgery and computer-assisted orthopedic surgery); four cardiac technologies (adult diagnostic cardiac catheterization, adult interventional cardiac catheterization, adult cardiac electrophysiology, and adult cardiac surgery); and five other services (cardiac rehabilitation, endoscopic lithotripsy, bariatric weight control, trauma center and hemodialysis). For each service, we assessed the availability in hospitals serving people of color vs. other hospitals using logistic regression models adjusted for region, teaching status, urban/rural location, ownership and bed size category.

Results

Table 1 displays the characteristics of Black-serving (n=448), Hispanic-serving (n=447) and all hospitals (n=4,476) included in our analyses; 63 hospitals were both Black-serving and Hispanic-serving. Hospitals serving people of color were larger, more often teaching hospitals, more commonly located in urban areas, and more frequently owned by government or for-profit entities (and less often by non-profits). They also had a higher share of Medicaid discharges. Black-serving hospitals were disproportionately located in the South, while a majority of Hispanic-serving hospitals were in the West.

Table 2 presents indicators of the assets available for patient care at Black-serving, Hispanic-serving, and other hospitals. Hospitals serving people of color had markedly lower capital assets and square footage whether measured per bed, per patient-day, or per discharge. For instance, the total value of capital assets per patient day was $5,197 at Black-serving hospitals and $5,763 at Hispanic-serving hospitals. In contrast, total capital assets at other hospitals averaged $8,325 (p<.0001 compared to both Black- and Hispanic-serving hospitals), 60.2% higher than at Black-serving hospitals and 44.4% higher than at Hispanic-serving hospitals. Similarly, new asset purchases between 2013 and 2017 averaged $1,242 and $1,7381 per patient day at Black-serving and Hispanic-serving hospitals respectively, vs. $3,092 (p<.0001) at other hospitals.

Sensitivity analyses using two alternative definitions of total capital (i.e. excluding fully depreciated assets, and excluding the value of land) yielded similar results and are shown in Supplement Table S1. Sensitivity analyses using alternative cutoffs to designate Black- and Hispanic-serving hospitals yielded similar results (data not shown).

In multivariate models adjusted for multiple hospital characteristics, hospitals serving people of color had significantly lower capital assets and purchases, but not square footage (Table 3). For instance, total capital assets per bed were $215,121 (p<.0001) lower at hospitals serving people of color than at other hospitals. Sensitivity analyses that included controls for Medicaid patients’ share of total discharges or for the Medicare Case Mix Index yielded similar results, although in the Medicaid-adjusted analyses p values were higher for a few comparisons (Supplement Tables S2 and S3).

Our logistic regression models indicate that hospitals serving people of color were less likely to offer 19 of the 27 specific capital-intensive services (Table 4). The odds ratios for the availability of these 19 services at hospitals serving people of color vs. other hospitals ranged from 0.37 (95% CI 0.29-0.46) for cardiac rehabilitation to 0.74 (95% CI 0.56-0.96) for diagnostic radioisotope facility. The availability of six services did not differ, while two, hemodialysis (OR 1.68, 95% CI 1.32-2.14) and intra-operative MRI (OR 1.47, 95% CI 1.03-2.11), was more likely to be available in hospitals serving people of color.

Discussion

The physical resources available for care at Black- and Hispanic-serving hospitals in the U.S. are sparse relative to other hospitals. The total value of plant and equipment per patient-day is about one-third less at hospitals serving people of color than other hospitals. Moreover, we found similarly large inequities in investment in new capital assets, which suggests that the gap in assets between hospitals serving people of color and other hospitals will persist, or even widen. Unsurprisingly in view of these large inequities, hospitals serving people of color are much less likely to offer many capital-intensive medical technologies and services.

What lies behind these differences? Until the Great Depression two main sources provided capital to build hospitals – federal, state, and local government funded the building of public hospitals, while private philanthropic donors funded the construction of private hospitals (18). The 1946 Hill-Burton Act (subsequently rolled into the Public Health Service Act) served to greatly expand the government’s role in hospital capital provision, offering grants and loans to build and modernize health care facilities (19). More recently, hospitals have funded most capital investments from their accumulated profits (which are called surpluses in non-profit hospitals), or from loans or bonds that must be paid back from future profits (20). For-profit hospitals can also raise capital from investors. In order to access any of these sources of capital, a hospital must be profitable or expect to garner profits in the future.

Several factors contribute to hospitals’ profitability, and hence access to capital. Payer mix, which is strongly linked to patients’ race, plays a key role. Hospitals have historically collected low payments for the care of uninsured and Medicaid patients (who are disproportionately Black and Latinx), while patients with private coverage are most lucrative. Furthermore, elective admissions are generally more profitable than emergencies (21), and non-white patients have a lower proportion of elective admissions than do white patients for a variety of conditions (22-24).

Additionally, regionally-dominant hospitals can often command higher prices from private insurers (25), while orthopedic and cardiac services are often particularly profitable because of their high reimbursement rates. Because hospitals have high fixed costs, low occupancy rates are associated with poor profitability. Finally, skillful management and effective governance can improve profitability by boosting revenues or decreasing expenses. However, it is unclear what (if any) relationship these factors have to the racial composition of a hospital’s patients.

Although studies linking hospital capital investment and health outcomes are scant, and mostly dated, they suggest a positive relationship between investment in hospital capital and improved patient care (15,16). Thus, the gaps in capitalization that we found may contribute to ongoing racial inequities in the quality of hospital facilities, and thus health outcomes.

This study has several limitations. We lacked data on service mix, and measures of efficiency, precluding full assessment of why hospitals serving people of color have less capital stock. However, adding controls for Medicare Case Mix to our multivariate models did not change our findings. We could not gauge historical differences in funding that might underlie the patterns we observed. We used the racial/ethnic composition of Medicare enrollees as a proxy for the composition of all hospital inpatients because no reliable data for other patients is available. This proxy measure may be especially imprecise for Latinx people, a relatively young population group of whom few have Medicare coverage. Unfortunately, we have no data on Asian or Native American patients.

We were unable to distinguish between capital used to enhance luxury amenities, and assets which improve patient care. However, the line between these two is often blurred. For example, single-occupancy patient rooms and natural light may be considered amenities tangential to patient care, but have been shown to improve patient outcomes (26).

Adequate physical resources are only one component necessary to provide high quality care, and the dedication of personnel in many institutions serving people of color is an immense, if intangible asset. However, hospital capital can have spillover effects on other determinants of quality. A dilapidated physical plant and lack of capital-intensive medical technology may impede recruitment of medical providers and demoralize staff and patients.

Hospitals’ capital investments “literally set in concrete the future physical configuration of the health care system” (27). The inequities we document reflect generations of deficient investment in the health care of communities of color. The term “structural racism” – the perpetuation of racial inequities by cultural, economic and political systems that are often inherited from the past and reproduced in the present – seems peculiarly apropos as a description of these stark inequities.

Table 1: Characteristics of Black-serving, Hispanic-serving, and all U.S. acute care hospitals, 2017

* p <.0001 for comparison between black-serving and other hospitals or Hispanic-serving and other hospitals
** p = .0005 for comparison between black-serving and other hospitals

Table 2: Assets of Black-serving, Hispanic-serving and other U.S. acute care hospitals, 2017

Table 3: Adjusted differences in capital assets between hospitals serving people of color and other hospitals, 2017

Table 4: Differences in odds of offering capital-intensive services, hospitals serving people of color vs. other hospitals, 2017

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Acknowledgments

Contributors: We thank Dr. Ashish Jha for providing the data used to define hospitals serving people of color, and Dr. Steffie Woolhandler for assistance with analysis of Medicare Cost Reports.

Funders: Ms. G Himmelstein’s work was supported by The Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number P2CHD047879. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Author Biographies

Gracie Himmelstein is an MD candidate at the Icahn School of Medicine at Mount Sinai, and a PhD candidate in Demography and Social Policy at the Office of Population Research at Princeton University. She received her MA in Demography from Princeton in 2019.

Kathryn EW Himmelstein is a resident physician in Internal Medicine at Massachusetts General Hospital. She received her MD degree from the Perelman School of Medicine at the University of Pennsylvania in 2018.

What will be the legacy of Barbara Starfield?

Detailing the Primary Care Imperative – Remembering Barbara Starfield

By James M. Perrin
The Milbank Quarterly, June 2020

Barbara Starfield built the field of primary care research and galvanized research and policy documenting the central importance of primary care in health and health care delivery. Her work spanned decades, showing how primary care improves population health and lowers health care expenditures. It guided many of us in the quest to improve health and health care, and rates of publications with primary care in the title have more than doubled from fewer than 1,000 in 2005 to more than 2,000 in 2018. The remarkable and comprehensive review that Starfield and her colleagues, Shi and Macinko, published in 2005 in The Milbank Quarterly summarized a wealth of US and international studies demonstrating that a) health is better in areas with more primary care physicians, b) people who receive care from primary care physicians are healthier, and c) the main characteristics of primary care are associated with better health. Those studied characteristics are first contact care, holistic person-focused care over time, comprehensive care, and coordinated care, concepts expanded in various primary care medical home criteria at the national and state levels. Furthermore, better health outcomes are found in communities and countries that distribute health resources equitably, have no or low copayments for health care, have a universal financing mechanism guaranteed by a publicly accountable body (government or government-regulated insurance plans), and have professional incomes for primary care physicians comparable to those for other specialists. Systems with strong primary care orientation and where primary care physicians are identified as the usual source of care are associated with decreased racial and socioeconomic health disparities and with decreased deaths from premature mortality, infant mortality, and overall mortality from chronic pulmonary disease, cardiovascular disease, and heart disease.

What progress has the United States made since the 2005 Starfield publication? During this period, the United States has become even more racially and ethnically diverse, especially among younger groups. Many in the health sector—and elsewhere—have recognized the importance of the social determinants of health and the role the health sector can play in addressing those determinants. Growing rates of mental and behavioral health conditions, often coexisting with other chronic health conditions, have spawned progress in integrating mental and behavioral health in primary care teams. Spurred partly in response to the recognition of the multifactorial antecedents of health and the central role of mental health, general and subspecialty clinical practice has increasingly embraced team-based care, including some combination of nurse care coordinators, mental health personnel, and family health workers—a phenomenon that Starfield recognized while pondering how to maintain important personal relationships between patients and providers with the transformation to teams. Much work has gone into training team members in their collaborative efforts and, through such work, emphasizing the importance of maintaining a productive personal relationship with ongoing patients.

Despite these generally favorable changes in primary care, the United States has recently experienced striking increases in mortality among people aged 15-60 years. Although some of this growth reflects the opioid epidemic and other drug and alcohol use, much mortality comes from suicide (reflecting the increase in mental health conditions) and cardiovascular and heart disease, partly resulting from the epidemic of obesity. Although high-quality primary care could prevent many of these deaths, the United States perpetuates a serious imbalance in financial support for primary care versus other health investments, with primary care and mental and behavioral health chronically underfunded. Starfield noted that greater relative investment in primary care improves population health and decreases health care expenditures. The US strategy limits access to preventive care throughout the life course for some populations, especially those with low income. Coupled with the persistence of poverty among young families in the United States—much worse than in other OECD countries—the lack of adequate primary care creates an unhealthy underclass beginning in childhood (or even prenatally) and continuing to affect health and death over the decades. The persistent rapid growth of US health care expenditures further indicates the lack of systematic work to implement Starfield’s findings and recommendations. For example, although the Affordable Care Act included provisions to lower the growth in total health care expenditures, many provisions required upfront funding that Congress declined to provide. This failure reflects a lack of political will to take on a complex and powerful health care industry driven by specialist investigations and interventions, rather than investment in primary care to increase access, promote prevention, improve overall quality of care, and reduce unnecessary and potentially harmful specialist care. The United States has paid the price of increased disability, mortality, and other indicators of poor health along with rising costs, all highlighted by Starfield and her colleagues.

Are there important points of light? The Centers for Medicare and Medicaid Services have stimulated greater investment in primary care, especially through their State Innovation Models and Primary Care Plus initiative. However, here too strategies have had negligible impact on equitable pay for primary care physicians, with, for example, the resource-based value structure oriented to procedures over cognitive services and, thus, balanced against adequate support for primary care tasks. Several states have worked to increase primary care investment, some through their Medicaid programs and others through broader health policy oversight, including direct calls for identifying and increasing the percent of health care dollars spent on primary care from public and private sources. The National Academies of Science, Engineering, and Medicine recently empaneled a new study on Implementing High Quality Primary Care, the first serious attention to primary care by the Academies in more than a quarter century. We can hope this new attention will lead to stronger political will and policy changes that begin to approximate Starfield’s original vision for primary care.

The Milbank Quarterly, June 2020, “Detailing the Primary Care Imperative–Remembering Barbara Starfield”:
https://www.milbank.org…

The Milbank Quarterly, September 2005, “Contribution of Primary Care to Health Systems and Health”:
https://www.milbank.org…

National Academy of Sciences, Engineering, and Medicine, “Implementing High-Quality Primary Care”:
https://www.nationalacademies.org…

Comment:

By Don McCanne, M.D.

It is interesting to observe how much we already know about how we can improve our health care system thereby reducing its profound waste that makes it the most expensive system in the world while improving its performance and outcomes, and yet we fail to act. Two systemic changes that would greatly improve value and performance would be to reinforce and expand primary care, and to enact and implement a single payer national health program – an improved version of Medicare that would include everyone.

Today’s selection honors Barbara Starfield and the legacy she left with her work in describing the virtues of primary care. We clearly need a single payer national health program built on a strong foundation of primary care. The task would not be at all difficult – simply enacting and implementing the single payer and primary care policies that have been well described in many other venues.

Since we know what is wrong, and we know how to fix it, why haven’t we done it? Without getting into the subject of divisive politics, we should recognize the imperative of single payer and primary care and just go ahead and do it. For those who clamor about politics, let’s just push them to the side and move forward. There should be plenty of others out there who would enthusiastically join together with us as we include other important policies such as improving our public health infrastructure, supporting the black lives matter movement, advocating for a sustainable environment, shielding us from the threat of guns, improving housing, reducing socioeconomic inequities – especially the maldistribution of income and wealth, making public education more accessible and affordable, providing opportunity for the Dreamers, and… well, you know, making our nation and the world a better place for all of us.

Let’s just not let great ideas, like those of Barbara Starfield, slip away from us by defaulting to mere inertia. We’re better than that.

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

Member How-To: Medicare to the Rescue

We need a fair and accessible health care system

By Nancy Glynn, Lynn Carpenter, and Gary Sobelson, M.D.
The (Concord, N.H.) Monitor, Our Turn, June 16, 2020

Of all the forms of inequality, injustice in health care is the most shocking and inhumane. – Martin Luther King Jr., 1966

The graphic image of one man’s death did more than break hearts – it opened the floodgates of memories, and generations of systemic racism and injustice. In one of our darkest hours, it reminded us that not all Americans are treated equally. And this is not a problem for some, but a problem for every one of us. If some of our leaders try to divide us in a fog of hatred, we need to speak out.

The issue at hand is equity – disparate results from our education, health care, and justice systems based on the tone of one’s skin. New research by Protect Our Care finds that African Americans are far more likely to face barriers to accessing health care and protecting themselves from the coronavirus. Additionally, due to a variety of social and economic factors, they are more likely to suffer the brunt of the financial consequences of the pandemic. And that is true right here in New Hampshire. African Americans account for 5.7% of COVID-19 cases, while making up less than 2% of the population.

This is not a new issue, but it is one that we have not given enough attention to, and now we are paying a human price for.

In New Hampshire, African Americans are more likely to lack insurance coverage. According to USA Today, “while the Affordable Care Act helped many people of color get health coverage, many still don’t have insurance and access to providers. According to the Census, 8.5% of whites were uninsured in 2017, compared to 10.6% of African Americans, 7.3% for Asian Americans and 16.1% for Hispanics.” And, the research found that black Americans have higher rates of chronic illnesses – putting them at a higher risk of contracting and dying from the coronavirus.

All that is compounded by the fact that 19% of African Americans were unable to see a physician in 2018 due to lack of coverage or cost.

There are times we look in the mirror and don’t like what we see. And, we don’t like what we have become. Last week, many of us felt that way. The deep-rooted political divide that has fractured our society ran up against one of the most tragic parts of our national legacy – racism and intolerance.

America lost George Floyd to unspeakable brutality on May 25 and countless other African Americans before him. New Hampshire has lost far too many people to the coronavirus and failed to provide health care to many in need. This is our wake-up call: We need a health care system that is fair, accessible, and does not discriminate against people of color here in New Hampshire. It is time to make it our top priority to close these gaps, to embrace tolerance, and celebrate diversity. These are deep and very old wounds, we need to heal them, and heal ourselves.

https://www.concordmonitor.com…

MedPAC recognizes system is not working but wants to go further down same path

Report to the Congress: Medicare and the Health Care Delivery System

Medicare Payment Advisory Commission (MedPAC), June 2020

As part of its mandate from the Congress, each June the Commission reports on refinements to Medicare payment systems and issues affecting the Medicare program, including broader changes in health care delivery and the market for health care services.

Realizing the promise of value-based payment in Medicare: An agenda for change

The Commission outlines a multiyear effort to establish a strategic direction for Medicare payment policy and delivery system design that could be implemented by the Congress and CMS. This work will be aimed at identifying changes that broaden the use of value-based payment (which characterizes methods of paying for health care services that provide stronger incentives than fee-for-service to control overall costs while maintaining or improving quality) by encouraging more providers to organize into “accountable entities.” Medicare Advantage and accountable care organizations could serve as vehicles to broaden the use of value- based payment, but both programs need to be improved to realize that potential.

The Commission contends that policymakers will need new approaches to both how Medicare pays providers and how services are organized and delivered to address the currently unsustainable trends in Medicare spending.

Challenges in maintaining and increasing savings from accountable care organizations

CMS has made it a priority to move more Medicare beneficiaries into alternative payment models in which providers are responsible for the cost and quality of care. One such model is the accountable care organization (ACO). ACOs are now responsible for 23 percent of Medicare beneficiaries with both Part A and Part B coverage. Given the rapid growth in ACOs, it is important to evaluate whether they are generating savings for the Medicare program and thus helping make the program more sustainable.

To date, ACOs have generated modest savings, with most evaluations estimating 1 percent to 2 percent reductions in spending from existing ACO models. Some have expressed a concern that the ability of Medicare ACOs to achieve savings has been limited because key constituencies are not sufficiently engaged with ACOs and have incentives that run counter to those of ACOs.

Because Medicare savings from Medicare Shared Savings Program ACOs have been relatively small thus far (although still greater than most care coordination demonstrations), there is a risk that those savings could be eroded, or even completely offset, by unwarranted shared savings payments. Patient selection in ACOs could result in unwarranted shared savings payments, whether the selection is intentional or not. For example, if high-cost beneficiaries are disproportionately shifted out of an ACO in its performance year—while remaining in the baseline years—performance-year spending will decrease in relation to the ACO’s benchmark. This phenomenon could occur if clinicians with high-cost beneficiaries bill under a taxpayer identification number (TIN) that is not part of the ACO or if a clinician bills for patients with low spending under the ACO’s TINs and bills for patients with higher spending relative to their risk score under a non-ACO TIN.

The current system allows an ACO to strategically change the composition of its TINs to increase the likelihood of receiving unwarranted shared savings relative to benchmarks, creating a vulnerability for the Medicare program.

Properly matching the clinicians included in an ACO’s baseline and performance years will allow a more accurate assessment of an ACO’s performance and reduce opportunities for unwarranted shared savings.

Replacing the Medicare Advantage quality bonus program

The Commission maintains that Medicare program payments should take into account the quality of care delivered to beneficiaries, and the Commission has formalized a set of principles for designing Medicare quality incentive programs. Medicare’s quality bonus program (QBP) for assessing and rewarding quality performance in the Medicare Advantage (MA) program is not consistent with these principles, and in Chapter 3 we recommend replacing it with a new quality program: the MA value incentive program (MA–VIP).

In our June 2019 report to the Congress, we outlined multiple significant flaws in the QBP program. Those flaws must be addressed so Medicare can have confidence that the MA program encourages and appropriately rewards high quality in a manner that ensures that program dollars are wisely spent.

The Commission recommends that the Congress replace the QBP with an MA–VIP that includes the following five key design elements:

Scores a small set of population-based measures.
Evaluates quality at the local market level.
Uses a peer-grouping mechanism to account for differences in enrollees’ social risk factors.
Establishes a system for distributing rewards with no “cliff” effects.
Distributes plan-financed rewards and penalties at the local market level.

To drive quality improvement, policymakers would need to choose an appropriate amount of payment to fund the reward pool and an effective performance-to-points scale methodology.

In the future, we will attempt to take lessons learned from today’s experience into our assessments of Medicare’s payment systems as we help the Congress grapple with the difficult task of controlling the growth of Medicare spending while preserving beneficiaries’ access to high-quality care and providing sufficient payment for efficient providers.

http://www.medpac.gov…

Comment:

By Don McCanne, M.D.

Medicare for All? Look at what they keep doing to Medicare!

First they decided that Medicare needed to be turned over to the private insurance industry, and so they established private Medicare + Choice to show that the private insurers could provide higher quality care at a lower cost. That didn’t work, so they replaced the program with private Medicare Advantage and provided the insurers with various incentives to establish plans which they claim lowered costs but actually increased costs when considering that the private plans were cream skimming the healthier patients. So then they introduced risk adjustment which provided the private plans with another opportunity – upcoding to make their patients appear sicker than they really were so the insurers could qualify for higher payments. And quality? They learned to game that as well.

The policy community recognized that there were problems so they decided we needed a new concept. Let’s put the providers in charge and make them accountable for the costs and quality of care. Well that hasn’t worked either. The cost savings were negligible, especially when considering the unaccounted for costs of the providers and the very modest bonuses that wiped out the savings for Medicare. Again there is evidence that they still do not have effective measurements of overall quality.

These two models – private Medicare Advantage and accountable care organizations have been a failure and should be abandoned and replaced with efforts to improve the traditional Medicare program – a program that has been neglected by Congress and the administrations of both parties. No, they won’t give up. Instead they want to replace the ineffective tools of these organizations with other tools that we can predict will be just as ineffective, but will prolong the life of these organizations that are designed under principles advocated by the medical-industrial complex while neglecting those who really count – the patients.

From MedPAC’s perspective, the problem is with Medicare Advantage and accountable care organizations, and that is what they want to fix. Well it’s the patient, doggone it, that needs relief. Medicare Advantage and accountable care organizations are incurable simply because they are artificial constructs that are designed to control costs while protecting the industry, but that doesn’t work because they are based on market incentives, and players in the market will always work the system to satisfy their own interests; patients are only their tools.

Medicare has some serious deficiencies, and they need to be fixed, but not by MedPAC since they fail to make recommendations on the deficiencies that negatively impact patients. There is a plethora of literature that demonstrates that the single payer model of Medicare for All corrects most of the deficiencies in the health care financing system such that patients would have free choice of health care that is accessible, effective, efficient, equitable and affordable for each of us. Tens of millions do not have that now but could without increasing our national health expenditures over the current level.

If you are not convinced, read the 244 page MedPAC report to Congress to see where we are headed. Then read PNHP’s Physicians’ Proposal. Then report back.

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

V. Fuchs: We may now have the dynamic for political change in health reform

Health Care Policy After the COVID-19 Pandemic

By Victor R. Fuchs, Ph.D.
JAMA, June 12, 2020

To simply return to the prepandemic health care system during a presidential election year would be a mistake. This is a time to think more boldly about the future of the US health care system. The health care system is dysfunctional for many individuals in the US; it is too costly, too unequal, and too uncertain in its eligibility and coverage, with an increasing number of uninsured. However, designing and implementing a better health care system will not be easy. In exploring the challenges and difficulties ahead, it is useful to distinguish between those that are primarily technical issues (although these are not exempt from politics) and those that are political obstacles to significant reform.

Technical Issues

The technical issues involve 2 main issues: how to raise the nearly $4 trillion each year to pay for US health care; and how to organize and deliver the care and compensate those who provide it.

An important goal of health care reform should be to replace the current byzantine system of premiums, taxes, tax exemptions, deductions, subsidies, and out-of-pocket payments with a much simpler system of financing health care. An equally important goal is to replace the current multiplicity of public and private health insurance programs with 1 universal program that covers everyone from birth to death. Because the US health care system is so large, it would probably be necessary to approach these goals in stages. It is important, however, to realize that the complexity of the current system is one of the main reasons it is so costly, with high administrative expenses.

A few countries find it more feasible to achieve universal coverage through compulsory health insurance administered by insurance companies under close regulation and supervision by the government. The intent and effect of such programs is similar to that achieved by tax-supported public insurance. For historical and political reasons, the US might prefer this approach in contrast to a so-called single-payer system. Regardless of approach, universal systems have proven to be the best way to ensure that everyone has access to care without bankrupting individuals or governments.

Most health policy experts agree that the prepandemic health care system was inefficient. However, there is no consensus as to what delivery system would be better for the US diversity of health plans. The competition among the plans will have several advantages if the plans follow a few general principles. First, the health plans should be private. Government-run health care would not work well for the US for its entire population. Over the past decade, Medicare has become increasingly privatized, with about 35% of its recipients enrolled in private insurance plans. Second, public insurance would pay for everyone to be enrolled in a health plan of their choice, with open enrollment every year for anyone who wants to change plans. Third, the plans would receive a risk-adjusted capitation fee to compensate plans for the differences in the expected use of enrolled populations.

Capitation reimbursement provides incentives to use resources efficiently, unlike fee-for-service reimbursement that provides incentives for overuse. This is not just a theoretical proposition. The Kaiser Permanente Health Plan has been paid per capita for more than 50 years and has seen its enrollment increase to 12 million patients, one-third more than in the Veterans Health Administration care system. Fourth, within that general framework, each health plan should be free to deploy resources as they deem best. Some plans might want to pay physicians a fixed salary; others might want to have productivity incentives for their physicians. Some plans might choose to deploy many nurse practitioners and physician assistants, others might not. Most plans would probably want to emphasize primary care, reserving specialists and subspecialists for patients who need their attention.

Physician-led health plans that receive risk-adjusted capitation payment are in the best position to allocate resources more efficiently and effectively according to judgments about benefits and costs.

Political Obstacles

Changes in the health care system have always been opposed by many. As Machiavelli observed, proposals for a new order face strong opposition from those who benefit from the old order. This group includes high-income patients who prefer a health care system that caters to their interests and values.

The cost of this system, more than $11 000 per person per year, is tolerable for those with high incomes, but oppressive to most individuals in the US and ruinous for many, leading to missed medicines and bankruptcy.

High-income individuals also prefer US health care research that emphasizes product improvement and ignores cost of care.

Opposition to change will also come from the manufacturers of drugs, devices, and equipment who have made large profits under the old system, and from some physician specialists who have made large incomes.

Most voters do not have high incomes, but another major obstacle is distrust of the government by many in the general population. That sentiment may still be true but may change as current events unfold.

Distrust of the government is difficult to dispel, but it is possible to do so as President Roosevelt proved with his New Deal reforms in the 1930s. Even though it has seemed that major reform of health care would only occur in the wake of a major war, a depression, or large-scale civil unrest that changed the political balance, it now appears that the COVID-19 pandemic may provide the dynamic for major political change. If that occurs, major health care reform will be more attainable.

https://jamanetwork.com…

Comment:

By Don McCanne, M.D.

For decades, Victor Fuchs has been telling us, “National health insurance will probably come to the United States after a major change in the political climate — the kind of change that often accompanies a war, a depression, or large-scale civil unrest.” He now says, “Even though it has seemed that major reform of health care would only occur in the wake of a major war, a depression, or large-scale civil unrest that changed the political balance, it now appears that the COVID-19 pandemic may provide the dynamic for major political change.”

In the past he has supported government vouchers to purchase private health plans. He apparently still supports competition of private health plans as in the Medicare Advantage program, though he does state, “an important goal is to replace the current multiplicity of public and private health insurance programs with 1 universal program that covers everyone from birth to death,” presumably considering traditional Medicare plus Medicare Advantage health plans to be “1 universal program.” He singles out Kaiser Permanente as an example of a private health plan – a delivery system that would be included in a single payer Medicare for All program anyway.

It looks like we are very close to agreement on the restructuring of the financing system for health care. And we do indeed have a major change in the political climate with the COVID-19 pandemic and its economic consequences. Though some are looking for a rapid end to the pandemic and a quick economic recovery, that is not going to happen. As the reality that we are in this for the long haul sinks in, the nation should be ready to move forward with single payer Medicare for All – a stable health care financing system that can withstand war, depression, large-scale civil unrest, or even a catastrophic pandemic.

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

Better Health for All, Economic Efficiency

The Case for Medicare for All

By Ed Weisbart, M.D.
St. Louis Metropolitan Medicine, Commentary, June/July 2020

In the 1940s, Winston Churchill is rumored to have said “Never let a good crisis go to waste.”¹ If he did say this, he was referring to the unlikely trio of himself, Stalin and Roosevelt creating opportunities in the midst of a global crisis. The world was changed by their combined capacity to imagine a better way forward.

Another global crisis is upon us, and once again we need to imagine a better way forward.

The pandemic has unmasked the hazards of linking health insurance to employment, along with our health care system’s long-standing inefficiencies, poor outcomes and injustices and disparities.

The same war that drove Churchill to seek such unusual bedfellows also drove American businesses to attract and reward employees with access to lifesaving medical care through employer-sponsored health insurance. Decades later, we are still locked into a failing system of job-based coverage. For many workers, losing that job for any reason—your own underperformance, your own entrepreneurship or a major change in the economy—jeopardizes your continued access to health care.

Our strategies to address COVID-19 must also address these systemic faults with our system. Let us do that by building on the successes of Medicare, improving its obvious shortcomings, and providing that to all of us.

Why Base a Solution on Medicare?

Medicare is far from perfect, but even in its present state it brings tremendous value.

Medicare patients may worry about surviving the pandemic, but they have the peace of mind that their health insurance will be there even in the worst of times. If Medicare already covered all Americans, the pandemic would not require emergency legislation to ensure access to affordable screening, prophylaxis and treatment for coronavirus. Even in the most desperate days of Italy’s catastrophe, Italians were not afraid to seek treatment due to cost, or worried about personal bankruptcy from medical bills.² Universal health care is not a panacea and certainly did not shield Italy from the coronavirus, but it did shield Italians from some of the worst economic consequences.

Traditional Medicare offers a national network including virtually every hospital and 93% of non-pediatric primary care physicians.³ I know octogenarian Floridians on Medicare who have flown to St. Louis for world-class subspecialty care, never having to ask for permission from their insurance company. Every American should have the freedom to choose their own health care.

Improved Health

Even outside of a pandemic, Medicare has a favorable impact on Americans’ health. After worst-in-class mortality rates for the first 65 years of our lives, American mortality rates quickly improve to the best in the world upon reaching the age of Medicare eligibility. (Fig.1) This should make us enormously proud; it’s only possible because we have many of the world’s best physicians, nurses, pharmacists, hospitals and the rest of the delivery system. We just don’t let everyone in until age 65.

Medicare also reverses racial disparities in life expectancy. In Missouri, African-American lives are 3.3 years shorter than those of whites.⁴ Nationally, 86% of the causes of these premature deaths are from conditions amenable to medical prevention and treatment.⁵ That suggests that part of the life expectancy gap is related to the fact that African-American Missourians are 40% more likely to be uninsured than are white Missourians (14% vs 10%)⁶ along with a broadly different mix of insurance products.

We have clear evidence that Medicare coverage reduces and even reverses racial health disparities. For example, every American who needs dialysis can enroll in Medicare regardless of age. Once on dialysis, African-Americans enjoy the same insurance as all other Americans and survive longer than whites on an age-matched cohort.⁷

One argument in favor of our private insurance industry is the proposition that it makes health care more affordable. But private health insurance has shown an unimpressive track record of controlling costs. Over the past decade, the cumulative growth in per-enrollee spending in Medicare has increased 21.5%; the comparable figure for private health insurers is 52.6%,⁸ a relative difference of 244%. (Fig. 2)

Medicare has provided American seniors with decades of success, more individual freedom, better health outcomes and greater economic efficiencies. Each of these attributes of Medicare could be available to all of us.

Improved Medicare for All is a public-private partnership without the waste of today’s corporate insurance middlemen. Proposed legislation, HR1384 and S1129, would improve the flaws with traditional Medicare and provide that to Americans of every age. With such robust universal insurance, the niche for commercial insurers virtually disappears, simplifying both the patient experience and independent medical practice.

Medicare for All would:

Provide first-dollar coverage of all medically necessary care, funded by an equitable tax model;
Include all essential benefits like dentistry, optometry, audiology, pharmacy and long-term care;
Transition hospitals to global budgets instead of today’s complex schemes, reducing their operating overhead and aligning their business interests with the public health imperatives of their communities;
Streamline physician reimbursements with fee-for-service, salary or capitation. Every physician and medical group would be free to select the model they prefer. Rather than having to accept employment in a large system, physicians would find the business of running a practice far less onerous and be more able to retain their independence if that were their preference;
Adopt one clinically based formulary with ready access to evidence-based medical exceptions;
Include many more features as defined by the Working Group on Single-Payer Program Design.⁹

Economic Savings

Despite all of these benefits for patients and physicians, I would not be on board with Medicare for All were I not convinced that it is the most prudent strategy. Hundreds of independent economists,¹⁰ including dozens of the most prestigious,¹¹ all came to the same conclusion: the U.S. would either break even or, more likely, have considerable economic savings by switching to Medicare for All. These studies do not even account for the indirect benefits, such as savings on workers’ comp, improved health or increased productivity.

The two strategies that drive the economics of Improved Medicare for All are the same two strategies employed by most successful businesses: structural efficiency and meaningful price negotiations.

Medicare operates with an overhead of 2.3%, as compared to the 12-18% overhead of commercial insurers.¹² Medicare achieves these low levels of overhead because—unlike private insurance companies—it does not need legions of staff for sales, advertising, account management, aggressive utilization management, redundant information systems, eight-figure executive salaries and shareholder profits.

Some critics claim that Medicare for All would hurt physicians and hospitals financially. However, neither Medicare for All bill proposes using the current Medicare fee schedule. Instead, the bills establish a “physician practice review board to assure … fair reimbursements for physician-delivered items and services.”¹³ These boards would be regionally representative and also bear responsibility for quality assurance and cost effectiveness.

Three recent studies (Mercatus, 2018; Rand, 2019; and Urban Institute, 2016) projected payments to physicians would remain close to the current $688 billion; their estimates under Medicare for All were $681 billion, $673 billion and $774 billion respectively.

In fact, Medicare for All would provide hospitals with tremendous savings. Today, hospitals in the United States spend 25% of their total budget on administration and billing, more than double what is required at comparable institutions in single-payer nations.¹⁴

Similar excesses exist in American physician office overhead; U.S. physicians spend two to three times as much as our Canadian colleagues on billing.¹⁵ The overall average Canadian clinical payment per physician in 2018 was $344,978; in family medicine $280,763; psychiatry was $278,069; dermatology was $384,786; ob-gyn was $391,743; ophthalmology was $768,958.¹⁶

Malpractice insurance costs are far less onerous in Canada. The Canadian Medical Protective Association reports that 2019 malpractice premiums for family medicine in Quebec were $1,583; in British Columbia and Alberta, the rates were $3,420.¹⁷ The 2019 average internal medicine premium in Missouri the same year was $13,425.¹⁸

Perhaps the most telling and quantifiable measure of the impact of single payer on medical practice comes from an analysis of the average number of characters per ambulatory progress note in electronic medical records. Epic, one of the world’s most common EMRs, is implemented differently in every institution around the world. Epic carefully optimizes each unique installation in every institution, optimizing the software to meet the particular needs of the specific setting. In 12 other modern nations, these notes average 1,000 characters. In the United States, the average is 4,000 characters.¹⁹ Here, our charting is structured to optimize reimbursement and protect against malpractice claims. Elsewhere, it is primarily focused on meeting the clinical requirements of a medical record.

When faced with an opportunity to relieve many of the pressures on medical practice, let’s ensure that every American can get all medically necessary care, and reduce the economic drain that has taken over our national economy. The imperative to move forward with Medicare for All is clear.

Ed Weisbart, MD, CPE, FAAFP, is chair of the Missouri chapter of Physicians for a National Health Program and an assistant professor of clinical medicine at Washington University School of Medicine. He can be reached at pnhpmo@gmail.com.

https://slmms.org…

References

Quora.com. https://www.quora.com…
Speri A. Why I’d Rather Be in Italy for the Coronavirus Pandemic. The Intercept. March 12, 2020. https://theintercept.com…
Boccuti C, Fields C, Casillas G, Hamel L. Primary Care Physicians Accepting Medicare: A Snapshot. Kaiser Family Foundation. Oct. 30, 2015. https://www.kff.org…
Lewis K, Burd-Sharps S. The Measure of America 2013-2014. Measure of America. http://www.measureofamerica.org…
CDC, MMWR, May 2, 2017.
Uninsured Rates for the Nonelderly by Race/Ethnicity. Kaiser Family Foundation. 2018. https://www.kff.org…
Norris K, Mehrotra R, Nissenson A. Racial Differences in Mortality and End-Stage Renal Disease. American Journal of Kidney Disease. Aug 2008. https://www.ncbi.nlm.nih.gov…
https://www.axios.com…
Gaffney A, Woolhandler S, Angell M, Himmelstein D. Moving Forward from the Affordable Care Act to a Single Payer System. American Journal of Public Health. June 2016. https://ajph.aphapublications.org…
Partners for Dignity and Rights. More than 250 Economists Sign Letter Backing Medicare for All. May 21, 2019. https://dignityandrights.org…
Kahn J., et al., Economists conclude that Medicare for All (M4A) could be considerably less expensive than the current healthcare finance system. The Hopbrook Institute. Feb. 20, 2020. https://www.hopbrook-institute.org…
2018 Medicare Trust Fund Report, and SEC filings for 1st or 2nd quarters, 2019. Note: Overhead here is defined as 1 – (medical benefits/premiums)
HR 1384 of the 116th Congress. Sec 612(b)
Himmelstein D, et al. A Comparison Of Hospital Administrative Costs In Eight Nations: US Costs Exceed All Others By Far. Health Affairs. Sept. 2014. https://www.healthaffairs.org…
Song Z, Ji Y, Safran D, Chernew M. Health Care Spending, Utilization, and Quality 8 Years into Global Payment. NEJM. July 18, 2019. https://www.nejm.org…
Canadian Institute for Health Information. Figures are pre-tax in Canadian dollars. https://www.cihi.ca/en
Canadian Medical Protective Association. www.cmpa-acpm.ca
Gallagher Healthcare website. https://www.gallaghermalpractice.com…
Downing N, Bates D, Longhurst C. Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause? Ann Intern Med 2018; 2018;169(1):50-51.

Why the current COVID-19 crisis necessitates a focus on U.S. healthcare reform

By Simrun K. Bal, M.D.
New Hampshire Union Leader, June 15, 2020

As an internal medicine resident (a doctor undergoing advanced training and working under supervision), the current medical and economic crisis related to COVID-19 has weighed heavily on my mind. Even before the pandemic, we residents often cared for patients experiencing the systemic inequities of our current health care system.

We serve uninsured and under-insured patients who may not be able to afford, for example, the $200 out-of-pocket cost for a vial of much-needed insulin for diabetes management.

In our primary care clinics, some patients save up over months to afford a needed diagnostic test. Now, with COVID-19, we serve patients who face even greater obstacles. Losing a job, losing health insurance, and getting sick is a deadly combination that reveals underlying vulnerabilities in our health care system.

Can we utilize the current crisis as an opportunity to focus on achieving access for everyone to health care that is affordable, universal, and equitable?

In the United States, our health care system is based on employer-based coverage, for up to half of all Americans. The main origins of this practice began around World War II when wages were frozen temporarily due to inflation. Individual companies were not allowed to raise pay, so they instead attempted to distinguish themselves from other businesses by offering health insurance as a key benefit to workers.

Although it may seem that employer-based coverage was functioning well prior to the pandemic, there are clear signs that it was not. Research in 2019 demonstrated that even with employer-based health coverage, more than half of Americans still delayed or postponed suggested treatments due to cost. Furthermore, as noted in the American Journal of Public Health in 2019, the majority of Americans who file for bankruptcy due to medical debt actually have health insurance.

Now, in another historic crisis, the COVID-19 pandemic has caused millions of individuals to lose their jobs. As of early May, at least 170,000 individuals in New Hampshire — about 12% of the state’s population — have filed for unemployment. This meant that many were suddenly and shockingly removed from their health insurance plan, finding themselves without coverage or being unable to afford coverage. Our patients describe feeling as though “someone has pulled the rug out from under [their] feet.”

Congress has taken temporary measures that appear reassuring, such as providing assistance through the CARES Act as well as the Families First Coronavirus Response Act. In New Hampshire, workers who have lost their jobs in the past 60 days or who anticipate job loss over the next 60 days can apply to enroll in the ACA marketplace. Unfortunately, those unemployed workers can often only afford the least expensive “Bronze” plans, with high deductibles. Fortunately, telemedicine services are also expanding, allowing providers to reach patients in rural areas of New Hampshire who might be unable to be present for in-person care.

Although I am grateful for these tentative signs of progress, I feel concerned that the vulnerabilities of our current health care system limit the possibilities of what we can achieve with these temporary measures. Access to health care coverage shouldn’t be a benefit given by an employer only during times of prosperity.

The health of all of us depends on the health of each of us. The public good depends on protecting individuals, particularly those who are most at risk. It is for this reason that we must carefully investigate alternatives to our current health care system. This choice will be a key component of the 2020 election. Different options include a public-option healthcare plan or single-payer health care (Medicare-for-All).

With a public-option plan, Americans would have a choice between private coverage and a public option (which could be purchased by employers). Unfortunately, people would still be at risk for changes in coverage due to job loss. About 10 million Americans would also still remain uninsured, and the same complexity in payments would still be present. In contrast, Medicare-for-All would provide universal, streamlined coverage. By eliminating private insurers and lowering the cost of prescription drugs, it would actually reduce spending on health care and allow us to begin improving the quality of care. These two options represent ways in which we can challenge the health care status quo and respond to the inequalities revealed by this pandemic.

Within each challenge is an opportunity. With the challenges posed by the current pandemic, we are learning many painful lessons about the vulnerabilities in our health care system.

I encourage citizens in New Hampshire to continue to educate themselves about the U.S. health care system and proposed reforms, to pay attention to temporary policy changes, to participate in making these changes permanent, and to consider involvement in groups advocating for change.

These opinions are my own and do not necessarily reflect those of my employer.

Dr. Simrun K. Bal is an internal medicine resident physician at Dartmouth-Hitchcock Medical Center in New Hampshire. She lives in Hanover.

https://www.unionleader.com…

Medicare for All Explained Podcast: Episode 36

Interview with Prof. Daniel Skinner

June 14, 2020

Health policy professor Daniel Skinner argues for a thorough reform of American health care that includes, but is not limited to, single-payer Medicare for All. Points of discussion include the “structural dynamic of inequality” that affects the health of Black Americans, people of color, and people with low incomes; and a recent op-ed by Skinner that called for a conversation on the nationalization of hospitals.

Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

SQ 802 would be a step forward for Oklahoma

By Daniel Pham
The Oklahoman, June 14, 2020

At my white coat ceremony almost a year ago, I pledged to “do no harm” in the pursuit of a medical career. However, one does not need to graduate from medical school to see that our fragmented health care coverage in Oklahoma harms patients and communities, yielding poorer health outcomes than the national average.

Patients share stories of being denied care because of inadequate coverage or paying unbelievably expensive out-of-pocket costs. Even as a first-year medical student, I hear these stories and even learn how to “manage” a patient who cannot afford their care.

In the United States, life expectancy increases linearly by income level, and Oklahoma is no different. Almost 200,000 Oklahomans do not have health care coverage and many more are underinsured. Often, they rely on free or low-cost clinics, where medical students volunteer and practice the clinical skills we learn. However, this system has become overwhelmed due to increasing demand and limited resources.

Expanding Medicaid would strengthen the financial situation of rural hospitals, which have struggled to keep their doors open. Additionally, studies have shown that states that expanded Medicaid produce net savings because of the reduction of spending on uncompensated care.

However, the economic arguments mean little to me because as a future health care professional, I do not want to practice in a system that fails to meet the health needs of our most vulnerable. The COVID-19 pandemic magnified the fact that individual health is connected to the health of an entire community. We are only as strong as our weakest link. For those with adequate and comprehensive health coverage, it is imperative that we collectively ensure everyone around us has access to the care they need.

In medical school, I learn to examine the social determinants of health and believe that one of the biggest developments the state could make would be to give every Oklahoman access to high-quality health care and guarantee it as a human right. There is work to be done toward providing everyone the care they deserve, and voting for State Question 802, Medicaid expansion, is the first step in that direction.

Daniel Pham, an Oklahoma City native, attends medical school at the University of Oklahoma Health Sciences Center. SQ 802 is on the ballot June 30.

https://oklahoman.com…

COVID-19 crisis comes with financial toxicity

18.2 Million Individuals at Increased Risk of Severe COVID-19 Illness Are Un- or Underinsured

By Adam W. Gaffney MD, MPH, Laura Hawks MD, David H. Bor MD, Steffie Woolhandler MD, MPH, David U. Himmelstein MD & Danny McCormick MD
Journal of General Internal Medicine, June 10, 2020

We analyzed a nationally representative survey to identify individuals at elevated risk for severe COVID-19 and, among these, those at high risk of financial toxicity from care at the start of the epidemic.

Discussion

At the start of the outbreak, 18 million adults at increased risk of severe COVID-19 were inadequately insured and hence at risk of delay in seeking care because of cost concerns and of financial toxicity if hospitalized. Traditionally disadvantaged groups—racial minorities, low-income persons, and rural residents—were more likely to be at risk of severe COVID-19 (consistent with the experience of previous viral respiratory epidemics) and of financial harm. Those living in states that failed to expand Medicaid or issue a stay-at-home order were also at greater risk of severe disease and inadequate coverage.

Gaps in insurance coverage, and states’ decisions to reject Medicaid expansion and defer prevention measures, may hence exacerbate the damage wrought by the COVID-19 epidemic, as well as health disparities. Rising unemployment after the onset of the epidemic in the USA will likely translate into health coverage losses that could further widen these gaps; our estimates of uninsurance and underinsurance are likely underestimates. These findings provide support for steps taken to address inadequacies in coverage for the diagnosis and treatment of COVID-19 and for the consideration of additional policies that could expand coverage during the economic downturn.

https://link.springer.com…

‘Lethal Inequality’: New Study Shows Millions at High Risk of Covid-19 in US Lack Adequate Health Insurance

By Jake Johnson
Common Dreams, June 10, 2020

Dr. Adam Gaffney, a critical care physician and lead author of the study, said the coronavirus pandemic “is laying bare the lethal inequality of American society and American healthcare.”

“Our ICU has been flooded with poor and minority patients; having Covid-19 is scary enough without worrying that you’ll be bankrupted by medical bills,” said Gaffney, who works at the Cambridge Health Alliance and Harvard Medical School and serves as president Physicians for a National Health Program (PNHP).

“These promises of new protections for patients with Covid-19 are full of holes,” said Dr. Danny McCormick, a primary care physician and senior author of the study. “Covid-19 threatens the health of people everywhere, but only in the U.S. will it also ruin patients financially. When people avoid testing and care because they fear the costs, it fuels the epidemic’s spread.”

Dr. Steffie Woolhandler, distinguished professor of Public Health at CUNY’s Hunter College and another of the study’s authors, said the new research bolsters the case for both an emergency expansion of Medicare to the uninsured—as proposed by Sen. Bernie Sanders (I-Vt.) Rep. Pramila Jayapal (D-Wash.)—and an eventual transition to Medicare for All.

“It’s not just Covid care that’s unaffordable,” said Woolhandler, co-founder of PNHP. “Patients with heart disease, asthma, and diabetes need protection too. Medicare for All is the long-term answer.”

https://www.commondreams.org…

Comment:

By Don McCanne, M.D.

As Steffie Woolhandler states, “Medicare for All is the long-term answer.”

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

Debating Beshear’s plan on health insurance for black Kentuckians

By Kay Tillow
Lexington (Ky.) Herald-Leader, Letters, June 11, 2020

Kentuckians are fortunate to have a governor who has responded to the pandemic with intelligence and humanity. His restrictions have saved lives. Now Gov. Andy Beshear looks at the unequal impact of COVID-19 on African Americans and, with compassion, declares that all African Americans in Kentucky should have health insurance. Yes. That would be an excellent beginning.

Now, governor, say its name. The only system that will cover every African American, letting no one fall through the cracks, is a national, not-for-profit, single payer plan — an improved Medicare for All. Such a plan, as set forth by Physicians for a National Health Program, would automatically enroll everyone, make care free at the point of service, yet save us money by removing the parasitic, for-profit insurance industry from our system.

Single payer would save rural hospitals by assuring funds through global budgeting and would cover dental work, eyeglasses, hearing aids, and drugs. It would cover nursing home care, banning the impoverishment now required for eligibility.

The plan would cover the rest of us as well. Please say its name, governor. National single payer health care — improved Medicare for All — publicly funded with the profit makers removed.

https://www.kentucky.com…

Abstract

Methods

Data

Analysis

Results

Discussion

Table 1: Characteristics of Black-serving, Hispanic-serving, and all U.S. acute care hospitals, 2017

* p <.0001 for comparison between black-serving and other hospitals or Hispanic-serving and other hospitals ** p = .0005 for comparison between black-serving and other hospitals

Table 2: Assets of Black-serving, Hispanic-serving and other U.S. acute care hospitals, 2017

Table 3: Adjusted differences in capital assets between hospitals serving people of color and other hospitals, 2017

Table 4: Differences in odds of offering capital-intensive services, hospitals serving people of color vs. other hospitals, 2017

References

Acknowledgments

Author Biographies

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Why Base a Solution on Medicare?

Improved Health

Economic Savings

References

‘Lethal Inequality’: New Study Shows Millions at High Risk of Covid-19 in US Lack Adequate Health Insurance

Comment:

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* p <.0001 for comparison between black-serving and other hospitals or Hispanic-serving and other hospitals
** p = .0005 for comparison between black-serving and other hospitals