By Alvin Powell
The Harvard Gazette, January 14, 2020

Health care, climate change, and political reality collided this week, when experts discussing national single-payer health insurance clashed over the question of whether Democrats should make it their top priority if the party manages to retake both the White House and Congress this year.

John McDonough, a professor of the practice of public health who played a role in the design and passage of the Affordable Care Act, shook his head, arguing that recent history suggests health-care overhaul debates tend to crowd out all other issues and to exact a high political price.

“Health care is vitally important, but so is climate change, so is voting rights, so is gun control,” he said. “When health reform is on the agenda, it sucks up all the political oxygen in the room, and there’s very little room or space for anything.”

Adam Gaffney, an instructor in medicine at Harvard Medical School and president of Physicians for a National Health Program, disagreed, citing Franklin D. Roosevelt’s New Deal and Lyndon B. Johnson’s Great Society as examples of packages of progressive initiatives that passed despite multiple controversial parts.

“If you look at American history, many times many important reforms can be sought and achieved at the same time and that’s what we’re hoping for,” Gaffney said.

The exchange came during The Forum at Harvard T.H. Chan School of Public Health. The webcast, “The Future of National Health Insurance: Debates During a U.S. Presidential Election Year,” also featured Robert Blendon, professor of health policy and political analysis at the Chan School; Sara Collins, vice president of health care coverage and access for The Commonwealth Fund; and Phil Ellis, president of Ellis Health Policy Inc. and former analyst, adviser, and deputy assistant director at the Congressional Budget Office.

McDonough reminded the panel what happened to Democrats the last two times they took on health care. The party has won the coveted “trifecta” of the House, Senate, and White House just twice in the last 40 years. The first was during the first two years of the Clinton presidency and the second was during the first two years of the Obama presidency. Both times, he said, health-care restructuring topped the agenda — unsuccessfully for Clinton and successfully for Obama. And both times Democrats lost control of Congress in the midterm election.

“Each of them made heath reform their signal, main issue, and very little else happened,” McDonough said. “I think we have to be pragmatic … because the consequences are severe, not just for health but for everything else we care about.”

He also said that even under Democrats’ most favorable election scenario, mustering the votes for Medicare for All or another single-payer national health plan is unlikely, because a Democratic Senate majority, if achieved, is unlikely to approach the 60 votes needed to forestall a Republican filibuster.

National polls show that voters care deeply about health care and Democratic presidential candidates have made the issue central to their campaigns. But Blendon cautioned that a closer look at polling responses shows that Democrats and the general public aren’t necessarily talking about the same thing. While Democrats are dedicated to making the health-care system more efficient overall, the public is more narrowly focused on personal costs, such as co-pays and other out-of-pocket expenses. They’re skeptical that they’ll see savings from any plan aimed at system-wide efficiencies.

Polls show Americans clearly split between keeping and tweaking the Affordable Care Act, scrapping the current system in favor of Medicare for All or other similar national health insurance, or Republican-sponsored changes that would reduce federal mandates and devolve more power to the states.

That split, Blendon said, shows that despite years of debate so far, the discussion about health care isn’t close to finished.

“This is what polarized looks like,” Blendon said.

Demographically, Blendon said, some changes are likely over the next 10 years. The wing of the Democratic Party that is most disaffected with today’s institutions and most willing to scrap the current health-care system is also its youngest, which means that support for fundamental change is likely to grow over the next decade.

Despite differing outlooks, panelists agreed that further action on health care is needed. Currently 27 million to 30 million Americans are uninsured, and another 44 million are underinsured, with high co-pays and out-of-pocket expenses. Though the ACA brought the nation’s uninsured below 9 percent for the first time, other developed countries have rates between 0 and 1 percent.

“That’s not nearly good enough. That’s important to keep in mind,” McDonough said of U. S. progress.

Recent studies show that Medicare for All may save money, Gaffney said. The U.S. spends $812 billion annually just for administration of its health-care system, twice what Canada pays. That indicates that even if the cost of care itself doesn’t change under Medicare for All, there may be administrative savings.

Panelists said it is difficult to predict the impact of a Trump reelection on health care, but the general trend of Republican action has been to make health insurance cheaper by reducing coverage and relaxing mandates that insurers cover preexisting conditions. If insurers are again allowed to refuse those with preexisting conditions, Ellis said it’s likely that markets would be split between healthy people paying lower premiums and the sick, who may be forced into high-risk pools with higher premiums. McDonough said it’s also likely we’d see a continued rise in the number of uninsured, whose ranks have risen by 2 million in recent years.

https://news.harvard.edu…

Forum – Harvard T.H. Chan School of Public Health, “The Future of National Health Insurance” – 1 hour video:
https://theforum.sph.harvard.edu…

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Comment:

By Don McCanne, M.D.

Clearly the single payer model of Medicare for All is vastly superior to other models of reform under consideration. It would provide all essential health care services to everyone at a cost close to that of our current highly dysfunctional financing system, while ensuring affordability for each individual by implementing equitable tax policies.

But the public is more concerned about their individual costs. They are concerned about the high cost of drugs, about high deductibles, about surprise medical bills, and about high insurance premiums if they are not covered by employer-sponsored plans. They want to see these issues addressed directly, though they are divided between whether the best way would be through expansion of the Affordable Care Act perhaps with a Medicare for All public option added, or if they would prefer more flexibility in private insurance products and in the health care marketplace.

Polls currently show that the nation is fairly evenly split in support of these three options. The neoliberals have apparently decided that we should improve ACA by adding a public option, and then try to bring the single payer supporters into their camp. The conservatives are still floundering with their efforts to patch together market solutions that simply won’t work for most individuals.

The polls are partly responsible for this effort to perpetuate ACA with a public option added. Opponents of single payer have been trying to convince the public that they should have the right to keep their private plans. Since most of those plans are employer-sponsored, beneficiaries believe that their personal costs will be less since they generally do not see the portion of the premium paid by the employer and they are quite unaware of tax expenditures for the deductibility of the plans for which we taxpayers are responsible. They contrast that with the prospect of paying for Medicare for everyone through a massive increase in their Medicare payroll taxes, or the equivalent in income taxes, or whatever, not considering that they would be equitable, progressive taxes

Since we really can’t improve on the single payer Medicare for All model, we should not use the poll results to compromise the single payer policies just to preserve choice of private plans. Instead we should use the poll results to show how single payer much more effectively addresses the individual concerns that the public actually has – controlling drug costs, eliminating surprise bills, eliminating insurance premiums and deductibles, eliminating provider networks that take away their choices of physicians and hospitals, and ensuring that they would be covered for life. Right now the opponents of single payer Medicare for All are using the polls as a deterrence by threatening loss of choice of private health plans.

Polling expert Robert Blendon: “For the average voter, they want to vote for someone who will deal with medical bills… This is a meat and potatoes issue for the average person not voting in the Democratic primary – ‘I want to see something done about these insulin costs, etc., etc.’.. And that’s what scares them about Medicare for All. If you could just talk about – ‘I’ll pay less next year’… But when you get into the trillions, people can’t deal with it – People say ‘I don’t know what a trillion is, but at the end of the day I’m going to be paying more.’ In reality if you can say your fees will go down, your delivery costs will go down, your drug costs will go down, that would be a debate the others would like to have, but that is lost in the aggregate numbers.”

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By Christopher Cai, Jackson Runte, Isabel Ostrer, Kacey Berry, Ninez Ponce, Michael Rodriguez, Stefano Bertozzi, Justin S. White, James G. Kahn
PLOS Medicine, January 15, 2020

Abstract

Background: The United States is the only high-income nation without universal, government-funded or -mandated health insurance employing a unified payment system. The US multi-payer system leaves residents uninsured or underinsured, despite overall healthcare costs far above other nations. Single-payer (often referred to as Medicare for All), a proposed policy solution since 1990, is receiving renewed press attention and popular support. Our review seeks to assess the projected cost impact of a single-payer approach.

Methods and findings: We conducted our literature search between June 1 and December 31, 2018, without start date restriction for included studies. We surveyed an expert panel and searched PubMed, Google, Google Scholar, and preexisting lists for formal economic studies of the projected costs of single-payer plans for the US or for individual states. Reviewer pairs extracted data on methods and findings using a template. We quantified changes in total costs standardized to percentage of contemporaneous healthcare spending. Additionally, we quantified cost changes by subtype, such as costs due to increased healthcare utilization and savings due to simplified payment administration, lower drug costs, and other factors. We further examined how modeling assumptions affected results. Our search yielded economic analyses of the cost of 22 single-payer plans over the past 30 years. Exclusions were due to inadequate technical data or assuming a substantial ongoing role for private insurers. We found that 19 (86%) of the analyses predicted net savings (median net result was a savings of 3.46% of total costs) in the first year of program operation and 20 (91%) predicted savings over several years; anticipated growth rates would result in long-term net savings for all plans. The largest source of savings was simplified payment administration (median 8.8%), and the best predictors of net savings were the magnitude of utilization increase, and savings on administration and drug costs (R2 of 0.035, 0.43, and 0.62, respectively). Only drug cost savings remained significant in multivariate analysis. Included studies were heterogeneous in methods, which precluded us from conducting a formal meta-analysis.

Conclusions: In this systematic review, we found a high degree of analytic consensus for the fiscal feasibility of a single-payer approach in the US. Actual costs will depend on plan features and implementation. Future research should refine estimates of the effects of coverage expansion on utilization, evaluate provider administrative costs in varied existing single-payer systems, analyze implementation options, and evaluate US-based single-payer programs, as available.

What do these findings mean?

• There is near-consensus in these analyses that single-payer would reduce health expenditures while providing high-quality insurance to all US residents.
• To achieve net savings, single-payer plans rely on simplified billing and negotiated drug price reductions, as well as global budgets to control spending growth over time.

https://doi.org… OR https://journals.plos.org…

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Single Payer Systems Likely to Save Money in U.S., Analysis Finds; Lower administrative and drug costs would be main drivers of cost savings

The University of California, San Francisco (UCSF), January 15, 2020

A single payer healthcare system would save money over time, likely even during the first year of operation, according to nearly two dozen analyses of national and statewide single payer proposals made over the past 30 years.

The study, published Wednesday, Jan. 15, 2020, in PLOS Medicine, comes as California Gov. Gavin Newsom has created a state commission to find ways to achieve universal coverage, possibly through a single payer system, and as the Democratic presidential candidates are debating “Medicare for All” proposals on the national stage.

The US spends more on healthcare than any other country, yet is one of only a few developed nations that does not provide universal coverage. Under proposed single payer bills, such as “Medicare for All”, a unified public financing system would replace private insurance, similar to the healthcare system in Canada and many other wealthy nations.

To estimate what would happen if the United States adopted a single payer system, researchers from UCSF, UCLA and UC Berkeley examined 22 economic analyses by government, business and academic organizations of national and state-level single payer plans, including proposals made in Massachusetts, California, Maryland, Vermont, Minnesota, Pennsylvania, New York and Oregon.

These analyses were used by policy makers to evaluate the proposals, estimating savings the plans would create through simplified billing and lower drug costs while also taking into account increases in health spending that would arise as newly insured people sought healthcare.

The researchers found that 19 of the 22 models predicted net savings in the first year after implementation, averaging 3.5 percent of total healthcare spending.

The researchers were able to estimate longer-term savings by using cost projections made in 10 of the models, which looked as far as 11 years into the future. These studies assumed that savings would grow over time, as the increases in healthcare utilization by the newly insured leveled off, and the global budgets adopted by single payer systems helped to constrain costs. By the tenth year, all modeled single payer systems would save money, even those that projected costs would initially increase.

“Even though they start with different single designs and modeling assumptions, the vast majority of these studies all come to the same conclusion,” said James G. Kahn, MD, MPH, a professor in the UCSF Department of Epidemiology and Biostatistics, and a member of the Philip R. Lee Health Policy Institute. “This suggests that fears that a single-payer system would increase costs are likely misplaced.”

Savings from simplified payment administration and reductions in drug prices and other efficiencies ranged from 3 to 27 percent, with the largest savings found in plans that lowered drug costs.

Higher initial costs were associated with plans that had low co-pays or none at all, offered rich benefits, or that did not expect savings from lower drug and medical equipment costs.

The models were created by analysts from different political perspectives, and they provided a range of cost estimates in the first year of operation, from 7 percent higher to 15 percent lower.

The researchers found that the economic models that were supported by left-leaning funders or that were done by academics found slightly larger net savings. But analyses supported by more conservative funders or performed outside of academia still predicted single payer systems would yield savings.

“This means that across the political spectrum, there is near consensus among these economists that a single-payer system would save money,” said Christopher Cai, a third-year medical student at UCSF and the study’s first author. “Replacing private insurance with a public system is essential to achieving these savings.”

Authors: Christopher Cai, Jackson Runte, Isabel Ostrer, Kacey Berry, Justin White, PhD, and James G. Kahn, MD, MPH, of the UCSF School of Medicine; Ninez Ponce, PhD, MPP, of the UCLA Fielding School of Public Health; Michael Rodriguez, MD, MPH, of the David Geffen School of Medicine at UCLA; Stefano Bertozzi, MD, PhD, of the UC Berkley School of Public Health.

https://www.ucsf.edu…

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Comment:

By Don McCanne, M.D.

What does the literature on modeling of single payer financing of health care tell us? As this systematic review confirms, “There is near-consensus in these analyses that single-payer would reduce health expenditures while providing high-quality insurance to all US residents.”

All models that qualified for the study would reduce health care spending after the transitional startup, and most of them would reduce spending even during the startup interval. Clearly the single payer model would work for all of us, and it would be more affordable than if we maintained the deficient status quo.

PLOS Medicine is an Open Access publication and thus there is no paywall for downloading this 18 page report. You should do so and share it widely so that other academics and activists can use it to refute the false claim that we cannot afford single payer Medicare for All. We can, and we must.

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