By Henry A. Waxman
Health Affairs Blog, October 4, 2019

As Americans, we like to think of ourselves as number one in everything, but in some cases — health care costs prime among them — it’s a dubious distinction. The fact that we spend twice as much on health care as the average for wealthy industrialized countries while having the lowest life expectancy and the highest infant mortality rates is a national disgrace.

While fixing this toxic combination of skyrocketing costs and poor health outcomes is complicated to say the least, there is one simple, common sense solution to a big part of the problem that can be achieved right now. All it takes is a small dose of political courage.

That step is to lower drug costs now by empowering Medicare to negotiate prices with the pharmaceutical industry. This is exactly what H.R. 3 — the Lower Drug Costs Now Act, introduced by House Committee Chairmen Pallone, Neal, and Scott — will achieve.

Skyrocketing Prices

Currently, U.S. drug prices are, on average, 3.7 times higher than the combined average of 11 other similar countries, according to a just-released study of 79 single-source brand-name drugs by the House Ways & Means Committee. In some cases, individual drug prices were an astounding 67 times higher. And they keep rising at unprecedented speed. The list prices for more than 3,400 drugs increased by 17 percent from July 2018 to July 2019, and from 2011 to 2016, prescription drug spending in the U.S. grew at 2.5 times the inflation rate. It’s especially disturbing that insulin costs per patient, taking into account prices and cost-sharing, nearly doubled from 2012 to 2016.

Why do these appalling price disparities exist? The primary reason is that every other industrialized country negotiates drug prices with the pharmaceutical industry, using their purchasing power to save taxpayer and consumer dollars. The drug companies, by their own admission, still earn profits in these countries — just not exorbitant windfalls. There is no logical reason why current law prohibits Medicare from doing the same.

In fact, the Veterans Health Administration and the U.S. Department of Defense’s TRICARE program both negotiate the price of drugs — and they pay much less than Medicare Part B and Part D, too.

Savings From Negotiation

Passing the Lower Drug Costs Now Act will save the federal government at least $100 billion over 10 years. That’s based on the amount the Congressional Budget Office (CBO) estimates would be saved by a similar but weaker drug pricing bill, introduced by Senate Finance Committee Chairman Charles Grassley (R-Iowa), that has many of the same provisions as H.R. 3. Like H.R. 3, for example, the Senate bill includes a cap on out-of-pocket costs. However, unlike H.R. 3, the Senate Bill leaves out Medicare negotiation.

In fact, H.R. 3 will likely save far more as a result of including negotiation. The bill creates a maximum fair price for any negotiated drug based on an average international market price index to ensure that Americans don’t pay more than the residents of other countries. The House Ways & Means Committee found that the U.S. could save $49 billion annually on Medicare Part D alone by using average drug prices for other countries.

The savings will go far beyond savings to the federal budget and taxpayers. There is a provision in the bill that requires manufacturers to offer the negotiated price to group health plans and health insurance issuers as well. So all Americans, including those with private insurance, will save money because they will pay the Medicare-negotiated prices.

The Lower Drug Costs Now Act will also help Medicare enrollees directly by creating a new, $2,000 out-of-pocket limit on their prescription drug costs, assuring financial protection that seniors currently are not guaranteed in the program. Furthermore, some of the bill’s savings will be reinvested in innovation and the search for new breakthrough treatments and cures at the National Institutes of Health (NIH).

The pharmaceutical industry claims this legislation creates an obstacle or disincentive to bringing new, life-saving medicines to market. In fact, the industry itself spends more on advertising, marketing and stock buybacks than they it does on research and development. Drug manufacturers also benefit enormously from taxpayer-funded research, yet still get to pocket the profits themselves. Notably, NIH funding contributed to research associated with every one of the 210 new drugs approved between 2010 and 2016. Moreover, H.R. 3’s use of the savings from lower drug prices to increase NIH’s research budget will arguably accelerate the development of innovative, life-saving drugs.

Building On Decades Of Progress

Passage of this legislation would mean a lot to me personally, as well. Over the course of my 40 years in Congress, I worked painstakingly to hold down prescription drug costs while creating incentives to encourage innovation. I was able to sponsor several pieces of legislation — the Hatch-Waxman Act, the Orphan Drug Act and the Affordable Care Act in particular — that increased access to prescription drugs for millions of Americans while balancing drug innovation with price competition. The Lower Drug Costs Now Act would take these gains a vital step further.

Unlike most issues in Washington, D.C., this has bipartisan support and the potential for achieving positive change. President Trump has long called for lowering prescription drug costs, even citing Medicare negotiation, and has indicated his willingness to support such legislation. While Big Pharma will furiously lobby to defeat these bills, when you have the speaker of the House and the president on the same side, there is no excuse for inaction.

There is simply no acceptable explanation for the fact that Americans spend seven times what the Japanese pay for prescription drugs. No reason why Americans pay nearly five times more for Humira, the best-selling prescription drug in the world, than the residents of other industrialized countries. The pharmaceutical marketplace in the U.S. is broken when it comes to brand-name drugs with long monopoly protection and it’s time we fix it.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

People are dying because of the exorbitant cost of drugs in the United States. Expanding the federal government’s ability to negotiate drug prices, as H.R. 3 would do, would make drugs more affordable for patients and taxpayers, and, more importantly, it would also reduce suffering and save lives.

Although many of us are generally opposed to incrementalism in health care reform – taking tiny steps that will never reach health care nirvana – addressing prescription drug costs should be considered an exception. In spite of our current highly dysfunctional government, passing this legislation now should be achievable, and in no way should it reduce our passion for and our efforts to enact and implement a program of health care justice for all.

Although only an incremental step, enabling our government to negotiate drug prices is an important step forward. We should do that immediately and then intensify our efforts on changing the political climate to make way for single payer Medicare for All.

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

By Annie Karni and Abby Goodnough
The New York Times, October 3, 2019, Updated 2:38 p.m. ET

President Trump is expected to unveil a new executive order on Thursday afternoon that calls for expanding the benefits offered by private Medicare plans, framing the decision as the responsible alternative to the “Medicare-for-All” policies supported by some of his Democratic political opponents.

The executive order, originally called “Protecting Medicare from Socialist Destruction,” was renamed “Protecting and Improving Medicare for our Nation’s Seniors” ahead of Mr. Trump’s speech.

Joe Grogan, the director of the White House Domestic Policy Council, said that the goal was to contrast what he said was the administration’s commitment to protecting seniors with “the vision for Medicare as a one-size-fits-all, single-payer system” supported by many Democratic candidates. He said the plan offered by Democrats would destroy health benefits for seniors who had paid into this program for their entire lives.

“Medicare for all is Medicare for none,” added Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, who has been a vocal critic not just of the Democrats’ proposals, but also of the Affordable Care Act. “Proposals like Medicare for All, as well as the public option, they are morally wrong because they would demote American seniors to second-class status.”

Mr. Trump has repeatedly promised to unveil a new health care plan; instead he has issued a series of executive orders and proposed rules to counter Democratic health care proposals for expanding coverage.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Sorry. Today’s message was to have been on President Trump’s executive order on “Protecting Medicare from Socialist Destruction,” though they changed the name to “Protecting and Improving Medicare for our Nation’s Seniors.” I listened to Trump’s uninformative harangue before he signed the executive order, but they have not released it yet.

Wait! Hold the presses! The White House just released the following Fact Sheet:

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President Donald J. Trump’s Healthcare Agenda Puts Seniors and American Patients First

The White House, October 3, 2019

“We will not rest until Americans have the healthcare system they need and deserve, a system that finally puts American patients first.” – President Donald J. Trump

PUTTING AMERICAN PATIENTS FIRST: Since the beginning of his Administration, President Trump has put patients first so every American has the highest quality of healthcare in the world.

• Making healthcare more affordable by lowering out of control prescription drug prices and making new affordable healthcare options available.
• Putting patients in control of their healthcare by finally providing transparency and choice so every American can choose the care that fits their needs.
• Unleashing American innovation to provide new treatment options for patients living with disease.

PUTTING AMERICAN SENIORS FIRST: President Trump is taking action to protect and improve the Medicare system for America’s seniors.

• President Trump is signing a new Executive Order to improve seniors’ healthcare and improve the fiscal sustainability of Medicare. The order will advance policies that:
  • Empower patients by giving them more plan choices, more access to telehealth and new therapies, and more time with providers.
  • Streamline the approval of therapies, while reducing obstacles to improved patient care.
  • Improve quality by implementing reforms that better link payments to value.
  • Protect beneficiaries by eliminating waste, fraud, and abuse.
  • Maximize freedom for Medicare patients and providers by reducing regulatory burdens and eliminating unnecessary barriers.
• President Trump is putting seniors first by strengthening the Medicare system and helping ensure the program’s availability for years to come.
  • Medicare-for-All bills proposed by Democrats in Congress threaten to end the Medicare program as we know it and eliminate choice for America’s seniors.
  • Seniors are overwhelmingly satisfied with their Medicare coverage and President Trump will stand up to protect it.
• This order will improve the ability of seniors to make choices about their insurance, helping them access the best healthcare providers and the latest innovative therapies.

PROTECTING VULNERABLE AMERICANS: President Trump is committed to protecting vulnerable American patients and families.

• The President has reaffirmed that protecting Americans with preexisting conditions is fundamental to his healthcare agenda.
• President Trump is committed to ending surprise billing so no American is ever blindsided by medical bills for services they never agreed to.
  • The President has put forward principles on surprise billing to ensure patients are not taken advantage of and have the information they need to make informed decisions.
  • More than two-thirds of Americans worry about unexpected medical bills, according to a 2018 poll by the Kaiser Family Foundation.

PROVIDING AFFORDABLE OPTIONS: By lowering costs, President Trump is making sure every American can afford high quality healthcare.

• Last year, President Trump released a historic blueprint to drive down drug prices.
• Medicare Advantage premiums will drop next year to their lowest level since 2007, a 28 percent decrease since 2017.
• Medicare Part D premiums next year will be their lowest in the last 7 years.
• Prescription drug prices fell in 2018 for the first year in nearly five decades.
• The Food and Drug Administration approved a record number of generic drugs in 2017 and 2018 that will improve competition and drive down prices.
  • New generic drug approvals saved consumers $26 billion through the first year and a half of President Trump’s Administration.
• The Trump Administration laid the foundation to start importing certain prescription drugs that are cheaper in other countries.

PUTTING PATIENTS IN CONTROL: President Trump is making sure patients control their own healthcare by empowering them to make informed decisions and giving them more choices.

• The number of Medicare Advantage plans available to our seniors has increased by nearly 1,200 over the last two years.
• President Trump is working to expand Association Health Plans, which make it easier for employers to join together and offer more affordable health coverage to their employees.
• Through Health Reimbursement Arrangements, employers will be able to help their employees pay for the cost of insurance that they select in the individual market.
• The Administration expanded the availability of short-term, limited duration plans, which offer flexible coverage options and can be up to 60 percent cheaper than Obamacare plans.
• President Trump is working to ensure hospitals cannot hide prices for their services, requiring them to publicize more data and put quality and price information into patients’ hands.
• The President signed legislation ending “gag” clauses that prevented pharmacists from providing patients with information about lower cost options.
• President Trump signed legislation ending Obamacare’s individual mandate penalty, which forced many Americans to buy health plans they did not want.
• The Trump Administration is working to provide electronic health records to patients by requiring providers to give patients their data.

ENSURING HIGH QUALITY CARE: President Trump is working to promote innovative solutions and expand treatment options for Americans living with disease.

• President Trump launched an effort to improve kidney health and treatment in America, giving hope to the over 30 million Americans afflicted with kidney disease.
• The Administration has significantly increased funding for opioid and pain research and is supporting research for a vaccine to prevent opioid addiction.
  • Drug overdose deaths declined nationally last year for the first time in decades.
• President Trump signed into law $1 billion in increased Alzheimer’s research funding, reflecting his commitment to finding a cure.
• The Trump Administration is working to encourage new, innovative approaches to treating childhood cancer.
• President Trump signed Right to Try legislation to give terminally ill patients the ability to access potentially lifesaving cures.
• The President launched an initiative to eliminate the HIV epidemic in the United States within 10 years.

https://www.whitehouse.gov…

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Further comment:

By Don McCanne, M.D.

We waited for this? Now I’m really sorry.

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Addendum:

By Don McCanne, M.D.

This is the link to President Trump’s “Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors” – the subject of today’s Quote of the Day:

By Alan Rappeport and Thomas Kaplan
The New York Times, October 1, 2019

Progressive Democrats are advocating the most drastic shift in tax policy in over a century as they look to redistribute wealth and chip away at the economic power of the superrich with new taxes that could fundamentally reshape the United States economy.

As they compete for the Democratic presidential nomination, Senators Elizabeth Warren of Massachusetts and Bernie Sanders of Vermont have proposed wealth taxes that would shrink the fortunes of the richest Americans. Their plans envision an enormous transfer of money from the wealthy to ordinary people, with revenue from the wealth tax used to finance new social programs like tuition-free college, universal child care and “Medicare for all.”

Income inequality has surged in the United States in the last 50 years, with the top 0.1 percent now controlling about a fifth of the nation’s wealth. That concentration of wealth has coincided with stagnant wages, rising college costs and the lingering effects of the Great Recession, which erased trillions of dollars in household wealth, ravaging the middle class. New figures from the Census Bureau released last week show that income inequality in the United States reached its highest level last year since the government began tracking it in 1967.

Polls have found widespread support for the idea of taxing wealth. A poll conducted for The New York Times by the internet research firm SurveyMonkey this summer found that two-thirds of Americans, including a majority of Republicans, backed a 2 percent tax on households worth over $50 million, which is the heart of Ms. Warren’s plan.

The tax proposed by Ms. Warren would apply to households worth over $50 million. She would impose a 2 percent tax on net worth above $50 million, and a 3 percent tax on net worth above $1 billion.

The plan from Mr. Sanders would apply to a larger number of households, and it would be particularly aggressive on billionaires. His tax would start out at 1 percent on net worth from $32 million to $50 million for married couples, and it would top out at 8 percent on net worth over $10 billion.

Emmanuel Saez and Gabriel Zucman, the two University of California, Berkeley, economists who helped Ms. Warren and Mr. Sanders develop their plans, project that Ms. Warren’s proposal would hit about 70,000 households and generate $2.6 trillion in revenue for the federal government over a decade. They project that Mr. Sanders’s proposal would apply to 180,000 households and raise $4.35 trillion over 10 years.

Mr. Zucman said in an interview that he believes a wealth tax would have a modest but positive impact on growth. By reducing the power of the wealthiest, he argued, it would make markets more competitive and spur innovation.

https://www.nytimes.com…

Comparison of the Warren and Sanders wealth tax proposals, by Emmanuel Saez and Gabriel Zucman, University of California, Berkeley:
http://gabriel-zucman.eu…

“Progressive wealth taxation” by Emmanuel Saez and Gabriel Zucman, Brookings Papers on Economic Activity:
https://www.brookings.edu…

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Comment:

By Don McCanne, M.D.

In the discussions of the single payer model of Medicare for All you frequently hear, “How are we going to pay for it?” – almost as if it is an unanswerable question. Well, the short answer is that our current national health expenditures are already enough to pay for such a system – comprehensive health care for everyone.

What is not working is the distribution of payments into the system. For perspective, annual premiums for employer-sponsored family health insurance are now over $20,000 whereas median household income is about $62,000. Clearly the typical family cannot afford to pay an equally allocated share of our nation’s health expenditures. Yet the money is there; it’s just that it has been distributed upwards with stagnant incomes for most of us and rapidly rising income and wealth for those at the top.

The work of Piketty, Saez and Zucman has shown that equitable financing of government functions can no longer depend on progressive income taxes alone, but now must include progressive wealth taxes, but without the need to tax the first tens of millions of personal wealth. It is difficult to be sympathetic towards the billionaire who would pay no wealth taxes on the first 30 to 50 million dollars of wealth and with progressive tax rates not exceeding a single digit on the remaining wealth. Since the productivity gains of the workers have flowed mostly to the top, along with the economy’s rents, progressive wealth taxes are essential if we are to return to the people some of these superabundant surpluses of the plutocrats. No plutocrat will be deprived of an evening aperitif or other favored indulgences.

Besides progressive income taxes and progressive wealth taxes, there are other equitable sources of revenues that could be used to help fund Medicare for All. An example is a Tobin tax on equity trades, taxing the gamblers who trade frequently, often with large profits that may have a negative impact on individual 401(k) and IRA retirement accounts. Basically these various equitable – fair – revenues would be used to fund a universal, national risk pool that would make health care affordable for everyone.

Some in the single-payer movement have even been reluctant to use the word “tax.” That’s wrong. It is equitable taxes that would make health care affordable for absolutely everyone. Why should you try to dodge that?

PNHP does not support any political party nor their candidates for office.

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

By Jordan Rau
Kaiser Health News, October 1, 2019

Medicare cut payments to 2,583 hospitals Tuesday, continuing the Affordable Care Act’s eight-year campaign to financially pressure hospitals into reducing the number of patients who return for a second stay within a month.

The severity and broad application of the penalties, which Medicare estimates will cost hospitals $563 million over a year, follows the trend of the past few years. Of the 3,129 general hospitals evaluated in the Hospital Readmission Reduction Program, 83% received a penalty, which will be deducted from each payment for a Medicare patient stay over the fiscal year that begins today.

These figures do not include 2,142 hospitals that Medicare exempted from the program this year, either because they had too few cases to judge; were veterans hospitals, children’s hospitals, psychiatric hospitals or were critical-access hospitals, which are the only hospitals within reach of some patients.

The hospital industry and some academics have raised concerns that some hospitals may be avoiding readmitting patients who require additional inpatient care out of fear of the financial repercussions, while others have said the program is not showing major benefits.

A few studies have even found an increase in mortality since the penalties took effect, but other studies, including a recent one by the Medicare Payment Advisory Commission (MedPAC), an independent body that helped devise the approach for Congress, identified no such link.

The MedPAC staff’s preliminary analysis, made public last month, found that the frequency of Medicare patients being readmitted within 30 days of discharge dropped from 16.7% in 2010 to 15.7% in 2017.

The penalties are based on the frequency of readmissions of Medicare patients who had originally been treated for heart failure, heart attack, pneumonia, chronic lung disease, hip and knee replacement or coronary artery bypass graft surgery.

“This is like driving your car by looking in the rearview mirror of the car three cars behind you,” Dr. Jonathan Perlin, the chief medical officer of HCA Healthcare in Nashville and a MedPAC commission member, said at last month’s meeting. “It’s very difficult to operationalize.”

Akin Demehin, director of policy at the American Hospital Association, said: “It raises the question: Is the value of the program to improve care or just to enact penalties on hospitals?”

https://khn.org…

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Comment:

By Don McCanne, M.D.

The Medicare Hospital Readmission Program is a penalty program, not a rewards program. It assumes that patients are readmitted after a recent hospitalization because of errors or omissions on the part of the hospitals, and thus the hospitals should be punished. But these are patients who were treated for heart failure, heart attack, pneumonia, chronic lung disease, hip and knee replacement or coronary artery bypass graft surgery. These are disorders that have a high rate of complications or protracted courses and thus would be expected to have a high rate of need for readmission even though given optimal care and followup.

And think about this. Most (83%) of the hospitals evaluated under the program can look forward to a year, and likely many years, when they provide exemplary care for most of their patients and yet they will be financially penalized for each patient for whom they provide care, regardless of how great that care is. That should certainly contribute to the epidemic of burnout.

This program is a dud and should be abandoned if for no other reason than it is a distraction from the need to advance reform that would be greatly beneficial to patients: enactment and implementation of Single Payer Medicare for All. Instead of playing around with gaming through penalties, let’s direct all of our attention to caring for the patients. That’s really what it’s all about.

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

By Rebecca Mary Myerson, Reginald Tucker-Seeley, Dana Goldman, and Darius N. Lakdawalla
National Bureau of Economic Research, September 2019

Abstract

Medicare is the largest government insurance program in the United States, providing coverage for over 60 million people in 2018. This paper analyzes the effects of Medicare insurance on health for a group of people in urgent need of medical care – people with cancer. We used a regression discontinuity design to assess impacts of near-universal Medicare insurance at age 65 on cancer detection and outcomes, using population-based cancer registries and vital statistics data. Our analysis focused on the three tumor sites with recommended screening before and after age 65: breast, colorectal, and lung cancer. At age 65, cancer detection increased by 72 per 100,000 population among women and 33 per 100,000 population among men; cancer mortality also decreased by 9 per 100,000 population for women but did not significantly change for men. In a placebo check, we found no comparable changes at age 65 in Canada. This study provides the first evidence to our knowledge that near-universal access to Medicare at age 65 is associated with improvements in population-level cancer mortality, and provides new evidence on the differences in the impact of health insurance by gender.

From Comparison with the literature

Medicare beneficiaries can choose to receive their benefits via traditional Medicare (the publicly administered Medicare plan) or Medicare Advantage (a Medicare plan paid for by the federal government but administered by a private company). After a cancer diagnosis, patients become less likely to leave traditional Medicare for a private Medicare Advantage plan, and become more likely to switch from a private Medicare Advantage plan to traditional Medicare.

We are not aware of any prior study of the effect of Medicare coverage on population-level cancer mortality. The most closely related study to ours focused on the impact of Medicare on post-detection survival, a different outcome from the one we study, using data from a different time period.

Importantly, the outcome of survival after cancer detection employed in these prior studies may be subject to diagnosis bias. Diagnosis bias includes lead and length time bias, which can be explained as follows. First, when people are diagnosed with cancer earlier, they may appear to survive longer after detection simply due to becoming classified as a cancer patient earlier – i.e., “lead-time bias.” Second, the additional tumors detected might be so slow-growing that they would never have killed the patient if left undetected, resulting in overdiagnosis and overtreatment – i.e., “length bias.”

For both these reasons, expansions in cancer detection may improve post-diagnosis survival even when they do not actually improve health or save lives.

As a result, analyzing population-level disease-specific mortality rates is considered a best practice to eliminate diagnosis bias.

Prior studies of the impacts of Medicare rarely stratified the data by gender except when studying gender-specific health care such as mammography. Yet, it is plausible that gender could play an important role in determining the impact of insurance on health. Several studies have found women to be more likely than men to use preventive health care, and less likely than men to delay seeking needed health care. Gaps by gender in socio-economic resources could also play a role, as the impact of Medicare could be larger among patients with less-generous prior insurance coverage and fewer financial resources.

From the Discussion

Insurance coverage rose to 97% at age 65, the age of near-universal eligibility for Medicare. This nearly universal Medicare coverage increased cancer detection by 50 per 100,000 population, a 10% increase compared to people aged 63-64; the majority of additional cancers detected were early-stage cancer. These findings are important for population health because prompt detection improves health for the tumor sites we study here, according to systematic reviews by the United States Preventive Services Task Force.

In vital statistics data, we found that cancer mortality increased by less than expected among women at age 65 by 9 per 100,000 population. The lack of significance among men is consistent with the magnitudes and standard errors we estimated. The increases in cancer detection and early-stage cancer detection at age 65 among men were both less than half the magnitude of the increases at age 65 among women.

Our analysis captures a local average treatment effect of the effect of access to Medicare at age 65, i.e., the effect of having access to Medicare compared to lacking access to Medicare at age 65. Given that access to Medicare is nearly universal at age 65 but severely limited prior to age 65, a research design such as ours which compares a “treated” group aged 65 and older to an “untreated” group younger than 65 has been deemed appropriate in closely related studies. While access to Medicare may be particularly beneficial for the previously uninsured, the previously insured also benefit. Within a few weeks of becoming eligible for Medicare, there is a sharp increase in the proportion of people with multiple forms of coverage, and the proportion of people with only managed care is reduced by half. Thus, Medicare provides the already-insured with access to more generous coverage and a broad network of providers. Generosity of coverage and network breadth are particularly important for cancer patients, who require costly specialty care.

In conclusion, access to Medicare insurance was associated with a significant increase in detection of cancers with recommended screening, as well a decline in mortality from these cancers among women. Our estimates provide new evidence of Medicare’s impact on health outcomes for people in need of medical care.

https://www.nber.org…

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Comment:

By Don McCanne, M.D.

This study of breast, colorectal and lung cancers demonstrated that enrollment in Medicare at age 65 is associated with a significant increase in detection of these cancers with recommended screening, as well as a decline in mortality from these cancers among women. Although mortality did not improve in males, there are other benefits of having coverage through Medicare: for instance, health care can improve quality of life in the presence of other infirmities and through preventive measures, and Medicare can reduce financial hardship caused by medical bills.

One interesting observation is that, when diagnosed with cancer, patients become less likely to leave traditional Medicare for a private Medicare Advantage plan, and become more likely to switch from a private Medicare Advantage plan to traditional Medicare. That should make us wonder why we taxpayers are paying more for the private Medicare Advantage plans and why so many politicians and bureaucrats are trying to push us into those programs, especially when most people want more choices, not less, in the experts and institutions that care for cancer patients.

The main point of today’s message is that Medicare for All is the right choice for reform. People do better after they are on Medicare than they did under our existing, fragmented multipayer system. Further, the single payer model of Medicare for All provides better health care benefits and greater financial protection than does the current Medicare program.

How can people say that they want to keep the plans that aren’t working as well? Don’t they understand what Medicare is all about, and, more importantly, what it could be?

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

By Sara R. Collins and Munira Z. Gunja
The Commonwealth Fund, September 2019

Replacing private insurance with public insurance like Medicare does not have strong support, but many need more information.

Q: Would you favor or oppose eliminating all private health insurance and making public insurance like Medicare the ONLY health insurance option for everyone, or do you not know enough about this to say?

All
27% – Strongly/somewhat favor
32% – Strongly/somewhat oppose
40% – Don’t know enough to say

Republican
12% – Strongly/somewhat favor
60% – Strongly/somewhat oppose
27% – Don’t know enough to say

Democrat
43% – Strongly/somewhat favor
15% – Strongly/somewhat oppose
41% – Don’t know enough to say

Independent
27% – Strongly/somewhat favor
34% – Strongly/somewhat oppose
38% – Don’t know enough to say

From the Conclusion

Our survey indicates that much of the public currently needs more information before supporting a Medicare-for-all approach.

https://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

This survey question emphasized “eliminating all private health insurance” while making “public insurance like Medicare the ONLY health insurance option.” But the question is somewhat unique in that it also specifically asked if respondents did “not know enough about this to say.”

To no surprise, a significant number agreed that they did not know enough to say. Only Republicans had strong views, and they are opposed, although in my experience, Republicans are even less well informed on the single payer model of Medicare for All; they just don’t seem to know it. Their understanding is more in terms of libertarian ideology than it is in terms of actual health policy.

The important lesson is that we have to do a much better job in communicating the beneficial policy features of single payer Medicare for All. They want to hear how health care can be made more affordable, and we have the answers.

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

Kaiser Family Foundation, September 25, 2019

This annual survey of employers provides a detailed look at trends in employer-sponsored health coverage, including premiums, employee contributions, cost-sharing provisions, offer rates, wellness programs, and employer practices.

Annual premiums for employer sponsored family health coverage reached $20,576 this year, up 5% from last year, with workers on average paying $6,015 toward the cost of their coverage. The average deductible among covered workers in a plan with a general annual deductible is $1,655 for single coverage. Fifty-six percent of small firms and 99% of large firms offer health benefits to at least some of their workers, for an overall offer rate of 57%.

(An 8 page Summary of Findings and the full 234 page Report are available at the link below.)

Discussion

Trends in the market for employer-based coverage have been moderate for several years now. Premiums go up each year, but in the low to mid-single digits, which seems tame for those who remember the much higher increases in the early 2000’s and periods before. Cost sharing, particularly deductibles, has increased meaningfully over time, but the largest percentage increases were now a few years ago. New ideas and new approaches – things like narrow networks, value-based pricing, telemedicine, direct contracting – are tried and sometimes gradually implemented, but with modest impact on the basic structure of the market or the overall cost of coverage. Even though actual cost levels are quite high (the average family premium exceeds $20,000 for a family of four), an expanding economy and historically low underlying health care cost growth appear to have dampened any impatience for big changes, although predicted economic slowing over the next couple of years could push employers to consider more significant actions.

One thing that is new this year is the context: the public debate over expanding Medicare or creating public program options is raising questions about the performance of employer-based coverage that are rarely triggered when looking only at annual performance. In particular, those suggesting a bigger role for public programs raise issues about the cost and affordability of health care for the society overall and for individuals and families. Although premium growth has been low, it still exceeds inflation, and the prices employer plans pay for care are rising faster than either Medicare or Medicaid. One side of the coin calls this a cost shift from public plans to private payers; the other side suggests a lack of any real cost-control efforts in private plans. Negotiating lower prices means that plans have to be willing to tell higher-priced providers they cannot be in the network, but as the survey finding show, narrowing networks is both unpopular with employers and, due to dispersed workforces and rural challenges, impractical for many. Other than increasing cost-sharing, this is the most (and maybe only) powerful cost-reducing tool that private plans have, but it is rarely employed.

How to best assure affordable access to care for individuals and families is really the main theme in the debate about public plan options, and our polling suggests this issue raises important questions about the adequacy of employer-based plans. In a recent survey conducted by KFF and the LA Times, 40 percent of non-elderly adults with employer-based coverage said that they or a family member had difficulty affording health insurance or health care or had problems paying medical bills. Roughly one-in-two said that they or a family member had skipped or postponed getting health care or prescriptions in the past 12 months due to costs. Among those with employer-based coverage who say that someone under the plan has a chronic health condition, roughly three in five say they are confident that they have enough money or health insurance to afford the cost of a major illness; this percentage falls to just one-in-three for those in plans with the highest deductibles ($3,000 for single coverage; $5,000 or more for family coverage).

This survey shows other affordability issues as well, particularly for some identifiable groups. Covered workers in small firms face relatively high deductibles for single coverage and a meaningful share face substantial premium contributions if they choose family coverage. Covered workers in firms with large shares of lower-wage workers on average face higher deductibles for single coverage and must contribute a greater share of the premium for family coverage than workers in firms with a smaller share of lower-wage workers. When people talk about the 153 million people with employer-based coverage they often gloss over the very real cost differences for different groups of workers across the marketplace.

Regardless of its outcome, the national debate about expanding Medicare or creating public program options provides an opportunity to step back and evaluate how well employer-based coverage is doing in achieving national goals relating to costs and affordability. In doing so, it will be important to look past averages and examine how well the market serves the many different types of employers and working families in the many different circumstances that they face.

https://www.kff.org…

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Comment:

By Don McCanne, M.D.

This somewhat mundane report on employer-sponsored health plans is apt to be glossed over since it represents more of the same – that costs of the largest source of health insurance in the United States continue to increase. Some might celebrate the fact that increases in premiums have slowed to 5 percent this year, but that is still over twice the rate of inflation! Our most prized source of insurance (if you believe the media) has failed miserably in its quest to make health care affordable for individuals and families.

Health insurance premiums for a family of four now average over $20,000. Though a portion of that is nominally paid by the employer, it is actually paid entirely by the employee because the employer’s portion is paid through forgone wage increases of the employee. Further, employees of small firms and low-income employees receive less generous health benefits even though they are less capable of paying premiums and out-of-pocket cost sharing. In fact, the health benefit offer rate overall is only 57 percent. That great insurance that the media keeps telling us we want to keep has premiums that continue to rise faster than inflation, fails to provide adequate financial protection for low- and middle-income families, and isn’t even offered to 43 percent of the workforce, particularly disconcerting when considering that there have been 67 million job separations in the past year (Bureau of Labor Statistics) – not exactly a stable source of insurance coverage.

This is serious. We are being told that the majority of the public will accept Medicare for All only if they continue to have the option of being insured through private plans, especially those offered by their employers. Yet the public is deliberately being confused as to what Medicare for All is. Is it single payer, or is it merely another option in our fragmented system of a multitude of private and public plans? The distinction is crucial. Too many still don’t understand what single payer is, even if they think they do.

Providing Medicare as an option leaves in place all of the dysfunctions of our current health care financing system. Today’s report shows that even employers have been unable to make a dent in the rate of health care cost escalation, leaving care unaffordable for the majority, while remaining incapable of tackling the profound administrative waste that is a major driver of our uniquely high costs, plus they cannot possibly benefit those who are not in their employ, not to mention failing to benefit the 43 percent of their employees who do not enroll in their plans.

On the other hand, a bona fide single payer model of Medicare for all automatically includes everyone for life, recovers hundreds of billions of dollars in administrative waste, switches to an equitable method of financing that everyone can afford (yes, progressive taxes!), and provides better benefits than essentially all employer-sponsored plans. The other proposals mislabeled as some variant of Medicare for All accomplish none of these goals.

Though many still object to the single payer label as being too wonkish and not well understood by the general public, unfortunately the Medicare for All label has been stolen from us and is being used frequently to refer to some form of Medicare as a public option, accomplishing essentially none of our goals of reform. Until we can agree on a better term, we should insist on “Single Payer Medicare for All,” and then we should be sure that everyone understands what single payer means – affordable, comprehensive care for everyone.

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By Andrew B. Bindman, Denis Hulett, Isabel Ostrer, and Taewoon Kang
California Health Care Foundation, September 2019

In the 1970s, California was the first state to introduce Medicaid managed care. It is now mandatory in 57 of 58 counties for most Medi-Cal enrollees. In 2018, approximately 10.4 million (80%) of Medi-Cal enrollees received services through one of 22 insurers who provided managed care plans (MCPs) specific to the counties in which they operated.

This report examines the performance of Medi-Cal MCPs over the past decade in quality of care provided to members. In addition to reporting on overall trends in performance, this report also examines differences by type of MCP ownership (public, nonprofit, for-profit) and model of managed care (County Organized Health System, Two-Plan model, and a few different models of competing commercial MCPs).

Key Findings

• From 2009 to 2018, quality of care in Medi-Cal managed care was stagnant at best on most measures. Among 41 quality measures collected in two or more years, more than half (59%) remained unchanged or declined. The picture looks only slightly better when limited to the 31 quality measures still collected by DHCS. Of those, 52% remained unchanged or declined. Specifically, quality of care significantly declined for Medi-Cal enrollees on 4 measures and was unchanged on 12 measures. There was significant quality improvement on 15 measures.
• While declines in quality in some cases were relatively small on a percentage basis, the clinical significance in all cases could be interpreted as substantial, given the size of the impacted population. The same is true for observed improvements in quality.
• Three of the four current measures that declined over time were related to the care of children. Six of the nine quality measures currently in use that are related to children declined or stayed the same; there was improvement in only three of these measures.
• Medi-Cal enrollees’ rating of their experiences with their MCP were consistently below the 50th percentile nationally. The only CAHPS measure that improved significantly over time was the one that asked enrollees to rate how well doctors communicate.
• Medi-Cal MCPs’ quality scores varied markedly within and across MCPs by ownership during the past decade. Most striking was the substantially lower quality scores of the for-profit MCPs, on average, relative to the nonprofit and public MCPs. These differences in quality scores by MCP ownership were not explained by observed demographic differences or the physician supply in the counties in which they were operating.
• While there was variation of MCP performance within each of the Medi-Cal managed care models, counties that rely on a single public MCP (County Organized Health Systems) had on average better quality scores than counties that furnish Medi-Cal services through either a Two-Plan or competing commercial model. This remained the case after adjusting county demographics and physician supply, and was even true for the quality measures used as the basis for the enrollment-based “auto-assignment” incentive in counties with competing MCPs.

https://www.chcf.org…

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Comment:

By Don McCanne, M.D.

California has been a leader in moving Medicaid patients into Medicaid managed care plans. It is now a mature program that can provide us with lessons on the wisdom of such a conversion. So how have these plans performed over the past decade?

One of the main motivations behind this shift was that managed care plans supposedly would improve the quality of care. Yet quality was “stagnant at best on most measures.” “Among 41 quality measures collected in two or more years, more than half (59%) remained unchanged or declined.”

“Six of the nine quality measures currently in use that are related to children declined or stayed the same.”

“Medi-Cal enrollees’ rating of their experiences with their MCP were consistently below the 50th percentile nationally.”

By ownership, “most striking was the substantially lower quality scores of the for-profit MCPs, on average, relative to the nonprofit and public MCPs.”

“Counties that rely on a single public MCP (County Organized Health Systems) had on average better quality scores than counties that furnish Medi-Cal services through either a Two-Plan or competing commercial model.”

We can conclude that for-profit, commercial Medicaid managed care plans often provide lower quality care, and levels of patient satisfaction are low.

More importantly, as stated above, counties that rely on a single public managed care plan (County Organized Health Systems) have better quality scores than counties that rely on competing health plans, belying the claim that health plan competition improves quality. This should speak well for the single payer model of Medicare for All.

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