September 15, 2019
Kenyon Farrow, senior editor with TheBody.com and board member of the New York Transgender Advocacy Group (NYTAG) discussed the impact Medicare for All would have on people living with HIV, and on those who are most vulnerable to contracting the virus. Hosted by Joseph Sparks. Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.
By Ezekiel J. Emanuel and Victor R. Fuchs
The New York Times, September 12, 2019
Fallacy No. 2: Medicare for All is unaffordable.
The key to evaluating the cost of Medicare for All is to distinguish between increasing spending on health care and shifting expenditures from private insurance to the federal government.
True, Medicare for All would increase federal health care spending. But that is not the same as increasing total health care spending, which was over $3.5 trillion last year. Instead, Medicare for All would move money from one column (private health insurance spending) to another (federal health spending); it does not automatically increase total costs.
A recent study by the Mercatus Center at George Mason University — a free-market center generally hostile to government programs — estimates that for the 10 years between 2022 and 2031 the total national health costs for Senator Bernie Sanders’s Medicare for All plan would actually be $50.1 trillion. That would be $2 trillion less than if we let the system operate as it currently does. However, Mercatus researchers doubt that the Sanders’s plan would ultimately save trillions because they believe Congress would have to increase Medicare rates paid to hospitals and physicians to get the legislation enacted. They may be right — or wrong. But that is a different argument — a prediction about the politics of enacting laws — than that Medicare for All would inherently increase total health care spending.
We have our doubts about Medicare for All. But unaffordability is not a reason to oppose it. Whether it’s our current arrangement or a future Medicare for All, the per capita cost of our health care system already far exceeds that of any other industrialized country — including those with single-payer systems. When you hear a health care price tag in the trillions, know that the existing system has already brought us there.
Ezekiel J. Emanuel is an oncologist and a vice provost at the University of Pennsylvania. Victor R. Fuchs is an emeritus professor of economics at Stanford University and former president of the American Economics Association.
The New England Journal of Medicine, March 24, 2005, “Health Care Vouchers — A Proposal for Universal Coverage” by Ezekiel J. Emanuel, M.D., Ph.D., and Victor R. Fuchs, Ph.D.
By Laurence Kotlikoff
The Hill, September 8, 2019
As with the previous Democratic debates, this week’s debate in Houston will likely start with our country’s forever question: How can we provide health insurance to all without bankrupting the country?
The Republican Party’s answer is to define basic health insurance as no health insurance. The party yearns for, and is suing in the courts, to restore the halcyon pre-ObamaCare days when 50 million Americans were uninsured and insurance companies could deny coverage at will.
This stance isn’t going to fly with the Party’s rank and file, whose own future health care and that of friends and relatives is at stake. But, hey, political self-immolation seems all the rage.
Vision two is Senator Sanders’ traditional Medicare (Parts A, B, and D) for All. Actually, it’s a far more generous version than traditional Medicare, which features co-pays, co-insurance, limits on catastrophic coverage and significant monthly premiums. As a result, millions of participants are forced to purchase Medigap coverage. Under BernieCare, there are no co-pays (except for prescription drugs) and no limits on coverage. Bernie care includes lab work, maternity, vision and dental care, and long-term care for the disabled.
Employers would, to their joy, be banned from the health care business. But their workers will be able to keep their doctors and use the same hospitals, who will simply send their bills to Medicare. Indeed, setting aside requisite tax hikes, BernieCare is far more generous than most employer-provided plans.
BernieCare, which Senator Elizabeth Warren (D-Mass.) and several other Democratic presidential candidates endorse, works great in theory. And it may in practice. The biggest bottom line is the share of GDP spent on health care. Other developed countries are delivering excellent universal health care at well south of 14 percent of GDP. We’re at 18 percent of GDP and growing. And they are all doing it with a healthy dose of central government control.
If it’s a choice between our current system and BernieCare, I’d go with BernieCare in a heartbeat. Yes, there are lots of concerns — people overusing the system, costs that far exceed the senator’s estimates, government price control over what is a fifth of the economy, doctors opting out of medicine because of limits on their reimbursements and long waiting lines.
But 14 percent of U.S. GDP can surely buy a truly first-class health care system for all. Also bear in mind that medicine in our country is already largely government run but done so with maximum inefficiency, leaving 30 million uninsured and far more underinsured.
BernieCare surely beats “Don’tCare” — the Trump-McConnell answer. But is there another reform that makes more sense?
Yes. “Medicare Part C for All.” This is the brain child of John Goodman, the father of Health Saving Accounts. I pushed for this solution in The Healthcare Fix. Goodman recently discussed the plan in the Wall Street Journal.
Medicare Part C is also called the Advantage Plan. Some 22 million Medicare participants – one in three – have opted for Medicare Advantage over traditional Medicare.
Laurence Kotlikoff is a professor of economics at Boston University (BU), a fellow of the American Academy of Arts and Sciences, a research associate of the National Bureau of Economic Research, and a fellow of the Econometric Society. He served on President Ronald Reagan’s Council of Economic Advisers.
The MIT Press, September 2007, “The Healthcare Fix” by Laurence J. Kotlikoff (proposes vouchers for health insurance)
By Don McCanne, M.D.
It has been fascinating to observe the insights on single payer Medicare for all of some of the nation’s more prominent economists who have not already been in the single payer camp. They seem to understand the clear benefits of the model, and yet they regress to supporting their own preferred but lesser models of reform, very often a model using variations of subsidized vouchers for purchase of private plans, as the authors of today’s excerpts support.
Even the Affordable Care Act was based partly on the voucher concept with the establishment of the ACA insurance exchanges. There is currently a push to use vouchers (“premium support”) to expand coverage through private Medicare Advantage plans. If we ever do approach having truly universal coverage, it will likely be the results of the contest between Medicare Advantage vouchers and a single payer model of an improved Medicare for all. A recent Quote of the Day discussed why this Medicare Advantage for All model is such a terrible idea.
Yes, it has been fascinating to see the insights of so many economists on the single payer model, yet it has been terribly frustrating to see that many if them continue to reject this obviously superior model.
Some years ago at Stanford University I was on a panel with Victor Fuchs in which he presented his voucher proposal and I presented the single payer approach. After the session was over, he approached me and asked me if I would like to work with him and Ezekiel Emanuel on their voucher model. I asked him if he would like to work with us on the single payer model. We both laughed, but, sadly, the impasse is not at all funny.
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By Ashley Kirzinger, Audrey Kearney, and Mollyann Brodie
Kaiser Family Foundation, September 12, 2019
Majorities of Democrats and Independents favor Medicare-for-all and public option, most Republicans oppose either proposal
Do you favor or oppose having a national health plan, sometimes called Medicare-for-all?
Democrats
51% – Strongly favor
26% – Somewhat favor
11% – Somewhat oppose
10% – Strongly oppose
Independents
27% – Strongly favor
26% – Somewhat favor
14% – Somewhat oppose
31% – Strongly oppose
Republicans
11% – Strongly favor
8% – Somewhat favor
10% – Somewhat oppose
69% – Strongly oppose
Do you favor or oppose having a government-administered health plan, sometimes called a public option?
Democrats
57% – Strongly favor
30% – Somewhat favor
5% – Somewhat oppose
5% – Strongly oppose
Independents
36% – Strongly favor
36% – Somewhat favor
8% – Somewhat oppose
17% – Strongly oppose
Republicans
15% – Strongly favor
26% – Somewhat favor
14% – Somewhat oppose
39% – Strongly oppose
Public divided on whether Medicare-for-all and public option are similar or different plans
Do you think a national Medicare-for-all plan and a public option government-administered health plan are…?
10% – Very similar
37% – Somewhat similar
29% – Somewhat different
15% – Very different
10% – Don’t know/Refused
Half say they have heard some about Medicare-for-all but large shares say they haven’t heard much about either Medicare-for-all or a public option
How much, if anything, have you heard about a national Medicare-for-all plan?
25% – A lot
26% – Some
26% – A little
22% – Nothing at all
1% – Don’t know/Refused
How much, if anything, have you heard about a government-administered health plan, sometimes called a public option?
14% – A lot
22% – Some
26% – A little
38% – Nothing at all
1% – Don’t know/Refused
By Don McCanne, M.D.
According to this new poll, Democrats support Medicare-for-all (“a national health plan”), Independents are split, and Republicans are opposed. Also, Democrats and Independents both support a public option (“a government-administered health plan”), and Republicans are split. However, the public is confused as to whether Medicare-for-all and a public option are similar or different, and half have not heard much about Medicare-for-all and even more have not heard much about a public option.
It seems as if individuals do have an opinion on Medicare-for-all and on a public option even though many are confused as to what they are. The fact that the pollsters referred to one as “a national health plan” and the other as “a government-administered health plan” likely leaves many of those polled with little understanding of the refinements distinguishing the two models.
Features that people might be interested in include the following:
Of course, these are features of the single payer model of Medicare for all and none would apply by merely adding a public option to our fragmented financing system of a multitude of public and private insurance programs.
When will the pollsters finally ask the following questions?
In other words, do we want a health care system that we can afford that takes care of all of us, or do we want to merely add a public option and a couple of tweaks to ACA that leaves our overpriced, highly dysfunctional system in place? People really need to understand the differences between Medicare-for-all (single payer version) and a public option. Let’s see that they do.
Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.
By George Bohmfalk M.D.
The Charlotte Observer, September 12, 2019
Healthcare will be a major topic in Thursday’s Democratic presidential debate. Only two of the candidates — Bernie Sanders and Elizabeth Warren — support real Medicare for All. The rest waffle around some lesser, politically more palatable version, like Medicare for All Who Want It or other euphemism for a public option. You will hear them insist that, while they agree on the need for universal healthcare, we should get there incrementally, not in one fell swoop.
They are all wrong.
Abraham Lincoln didn’t end slavery incrementally, nor did we incrementally become a nation or defeat Hitler. Some things require bold action to help the most people. Medicare for All is one of those things.
There are two fundamental reasons that a public option cannot work.
The big, solvable issue in our healthcare system is the 30 percent of every healthcare dollar that is squandered on administrative overhead — paperwork, the pre-approvals, denials, and appeals that are an integral part of myriad for-profit private insurance companies. That’s around $1 trillion every year. Only a single-payer system like Medicare for All can cut that trillion dollars in half, by eliminating that bureaucratic waste. That half — $500 billion — can be redirected to providing comprehensive healthcare to all Americans. It’s not free. We’ll all pay for it in taxes, which for most of us will be less than what we’re currently spending on premiums, co-pays, deductibles, and other healthcare expenses. We’ll pay less in the end for more healthcare, for everyone.
A public option cannot save that $500 billion, nor can it reduce healthcare costs. It will only add one more choice of insurance provider to the current complex mix. Most of us neither know nor care which company provides our insurance. The choice we really care about is choice of doctors and hospitals. Most private insurers restrict that choice to maximize profits. They also restrict our access to healthcare by imposing deductibles and co-pays, which many of us can’t afford. Medicare for All offers free choice of doctors and hospitals, with no deductibles and co-pays. What more choice can anyone want?
The other fatal flaw in a public option is that it will likely become the insurer of last resort to the sickest and oldest among us. The insurance playing field will be anything but level. As deficient as they are, for-profit insurers will cleverly market themselves to the young and healthy, leaving those who use more healthcare to the public option. Its costs will balloon, dooming it to fail, to the delight of for-profit companies.
Sanders and Warren understand this. They understand that fear of change is what causes people to think that they would rather keep their present, inadequate, expensive insurance plans. They understand that most people are eager to turn 65 and trade their employer-provided plans for Medicare. They understand that everyone would be better off with Medicare for All, and that a public option simply won’t get us there.
Incrementalism is often a valid approach to change. Allowing people to choose between keeping their current restrictive plans or a Medicare for All option sounds reasonable, but it just won’t work. As with Emancipation, the Declaration of Independence, and World War 2, this is a time for major change that will benefit the most people. It may seem scary, as all change does, but it’s the only way to get all of us the healthcare protection we deserve, at lower cost than we’re paying now. Rather than fear it, we need to understand and embrace Medicare for All.
Dr. George Bohmfalk, a retired neurosurgeon, chairs the Education Committee of Health Care Justice – North Carolina, the Charlotte chapter of Physicians for a National Health Program.
By Angèle Malâtre-Lansac
Health Affairs Blog, August 28, 2019
Editor’s Note: In addition to Angèle Malâtre-Lansac, this post was conceived of and written by the 2018-2019 Harkness Fellows on health care policy and practice listed at end of this post.
Each year, the Commonwealth Fund selects an international cohort of Harkness Fellows in health care policy and practice, consisting of mid-career researchers, policy makers, and practitioners with leading positions in their countries, who come to the US to study the health care system, work with renowned US health policy experts, and provide input to US health care and research, drawing on insights from their own international contexts.
Reflections on health care in the US are commonplace: In our view, what is less common are observations and reflections from health experts from seven other countries on US health care. What are the most surprising aspects of the US system through the lenses of 10 observers from Australia, France, Germany, the Netherlands, New Zealand, Norway, and England?
No Such Thing As The US Health Care System
The United States undeniably provides some of the best health care and is one of the most innovative nations in the world. Financial investments in health and medical research are the envy of us all. Pockets of excellence can be seen in so many places. However, one of our first realizations is that there is no such thing as a single, unified, and coordinated US health care system — but rather a complicated and fragmented health care marketplace. Variations between US states, communities, and health insurance plans are in many cases greater than the differences between our countries. There are many reasons for this, but key among them are our countries’ shared principle of universal health coverage (both within single and multi-payer systems) and our usually nationally negotiated prices.
The diversity across US states is striking to us, particularly in terms of access to, and quality of, health care services. Perhaps, most surprising from our international perspective is the importance of political differences as a unique determinant of regional variations in health care performance. The ongoing debate over the Affordable Care Act (ACA) and the state-based variation in implementation of the ACA are vivid examples of this diversity and polarization within health care.
While there can be many benefits to diversity and choice, particularly in terms of tailoring services and resources to meet the specific needs of different populations and to ensure appropriate care, too much of a good thing can create problems. As an example, the sheer number of options individuals need to review and decide upon when considering a private health insurance plan or selecting a provider creates complexity, decision fatigue, and frustration.
Health Care As A Privilege, Not A Right
In our countries, there is a broad consensus on the role of the government in health care, as there is in education. Health care is considered a fundamental right. In the US, the federal government does not assume full responsibility for ensuring the right to health care for its citizens. The predominant narrative here frames health as a privilege. This plays out in many ways, but perhaps most notably it is advanced by proponents of work requirements for Medicaid, premised on the idea that access to health care is something to be earned. And yet, many US people cherish Medicare, a government program that provides universal coverage for people ages 65 years and older.
In addition, although we hear a lot of discussion about the costs of care, it is surprising how little of the conversation is on the costs of care not delivered. Approximately 28.5 million Americans have no health insurance, and it’s well known that being uninsured negatively affects your health and is costly. There are costs for the individuals; for the families who rely on those individuals for financial and other forms of support; for the businesses whose employees are absent, unproductive, or retire early; for the health care system, which ends up providing more expensive reactive care; and for society at large.
Another stark difference between the US and our own countries is the high level of financial burden placed on its people. Prominent in the US health care system are the high-deductible health plans driven by the idea that cost-sharing obligations will encourage people to prioritize high-value care and reduce health care spending. Yet, recent evidence suggest that populations on such plans delay or skip essential care entirely and as a consequence, experience adverse effects.
The Price Problem
On average, the US spends twice as much as other Organization for Economic Cooperation and Development countries on health care without evidence of superior care or health outcomes. In fact, life expectancy is declining in the US while health care costs continue to rise. Grossly inflated drug and device prices, overall health care costs, and surprise billing are big challenges. Substantial administration and advertising costs are a further unintended consequence of the primacy placed on individual choice. Quite simply, everything is more expensive in the United States than it is in our countries.
Drug prices in the US are three to six times higher than in many European countries, despite decades of calls for change. Our countries use Health Technology Assessment (HTA)—a multidisciplinary approach that considers the clinical, economic, legal, ethical, and organizational aspects of new technologies such as drugs, devices, and procedures. The core principle is to determine the added value of new technologies compared to existing alternatives to inform authorities responsible for coverage and reimbursement decisions. Unlike in our countries, there is no single agency tasked with addressing this issue in the US.
The Accountability Problem
In an article recently published in the New England Journal of Medicine, “The Not-My-Problem Problem,” Lisa Rosenbaum provides a persuasive account of the unintended consequences of diffusion of responsibility in a highly fragmented US health care system. According to the World Health Organization’s Health System Framework, well-functioning health care systems share several characteristics, including leadership and governance, factors that play essential roles in achieving the goals of health systems, regardless of how health systems are organized and designed.
In the US, governance is often unclear, and there is no shared understanding of what each actor in the health care system is accountable for (and to whom). At the end of the day, the entire system seems beholden to one thing: the “bottom line.” The lack of a commitment to universal coverage, as well as the many different stakeholders and multiplicity of intermediaries in the supply chain, might explain this phenomenon.
These lessons may not come as a great surprise to the many policy makers and researchers who have long studied and aspired to improve health care in the US. Our hope is that, by highlighting the challenges that stand out most acutely to us as outsiders, this international perspective may provoke thoughtful discussion about how to achieve better health outcomes. Addressing those great challenges is like tackling climate change — it’s both crucial and painful. Taking the necessary steps toward a greater good first requires agreement on what that looks like. The opportunity of the upcoming presidential campaign will undoubtedly make it possible to bring a new vision for the future of US health care.
Author’s Note
Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and should not be attributed to the Commonwealth Fund or its directors, officers, or staff.
2018-2019 Harkness Fellows on health care policy and practice from the Commonwealth Fund:
Angèle Malâtre-Lansac, France
Mary Docherty, UK
Unni Gopinathan, Norway
Cornelia Henschke, Germany
Prakash Jayakumar, UK
Nadine Kasparian, Australia
Grégoire Mercier, France
Huseyin Naci, UK
Andrew Old, New Zealand
Laura Shields-Zeeman, Netherlands
https://www.healthaffairs.org…
By Don McCanne, M.D.
This perspective is very helpful to us because it represents the views of highly qualified health policy experts from other nations who have come to the United States to study our system. The objective view they present can be invaluable in our own assessment of our health care system as we consider what can be done to improve it.
Considering our unique culture and politics, it is very difficult to see how we could effectively address the issues discussed short of enacting and implementing a single payer model of an improved Medicare that covered everyone. The sooner, the better.
Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.
By Tara Bannow
Modern Healthcare, September 7, 2019
The problem of overlap in the CMS’ various payment initiatives, including ACOs and bundled-payment programs, can introduce confusion and frustration when it comes to determining which program gets credit for those patients’ care. The CMS wants to avoid double-rewarding for savings on an individual patient’s care, such as if the patient is in an ACO and received qualifying care from a Bundled Payments for Care Improvement Advanced provider. So when it comes down to reconciling who is credited for the savings, things get tricky. And they’re bound to get even more complicated as the CMS adds alternative payment models to the mix.
New research highlights just how sweeping the problem is. More than 1 in every 4 patients receiving care under the CMS’ flagship bundled-payments program, the Bundled Payments for Care Improvement initiative, were also attributed to its flagship ACO program, the Medicare Shared Savings Program, in 2016, according to an August study in the Journal of Hospital Medicine. Conversely, 1 in every 10 MSSP patients received care at a BPCI participating hospital in 2016.
The CMS attempted to clarify things in June when it announced that starting in 2020, providers participating in BPCI Advanced will take precedence over all MSSP beneficiaries—meaning, their savings will be carved out from the ACO’s savings. Currently, this is only the case for certain MSSP beneficiaries, those categorized under the program’s basic track.
On a practical level, the June announcement means if John Doe is a patient in an MSSP ACO, and is admitted to a BPCI Advanced hospital with a clinical episode, such as congestive heart failure, that episode of care will be attributed to the BPCI Advanced provider, said Gina Bruno, vice president of value-based care with naviHealth.
The CMS is also trying to calculate a way to compensate aligned ACOs for their contributions to those patients’ care, Bruno said. “ACOs, especially those that work with BPCI Advanced providers will say, ‘Well, wait a minute. John Doe has been our patient for a period of time. We have a team that follows up with him. We play a part in managing his chronic disease. How do we get credit for our contributions to his outcomes?’ ”
Therein lies the trickiness of overlap. Experts say providers who contributed to a patient’s care often wind up feeling as though they didn’t get the commensurate reward.
“There is a risk of expending resources to support patients who ultimately are not attributed to the model to which that operating expense was aligned,” Bruno said.
At least five CMS payment models could overlap with one another: MSSP, BPCI Advanced, CJR, the advanced primary-care medical home model Comprehensive Primary Care Plus and the Oncology Care Model, said David Muhlestein, chief research officer with Leavitt Partners.
“If everybody is getting credit for it, you could potentially pay the same bonus payment five times,” he said. “Or if everybody does really poorly, all of them would pay the same penalty payment.”
There’s also a broader societal problem with overlap. It makes it difficult for the CMS Innovation Center to study whether its payment model experiments are actually saving money and improving patient outcomes. In that respect, the CMS is between a rock and a hard place, Muhlestein said.
“If they want to test many different programs to find out what works currently and not have overlap, you kind of can’t,” he said.
https://www.modernhealthcare.com…
By Don McCanne, M.D.
While the policy community is ignoring the truly effective model of Single Payer Medicare for All, they remain fixated on accountable care organizations (ACOs) and alternative payment models (APMs). Not only has the initial experience with these models been relatively disappointing, the patients may be simultaneously enrolled in multiple models, often without their knowledge, creating confusion as to which entity should be receiving payment or assessed a penalty for falling short on parameters of care.
As David Muhlestein of Leavitt Partners states, “If they (CMS) want to test many different programs to find out what works currently and not have overlap, you kind of can’t.”
Yesterday’s Quote of the Day made the point that we don’t need more policy studies to figure out how we can fix the system. We merely need to enact and implement the single payer model of an improved Medicare for all.
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FOR IMMEDIATE RELEASE, September 10, 2019
Contact: Clare Fauke, Physicians for a National Health Program, clare@pnhp.org
Statement from Dr. Adam Gaffney, president of Physicians for a National Health Program, in response to the U.S. Census Bureau’s 2018 Income, Poverty and Health Insurance Coverage report:
“The number of Americans without health coverage is on the rise, new figures from the Census Bureau show. In 2018, some 2 million people in the U.S. lost coverage relative to the previous year, demonstrating that our current system is not only broken, but getting worse.
“This rise in the number of the uninsured reflects the Trump administration’s ongoing attacks on our health care safety net, specifically Medicaid, a public insurance program relied upon by low-income Americans. Yet these attacks exacerbate an already untenable situation, in which nearly 30 million Americans have been left without health coverage, and many more with inadequate coverage.
“Physicians see daily the harm that this inflicts on our patients. People with asthma or heart disease who don’t take their medications because they can’t afford the prescription; people with multiple sclerosis, diabetes, or cancer who can’t get the care they need because of skyrocketing costs and wind up in the hospital, or worse.
“The only solution is improved Medicare for All — a system that guarantees first-dollar coverage for all medically necessary services to everyone in the U.S. Other patches – like a public option – will invariably fall. A majority of Americans and a majority of doctors now support Medicare for All. It’s time for our elected officials to follow.”
Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization whose more than 23,000 members support single-payer national health insurance.
Making Contact, September 10, 2019
As the cost of insulin continues to skyrocket patients are dying from trying to ration their medication. It’s an extreme example, but not unusual – the cost of insulin mirrors the broader health crisis in the United States. Medicine is too expensive and inaccessible. And as insurance companies continue to raise prices, more and more people are put at risk, especially if they’re uninsured, or under-insured.
Today, we look at ways to combat the health costs associated with diabetes.
First, we hear from a woman living with diabetes about her experience using Insulin. Then, we visit a group of community scientists called the Open Insulin Project, an organization trying to create its own insulin outside the lengthy FDA process and whether it’s worth the associated risks.
And we talk about the benefits of Medicare for All, a policy which would get rid of private insurance and make all medicine and medical care accessible and affordable.
Featuring:
By Austin Frakt
The New York Times, September 9, 2019
Rigorous evaluations of health policy are exceedingly rare. The United States spends a tremendous amount on health care, but very little of it learning which health policies work and which don’t.
Evaluations of health policy have rarely been as rigorous as clinical trials. A small minority of policy evaluations have had randomized designs, which are widely regarded as the gold standard of evidence and commonplace in clinical science.
Because randomized health policy studies are so rare, those that do occur are influential. The RAND health insurance experiment is the classic example. This 1970s experiment randomly assigned families to different levels of health care cost sharing. It found that those responsible for more of the cost of care use far less of it — and with no short-term adverse health outcomes (except for the poorest families with relatively sicker members).
The results have influenced health care insurance design for decades. In large part, you can thank (or curse) this randomized study and its interpretation for your health care deductible and co-payments.
Problems can also plague rollouts that are voluntary and not randomized. Programs showing promise suffer from diminishing participation as health care organizations drop out. The innovation center’s pioneer accountable care organization program offered health care organizations the opportunity to earn bonuses in exchange for accepting some financial risk, provided they meet a set of quality targets. It started with 32 participants in 2012. Although studies showed it reduced spending and at least maintained, if not improved, quality, only nine remained by 2016 when the program ended.
Beginning in April 2016, Medicare randomly assigned 75 markets to be subject to bundled payments for knee and hip replacements, and 121 markets to business as usual. But the innovation center didn’t maintain the design, announcing in November 2017 that hospitals could leave it. This will greatly limit what can be learned from the program.
Just as in clinical care, there are examples of incorrect thinking based on low-rigor studies that more rigorous ones later overturn. For example, many low-quality studies suggest that wellness programs reduce employers’ health care costs as they improve health outcomes. But when the programs have been subject to randomized controlled trials, none of these findings hold up.
Hospital cost shifting — the idea that shortfalls from Medicare or Medicaid cause hospitals to charge higher prices to private insurers — can also seem commonplace from studies without rigorous designs. But when subject to more careful evaluation, the phenomenon is almost never observed.
It’s hard to rid ourselves of ideas that are little more than wishful thinking or to end policies that don’t work.
By Don McCanne, M.D.
Health policy research is potentially beneficial, but it should not distract us from adopting policies that do not require research to know whether or not they work.
Currently much research is directed to studying value over volume, yet the preliminary results have been disappointing, and the response has been to call for more such studies. This is actually harmful when it deters us from adopting policy changes that would be inherently effective. Current research on alternative payment models is largely wasting resources, partly through an increase in useless administrative complexity.
On the other hand, we can enact and implement policies that would automatically include everyone, sharply reduce the profound administrative waste of private insurers and the burden they place on the system, make health care affordable for everyone by financing the system with equitable progressive taxes, and improve access by removing financial barriers to care. You do not need a complex policy study to see whether or not those goals would be realized. They are inherent in a well designed, single payer model of an improved Medicare that covered everyone.
Policy research is fine, but let’s not walk away from common-sense solutions just because the policy community hasn’t done the research yet, when no such research is required.
By Don McCanne, M.D.
The granddaddy of health policy research is the RAND health insurance experiment (RAND HIE) which supposedly showed that cost sharing decreased the use of health care without increasing adverse health outcomes (though that’s not quite true, at least for patients with hypertension). Yet commonly ignored is the fact that this study was confined to healthy workers and their young healthy families. That, in effect, excluded most of the 20 percent of individuals who use 80 percent of our health care. Thus the study has intrinsic validity for healthy individuals, but it does not have extrinsic validity for individuals receiving most of the health care in the United States.
Though this study showed that young, healthy people remained healthy (no surprise there), it was nevertheless used to advance the principles of consumer-driven health care – requiring high deductibles to keep people away from health care that they may not need. So today we have high deductibles that keep sick people away from the health care that they should have simply because the policy community ignored the fact that the RAND HIE does not have extrinsic validity. So this greatest health policy experiment of all time has had a detrimental impact on health care in America – the opposite of what policy science should be bringing us.
So what studies do we need to establish health care justice for all?
If we want everyone included, what study would show us how we can do that? Well, you don’t need a study. Simply include everyone.
If we want to reduce the high costs of the profound administrative waste of the private insurers and the burden they place on the health care professionals and institutions, what study would you need to figure out how to do that? How would a study help when what we need to do is simply eliminate the private insurers, substituting a universal, publicly financed and publicly administered program?
What study would you need to make sure that each person can afford his or her share of our national health expenditures? Again, you do not need a study. Simply fund the universal risk pool based on ability to pay by implementing equitable, progressive tax policies.
What study would you need to update the RAND HIE that would remove financial barriers to essential health care services? Again, it doesn’t take a study to conclude that you simply remove the barriers such as high deductibles.
What study would you need to return to the patient choices in health care professionals and institutions beyond the restrictive networks established by the private insurers? By now you’ve gotten the message. Simply eliminate the networks along with the private insurers that established them.
It’s time to reconnoiter and regroup. Let’s chase to the sidelines those in the policy community who just don’t get it and let them watch us fix our system. We don’t need more endless policy studies to figure out how to do that.
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By Robertha Barnes, Chris Cai, Diana Chang, Ashley Duhon and Michael Zingman
Modern Healthcare, September 7, 2019
Last month, the American Medical Association announced its departure from the Partnership for America’s Health Care Future. While the AMA still does not support improved Medicare for All, this is an important step. Last year, the partnership spent $143 million lobbying against Medicare for All using decades-old scare tactics like the fear of “socialized medicine,” rising costs and loss of consumer choice.
As future doctors, we know the evidence doesn’t support this. Several studies, including by the libertarian Mercatus Center, show Medicare for All will expand coverage while reducing overall health spending. Over 200 economists agree that Medicare for All would save money for most Americans. Unlike commercial or employment-based insurance, the programwould provide all medically necessary care free at the point of service, including dental, vision, reproductive and long-term care. Finally, a Medicare for All system would not significantly increase hospital use or lower doctors’ incomes.
Why does the AMA oppose Medicare for All? Today the association represents fewer than 25% of physicians and clings to policies that elevate the interests of for-profit corporations and private hospitals over those of patients. The AMA has fought against national health insurance as far back as the 1950s when it opposed Medicare and Medicaid.
That is why Students for a National Health Program co-led a demonstration at the AMA’s annual meeting in June. Our demands were clear: Leave the anti-single payer partnership and end your misguided opposition to single-payer.
While we applaud the AMA for leaving the partnership, we believe this is not enough. If the AMA is truly in favor of healthcare justice, it must support improved Medicare for All.
Robertha Barnes, Chris Cai, Diana Chang, Ashley Duhon and Michael Zingman all are medical students and national board members of Students for a National Health Program.
By Akilah Johnson
ProPublica, September 6, 2019
GAITHERSBURG, Md. — Ritchard Jenkins reached into the black computer bag he keeps near his workstation at Graceful Touch Barber and Beauty Salon and rifled through medical papers, pulling out an envelope buried deep at the bottom.
It was an unopened medical bill for $971.78, now 17 months overdue, that he had put out of sight and out of mind. Another unpaid bill from May for $447.13 rested in a nearby drawer. Both are the result of an arthritic knee that needs to be replaced and keeps the 55-year-old master barber in near-constant pain.
He makes numerous phone calls to doctors and insurance companies to discuss his coverage. And just when he thought he couldn’t take any more, he fell down the steps, breaking his right wrist, tearing his rotator cuff and kickstarting a new round of hospital stays, tests — and insurance claims.
“Health care is ridiculous. These politicians really need to step their game up,” Jenkins said recently, using his left hand to hold clippers and a comb because his right remains swollen and partially immobile.
But Jenkins shrugged when asked if Medicare-for-all, the slogan that has dominated early campaigning in the 2020 Democratic primary, was the solution to his and America’s health care woes. He mumbled something about being too young for Medicare and laid bare the disconnect between how voters think and talk about health care and how candidates do.
As the Democratic primary campaign heats up, with the third debate scheduled for Sept. 12, candidates have used the slogan to distinguish themselves as bold progressives, moderate pragmatists or, in some instances, a little of both. The Trump administration has made it a point of attack, vowing to create a better system at lower costs. But interviews with voters and research by health policy experts show that the average voter has little idea of what is meant by the phrase that has already become a campaign signpost.
In its broadest terms, Medicare-for-all is what health care experts call single-payer: A system in which a government entity reimburses doctors and hospitals at a set rate. Many of the world’s most admired health care systems, from France to Israel to Canada, use some version of this approach.
Many health care experts argue that single-payer is the most effective way to deliver medical care to the greatest number of people. But until now, it has been politically unimaginable, taken off the table by most candidates seeking national office.
Health care “is the most important issue” of the election, and “single-payer is the right solution for American health care,” said Dr. Adam Gaffney, president of Physicians for a National Health Program and instructor at Harvard Medical School, who supports calling it Medicare-for-all but acknowledges pitfalls with the framing.
This “is an issue that affects, literally, every single person in this country,” he said. “Even putting the medical issues aside, it’s an economic issue. The way we finance health care promotes economic inequality.”
Medicare-for-all, in the purest sense, largely would replace private health insurance with a single, government-run program covering most everyone. It would be similar to traditional Medicare, the current federal health insurance program for most adults over 65 and young people meeting federal disability requirements, hence the name.
Sounds simple? It’s not.
Medicare was signed into law in 1965 after a 50-year effort to create a national health insurance system covering everyone. Opposition was so fierce that President Franklin Roosevelt excluded health insurance from the Social Security Act of 1935, and 13 years later President Harry S. Truman’s efforts to close what he called “the greatest gap in our social security structure” died in committee. The only way to get the law passed was by limiting coverage to older Americans.
And it’s worked, more or less, because of the government’s ability to set payments to health care providers. Still, high-quality, affordable coverage remains out of reach for many Americans, including many on Medicare. (Medicare covers only a portion of medical expenses, with many people buying supplemental plans to mitigate out-of-pocket costs.)
The Affordable Care Act, passed in 2010 during the Obama administration, was seen by many experts as a once-in-a-generation reform. Some argue it didn’t go far enough to provide every American with quality health insurance at a reasonable price. Others say it proves that the government isn’t the solution.
The fight over whether to expand the government’s health care system to cover all Americans has been part of the national conversation for generations, albeit often on the fringes, and was a topic of debate even before independent Sen. Bernie Sanders, of Vermont, made it his campaign rallying cry during his first Democratic primary presidential campaign in 2016.
In fact, it was the lessons learned during President Bill Clinton’s failed health care reforms in the 1990s that inspired the term Medicare-for-all. The phrase first appeared in the Congressional Record in 2003 on a House bill introduced by former Rep. John Conyers Jr., of Michigan, and again in 2006 when the late Massachusetts Sen. Edward M. Kennedy, long a proponent of national health insurance, introduced the “Medicare for All Act.”
But it was a former staffer who suggested Kennedy start saying Medicare-for-all instead of single-payer.
“It was too wonky, and no one knew what it meant,” Dr. Philip Caper, a single-payer advocate for nearly 50 years who worked with Kennedy from 1971 to 1976, said during a phone interview from his home in Maine. “I said: What we’re really talking about is expanding Medicare for everybody. I think you should use Medicare-for-all from now on. It’s harder to demonize it … and you don’t have to explain it.”
The senator took his advice, but the bill died in committee.
“This is the first time the notion of Medicare-for-all has really had any political traction” since 1974, Caper said.
It was the subject of the first question asked during the first night of the second Democratic presidential debate in Detroit, where the discussion lasted more than 20 minutes. And a recent Morning Consult/Politico poll showed that 65% of voters say they would support a candidate in the Democratic primary who favors Medicare-for-all over preserving and improving current health care laws.
Still, Caper said, for such a shift to work, there would be a huge need to educate the public and grow a large, active constituency around Medicare-for-all. Elected officials “hate the political pain” that often accompanies large-scale change, he said.
Plenty of people are arguing against Medicare-for-all, urging program reforms but not restructuring. Dozens of health care business groups created the Partnership for America’s Health Care Future to eschew “one-size-fits-all health care … whether it’s called Medicare for all, buy-in, or a public option.” And though the American Medical Association is not listed as a member on the alliance’s website, its president said recently that it too believes in a “pluralistic system.”
“Rather than disrupt what we have now, let’s build up on the progress of it,” said Dr. Patrice Harris, president of the AMA. “Ninety percent of folks have health insurance. It really is about the 10% of folks who don’t.”
Making national health insurance a reality would mean redesigning the country’s health care payment infrastructure. It would involve going from a diffuse network that includes private insurers for those who can afford it and public services for a limited number of those who can’t into a single government-administered system. The role of insurance companies would be vastly reduced. By one estimate, as many 2 million people who are paid to process insurance claims or argue about them would lose their jobs.
Would people get to keep their doctors? Unclear. Would prescription drug costs decrease? Uncertain. Would wait times increase? Unknown. Copays? No, depending on the plan. Increase in taxes? Almost certainly, but again, it depends.
Because the current system doesn’t cover everyone, the government would have to raise money (that is, taxes) to pay for a national health care system. Economists and health experts agree that this would cost significantly more than the $3.5 trillion the nation currently spends on health care, about a third of which is spent on private insurance. And a substantial sum of the nation’s health care costs goes to administering and processing insurance claims.
They disagree on who would get taxed or how much and over whether the trade-off — higher taxes in exchange for limited to no copays, premiums or deductibles — would be worth it. Some experts argue that creating a national health care system would cost the country an additional $32 trillion. Others say it would eventually save $12.5 trillion. Determining who’s right, and by how much, depends on the design of the system which remains a heavily debated point of contention.
“When you say Medicare-for-all, there are eight different flavors,” with each dependent on each presidential candidate’s platform, said John McDonough, a professor at Harvard’s T.H. Chan School of Public Health who was instrumental in both Massachusetts’ universal health care plan and the Affordable Care Act. “It’s an advertising slogan; it’s not a scientific concept.”
A Kaiser Family Foundation report from July found that about three-fourths of the country supports expanding public health insurance programs, including allowing those 55 to 64 to buy into Medicare.
But the report showed that how politicians talk about the issue matters, with 63% responding favorably to the terms “Medicare-for-all” and “universal health coverage.” Those positive feelings begin dissipating when it’s called a “single-payer national health insurance system,” dropping to 49%. They essentially evaporate if it means eliminating private insurance, increasing taxes or disrupting the current Medicare system, with about 60% opposing a national health care plan.
“The problem is: What is Medicare-for-all?” asked Ashley Kirzinger, associate director for the Kaiser Family Foundation’s public opinion and survey research team, which has been polling on the topic since Sanders’ 2016 campaign pushed it into the mainstream. “It’s not Medicare and lots of times it’s not for all, so it’s a little bit of a misnomer.”
Core dimensions of health policy — cost, access, quality and equity — vary wildly depending on factors such as income, geography, race, gender, ethnicity and job type, McDonough said, adding that creating a formula to improve everyone’s health care is “very hard. When you make changes, you will improve it for many but diminish it for others.”
All 20 Democratic candidates say health care is a human right, and universal coverage has been a cornerstone of the Democratic Party’s platform. But universal coverage and Medicare-for-all can be achieved in very different ways — one can include keeping private insurance and the other, in the strictest sense, doesn’t — and are not necessarily synonymous.
Candidates’ health care platforms exist on a spectrum from least to most disruptive, with some calling for building on the current system while others champion its complete dismantling.
Twelve support Medicare-for-all — or something like it — with some, such as Beto O’Rourke, the former Texas congressman, and Mayor Pete Buttigieg of South Bend, Indiana, opposing a single-payer system while trading in the brand recognition that is Medicare-for-all with their respective slogans “Medicare for America” and “Medicare for all who want it.”
The candidates views are not fixed. Some have occupied several positions at once or adjusted their plans to be more mainstream.
Three of the six senators in the race co-sponsored the bill written by Sanders to establish a national Medicare-for-all health insurance program. And until recently he remained the consistent single-payer stalwart, committed to the bill as written. But he, too, reportedly announced compromises for union workers that would allow any employer savings under Medicare-for-all to be passed along to workers in money or other benefits. Others, however, have flirted with — or flat-out embraced — maintaining private insurance.
And Sen. Kamala Harris of California, who calls her plan Medicare-for-all though it includes a mix of public and private insurance, co-sponsored the Sanders bill. She also co-sponsored four other bills along the ideological spectrum currently before Congress.
Then there are candidates such as former Vice President Joe Biden and former Maryland Rep. John Delaney who say Medicare-for-all is too controversial and costly an experiment. Universal coverage can be reached without completely upending the system, they contend.
Caper, the single-payer evangelist who helped popularize the term, said presidential candidates “water it down” and “confuse the issue” by suggesting Medicare-for-all can include commercial insurance.
To him it’s simple: The mission of commercial insurance is to make money while Medicare’s mission is to facilitate care for people. “That’s a fundamental difference,” he said.
Some voters remain unmoved, convinced that the health care debate is little more than meaningless campaign rhetoric.
“Politicians have no clue what it’s like out here,” said Margaret Coates, who, for more than two decades, worked in medical billing for providers and insurers.
Medicare is expensive and confusing, she said, and so is trying to buy health insurance. About two years before she turned 65, Coates said the government began inundating her with a dizzying array of information about Medicare.
“I did not know how expensive these plans were until I reached Medicare age,” she said, sitting in the magazine section of the Gaithersburg library, where signs posted against the back wall ask, “Are you eligible for help with Medicare costs?”
The need for help is widespread. Medicare covers about 80% of the costs of doctor visits and outpatient services; most seniors buy insurance to cover some or all of the remainder.
Coates’ 28-year-old daughter, a cosmetologist, has had her own health care struggles. Last year, she paid more in federal taxes for not having insurance, a penalty that costs at least about $700 per adult. (The Tax Cuts and Jobs Act of 2017 eliminated penalties for taxes filed in April 2020.) To avoid another penalty, she took on the cheapest insurance she could find at a cost of about $120 a month. With a $3,000 annual deductible, she has had to turn to her parents for help with medical bills.
“Everyone is up there cheering and happy because you have medical insurance,” Coates said. “But no one is saying what happens after you get it.”
Much of the conversation about the costs associated with Medicare-for-all include trillion-dollar figures, which does little to explain how it would affect taxpayers’ wallets. What resonates most with voters are not big aggregate numbers, but people’s out-of-pocket costs, said Kenneth Thorpe, an Emory University health policy researcher who worked as a legislative consultant to Vermont during its failed effort to create a single-payer system.
“We spent two years doing estimates, saying if we ran [health care] through the state, what would the state have to raise in taxes?” The answer, he said: Almost a 20% increase in payroll and income taxes. Creating a single-payer plan that would have covered everyone in Vermont would have forced some small businesses to close and put some people out of work.
In the end, he said the trade-off — increase taxes to expand coverage and decrease health care costs — wasn’t worth it, so “they dropped it, one of the most liberal states in the country.”
Charles Blahous, a senior research strategist at the Mercatus Center at George Mason University, and a former trustee of the Medicare and Social Security programs, said it would be an “analytical mistake to say we’re paying for this in other ways.” Because, he continued, “even if you make a very aggressive assumption for substantial administrative cost savings and substantial drug cost savings. It would still be the case that national spending would be higher.”
About 81% of Democrats and left-leaning independents say the federal government has a responsibility to ensure health insurance for all Americans, according to a recent Pew Research Center poll. The opposite is true of Republicans and right-leaning voters, 77% of whom say this is not the government’s responsibility.
Anger over the passage of the Affordable Care Act, which made health care more accessible and affordable for millions of Americans without coverage (though, critics say, not affordable and accessible enough), helped give rise to the Tea Party. Republicans made repealing President Barack Obama’s signature health care legislation central to their party’s effort until the 2018 midterm elections, when voters turned out en masse demanding that key provisions be retained.
Still, the Trump administration said replacing the ACA is key, backing a federal lawsuit seeking to overturn the law and proposing rules allowing individuals to purchase short-term insurance, small businesses to join forces to offer employees health plans, and employers more flexibility in how they fund health insurance.
Health and Human Services Secretary Alex Azar reiterated the administration’s objective of “choice and competition” during a July speech before an advocacy group whose mission is to improve private health insurance options for Medicare beneficiaries while taking aim at the Medicare-for-all debate. He criticized “a total government takeover” as a “reckless” idea.
Taking a seat at an empty barber chair at Graceful Touch, Antonio Dickerson shakes his head in disgust at the idea of government working to improve life for people like him.
“Absolutely not,” said the 50-year-old, rubbing a scar on his shin, a reminder of health care interactions that have left him with a heavy dose of skepticism that Medicare-for-all — or essentially any government action — will result in meaningful reform.
He watched Jenkins, his friend and co-worker, return to work instead of recuperating after surgery because he can’t afford the supplemental coverage that would allow him to take more time to heal.
He watched his grandmother die two weeks after being released from the hospital, saying her insurer would no longer cover the cost of her care.
He watched one nurse’s shift end — and begin again — as he waited, uninsured, in an emergency room for hours, blood oozing from an open wound on his shin that eventually required 32 stitches.
“If you don’t have any money, get to the back to the line,” he said asking if those in the barbershop had ever seen “John Q,” a 2002 movie starring Denzel Washington about a husband and father whose son needs a life-saving operation but insurance won’t cover it.
Washington’s character takes the emergency room hostage, forcing the hospital and doctors to perform his son’s heart transplant.
That, said Dickerson, is “a very understandable situation.”
By Michael Hiltzik
Los Angeles Times, September 4, 2019
You’ve got to hand it to Sen. Bernie Sanders for his ability to keep hot-button issues in the forefront of the presidential race.
The latest example is his assertion, made at least twice in the last month, that medical bills drive 500,000 Americans into bankruptcy every year. The Washington Post’s fact-checker column examined the numbers and concluded that Sanders deserved “three Pinocchios” for the statement, which means the Post found it “mostly false” and that Sanders was, basically, lying.
The Post blundered, as the authors of the study on which Sanders based his claim point out. In the real world, Sanders’ assertion that “500,000 Americans will go bankrupt this year from medical bills” is “mostly true.” Medical bankruptcy is an American scandal, and possibly even more common than he or the study’s authors calculate.
“At this point everyone agrees that many thousands of Americans suffer medical bankruptcies each year, but there’s still scholarly debate over exactly how many,” Himmelstein and Woolhandler wrote in response to the Post fact-checking. “Economists and business school professors (including some funded by the health insurance industry) generally offer lower estimates, and medical and legal researchers find higher numbers.”
Unquestionably, the individual burden of medical costs in the U.S. can be unsupportable and, in the richest country in the world, should be unnecessary. Sanders and Warren are right to point the finger at a dysfunctional healthcare financing system. Those who say things aren’t that bad are wrong; it’s worse. Debating whether the number of Americans forced into bankruptcy by medical debt is 500,000 or some other figure is nitpicking, and woefully beside the point. What everyone knows is that the threat is bad enough, and it can strike at anyone.
By Salvador Rizzo
The Washington Post, August 28, 2019
This fact check has been updated with a rebuttal response
Sanders’s statements — “500,000 people go bankrupt every year because they cannot pay their outrageous medical bills” and “500,000 Americans will go bankrupt this year from medical bills” — are unambiguous. He’s saying medical debts caused those 500,000 bankruptcies. However, correlation is not causation, and the study he’s citing doesn’t establish causation for all 500,000 bankruptcy cases.
One of the authors sent us rough estimates showing that Sanders might be on target, but those numbers deserve scientific scrutiny before they can be taken as fact.
The omissions and twists are significant enough to merit Three Pinocchios for Sanders.
By David U. Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H
The Washington Post has broken new ground, calling a presidential candidate a liar for citing a statistic from research published in the world’s leading public health journal. The Post’s Fact Checker column labeled Bernie Sanders a “three pinocchio” level liar for saying that 500,000 Americans are bankrupted by medical bills each year. Sanders’ statement relied on research that we and three colleagues published in the American Journal of Public Health (AJPH). Dozens of politicians and publications (including the Post itself!) have cited that study as a reliable source.
Our AJPH study was part of an ongoing research effort by the Consumer Bankruptcy Project (CBP). For decades, the CBP has been surveying debtors about the causes (including medical ones) and consequences of their bankruptcy. In our 2019 research, 37.0% of bankrupts “very much” agreed that medical bills were an important factor, while another 21.5% “somewhat agreed”. Many others cited lost wages due to illness, and overall, two-thirds cited illness-related bills, income loss or both. As we wrote in the AJPH, that’s “. . . equivalent to about 530 000 medical bankruptcies annually.” That figure is in line with estimates based on our earlier CBP studies (carried out with then-Harvard law professor Elizabeth Warren and sociologist Deborah Thorne), which were published in leading medical and policy journals.
But even the 530,000 figure is an underestimate of the number of people affected by medical bankruptcies. Most bankruptcies involve more than one person – an average of about 2.7 people, often including a spouse/partner and children. That means that the 750,000 bankruptcies last year involved more than 2 million people. And even if you use the most restrictive definition of medical bankruptcy – i.e. including only debtors who “very much” agreed that medical bills were a cause of their bankruptcy – Sanders’ 500,000 figure is, if anything, too low. The right number is more like three quarters of a million.
And our studies aren’t the only indicator that many American families suffer a crushing burden of medical bills. A Nobel Prize winner was forced to sell his medal to pay medical bills. More than 250 000 people sought to raise funds for medical bills through GoFundMe campaigns last year. According to the Consumer Financial Protection Bureau, medical bills account for more than half of all unpaid bills sent to collection agencies. And in a New York Times/Kaiser Foundation survey, more than one quarter of respondents said they or someone in their household had a problem paying medical bills, and of them, 11% said they’d declared bankruptcy due, at least in part to medical bills.
So why did the Fact Checker claim that Sanders told a whopper? That claim rests on an econometric study that found only a modest uptick in bankruptcy filings among persons hospitalized in California between 2003 and 2007. But that study appeared tailor made to undercount medical bankruptcies. As we and Elizabeth Warren noted in our response to it in the New England Journal of Medicine, it excluded most people who were frequently hospitalized (a group that’s at high risk of medical bankruptcy); it assumed that anyone not hospitalized could not suffer medical bankruptcy (even though people who aren’t hospitalized in the course of a year account for four-fifths of all out-of-pocket medical bills); that no one is bankrupted by bills for a child’s or partners’ care; and that potentially bankrupting illnesses never start before the moment of hospitalization – an assumption contradicted by the study’s own data.
Yet despite these flaws, the economists behind the study insisted (and the Post believed) that their math was a more reliable indicator of what caused financial ruin than the testimony (and court records that we’ve used as cross-check) from the thousands of debtors surveyed and interviewed by the CBP.
At this point everyone agrees that many thousands of Americans suffer medical bankruptcies each year, but there’s still scholarly debate over exactly how many; economists and business school professors (including some funded by the health insurance industry) generally offer lower estimates, and medical and legal researchers find higher numbers. We’d be happy to see the Post report the facts and nuances of that debate. But instead it’s chosen a side and labeled those on the other side – researchers, public figures who cite their research, and the debtors who shared their painful stories – “liars.”
David U. Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H. are both Distinguished Professors of Public Health, City University of New York at Hunter College and Lecturers in Medicine at Harvard Medical School, and the founders of Physicians for a National Health Program.
By Don McCanne, M.D.
The United States is unique in supporting a health care financing system that results in financial hardship for millions of people due to medical bills. Many of those individuals end up in personal bankruptcy whether those bills were a contributor or a “cause” of the bankruptcy.
For many years now, the bankruptcy statistics have been debated, not based on whether medical bills cause financial hardship or contribute to bankruptcy – they clearly do and on a massive scale. Rather, the debate has been over the definition of “cause” when used to estimate the number of bankruptcies “caused” by medical bills. Those who wish to discredit the bankruptcy studies seem to disregard medical debt as “a” cause of bankruptcy and insist that only medical debt as “the” (presumably sole) cause of bankruptcy be counted in the statistics.
David Himmelstein and Steffie Woolhandler, in their response above, set the record straight. Medical debt in the United States is a horrendous problem that creates much hardship, and it is totally unnecessary.
All we need to do is to separate the health care financing system from the delivery of health care. We can finance the entire health care system with equitable taxes that are affordable for each of us without creating any personal financial hardship. Then when individuals need health care they can get it without the necessity of paying insurance premiums nor deductibles, copayments or coinsurance as a condition for accessing health care.
A Single Payer Medicare for All system would ensure health care for everyone without exposing them to financial hardship nor personal bankruptcy due to medical debt. The media and policy community should stick to the issues that actually impact our health care rather than distracting us with their pinocchio mischief.
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