PNHP

What would a public option do to ACA marketplaces?

What would a public option do to ACA marketplaces?

Assessing the Impact of a Public Option on Market Stability and Consumer Choice

FTI Consulting, November 2019

Key Findings

  • Introducing a public option could create a “two-tier” health system where employer- based insurance provides access to a different set of hospitals or services than those available to enrollees in public insurance.
  • The government would be expected to set premiums for the public option approximately 25 percent below market value for comparable private insurance plans, squeezing out private competition and diminishing consumer choice. The significant discrepancy in premiums would cause the eventual elimination of all private plans in the individual market.
  • By 2028, 20 percent of state marketplaces would not offer a single private insurance option as a result of the introduction of the public option.
  • In the first year following introduction of the public option, over 130,000 Americans enrolled in ACA coverage would be forced off of their existing health plan as private insurers exit the marketplaces. Over a decade, up to two million marketplace enrollees could experience a loss of private coverage.

Conclusion

The success of the ACA in expanding affordable coverage through increased private sector competition is one reason why it remains popular today. For years, politicians have toyed with the idea of introducing a public option into our nation’s health care system. Time and time again, efforts have failed when it became clear that doing so would destabilize health coverage for the millions of Americans satisfied with their existing coverage. The results of FTI’s analysis demonstrate that introducing a public option to the ACA marketplaces would not serve to build upon the existing system, but would instead displace private insurance plans in most markets. Instead of bearing the risks associated with public option plans, several states have implemented market stabilization measures, such as reinsurance, that have successfully reduced costs to consumers and state governments. Such programs offer a potential alternative to the public option for policymakers seeking to reduce health care costs while preserving consumer choice.

Acknowledgments: This work was supported by the Partnership for America’s Health Care Future.

https://americashealthcarefuture.org…

Comment:

By Don McCanne, M.D.

This consultant’s report was supported by the Partnership for America’s Health Care Future – “an ad hoc alliance of American hospital, health insurance, and pharmaceutical lobbyists committed to preventing legislation that would lead to single payer healthcare, expanding Medicare, or creating Medicare for All in particular” (Wikipedia). So what bias does the report demonstrate?

The consultants conclude that introducing a public option (a publicly administered insurance program) to the ACA insurance exchanges (marketplaces) would place the private plans at a considerable competitive disadvantage and drive them out of the exchanges.

What could the public option do that would be more appealing to patients than the private plans? Rather than the narrower provider networks of the private plans, the public option might be open to all current Medicare providers, which constitute most of our health care delivery system. Also they expect premiums for the public option to be 25 percent lower than private plans, likely representing both administrative efficiencies and administered pricing that would be features a public option.

The public option does sound like a much better deal for beneficiaries than the private plans. In fact, driving out the more expensive private plans through competition is touted to be a benefit of markets. The risk under market theory would be that the single plan remaining would be a monopoly that could drive prices up and reduce services. But in this case the public option would not be driven by profits and shareholder demands; instead, it would continue as a public service providing appropriate health benefits at a fair cost.

Although it would seem that this report was produced to scare the public by threatening them with the loss of their private coverage, it seems that it might have the opposite effect of enticing them into supporting a public option. More likely, this report may be used internally to scare the members of the Partnership for America’s Health Care Future, causing them to intensify their lobbying efforts against the public option, and, by extension, especially against Medicare for All.

This report emphasizes the consequences of a public option since many consider it to be an incremental step towards Medicare for All. But merely enacting a public option would add yet one more player to our highly dysfunctional, fragmented health care financing system. It would be much more logical to move directly to a single payer system of Medicare for All.

Can you imagine what the members must think about the prospect of the government offering the entire nation superior benefits with spending moderated through administrative efficiencies and negotiation of fair prices that would be paid by a public universal risk pool? Unfair competition! Maybe the medical industrial complex would consider it unfair, but what could be more fair for the patients?

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“The idea that employer-based coverage is stable is just incorrect”

Interview with Dr. John Perryman

The Morning Briefing with Tim Farley, November 18, 2019

Audio Player

PNHP-IL co-president Dr. John Perryman appeared on POTUS (Politics of the United States) on SiriusXM to discuss how single-payer Medicare for All would expand choice for patients. “If you have a single-payer system, the entire country becomes your network” he said, in contrast to the current restrictions imposed by insurance companies.

https://www.siriusxm.com/potus

Elizabeth Warren’s proposed transition to Medicare for All

My First Term Plan for Reducing Health Care Costs in America and Transitioning to Medicare for All

By Elizabeth Warren
Medium, November 15. 2019

Every serious proposal for Medicare for All contemplates a significant transition period. Today, I’m announcing my plan to expand public health care coverage, reduce costs, and improve the quality of care for every family in America. My plan will be completed in my first term. It includes dramatic actions to lower drug prices, a Medicare for All option available to everyone that is more generous than any plan proposed by any other presidential candidate, critical health system reforms to save money and save lives, and a full transition to Medicare for All.

(Most of the report describes transitional steps including strengthening the Affordable Care Act, Medicare and Medicaid, and establishing a “true Medicare for All option.”)

Completing the Transition to Medicare For All

By pursuing these changes, we will provide every person in America with the option of choosing public coverage that matches the full benefits of Medicare for All. Given the quality of the public alternatives, millions are likely to move out of private insurance as quickly as possible.

No later than my third year in office, at which point the number of individuals voluntarily remaining in private insurance would likely be quite low, I will fight to pass legislation to complete the transition to the Medicare for All system defined by the Medicare for All Act by the end of my first term in office.

Moving to this system would mean integrating everyone into a unified system with zero premiums, copays, and deductibles. Senator Sanders’s Medicare for All Act allows for supplemental private insurance to cover services that are not duplicative of the coverage in Medicare for All; for unions that seek specialized wraparound coverage and individuals with specialized needs, a private market could still exist. In addition, we can allow private employer coverage that reflects the outcome of a collective bargaining agreement to be grandfathered into the new system to ensure that these workers receive the full benefit of their bargain before moving to the new system. But the point of Medicare for All is to cut out the middleman.

I believe the next president must do everything she can within one presidential term to complete the transition to Medicare for All. My plan will reduce the financial and political power of the insurance companies — as well as their ability to frighten the American people — by implementing reforms immediately and demonstrating at each phase that true Medicare for All coverage is better than their private options. I believe this approach gives us our best chance to succeed.

Why do we need to transition to Medicare for All if a robust Medicare for All option is available to everyone? The answer is simple and blunt: cost and outcomes. Today, up to 30% of current health spending is driven by the costs of filling out different insurance forms and following different claims processes and fighting with insurance companies over what is and is not covered. I have demonstrated how a full Medicare for All system can use its leverage to wring trillions of dollars in waste out of our system while delivering smarter care — and I’ve made clear exactly how I would do it. The experience of other countries shows that this system is the cheapest and most efficient way to deliver high-quality health care. As long as duplicative private coverage exists, we will limit our ability to make health care delivery more effective and affordable — and the ability of private middlemen to abuse patients will remain.

This final legislation will put a choice before Congress — maintain a two-tiered system where private insurers can continue to profit from being the middlemen between patients and doctors, getting rich by denying care — or give everybody Medicare for All to capture the full value of trillions of dollars in savings in health care spending. I believe that the American people will demand Congress make the right choice.

https://medium.com…

Comment:

By Don McCanne, M.D.

As promised, Elizabeth Warren is proposing dramatic transitional steps in improving our health care financing system, ending in the third year with a full transformation into a bona fide single-payer improved Medicare for All program. The sketchy details of the transformation are spelled out in her article, but much more important is that the end goal of a single payer model of Medicare for All is not compromised. It really can be achieved.

PNHP does not endorse any political candidate for public office.

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Medicare for All Explained Podcast: Episode 24

Interview with Prof. Donald Light

November 15, 2019

Professor Donald Light highlights the negative effects of corporate influence over the FDA. How bad is it? “There’s very little evidence that [new drugs] are clinically effective, and also very little evidence that they’re clinically safe.” Hosted by Joseph Sparks. Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Is single-payer the best solution for America’s health care conundrum?

Interview with Dr. Adam Gaffney

By Kerri Miller and Kelly Gordon
Minnesota Public Radio, November 15, 2019

full audio:
https://www.mprnews.org…

The United States spends more on medical care than any other country in the developed world —about 18 percent of our gross domestic product, almost twice the average of other wealthy countries. Maybe that’s why nearly 7 out of every 10 Americans say cutting health care costs should be a top priority of Congress. But how to cut those costs and make health care available to everyone is a thorny question.

Monday, Kerri Miller dug into the concept of universal, or single-payer, health care. Is it really the best solution to fix a health care system that’s badly in need of repair? What would it cost? How would we pay for it? How would it affect quality? And maybe most important to the consumer – how would it affect the bottom line? Two experts joined Miller to sort out the single-payer proposals.

Guests:

  • Adam Gaffney, a critical care physician in Cambridge, Mass., and president of Physicians for a National Health Program
  • Bradley Herring, professor of health economics at Johns Hopkins Bloomberg School of Public Health

https://www.mprnews.org…

BlueCross BlueShield Association shifting support to narrower network plans

Blues plans to launch high-performance network nationwide in 2021

By Paige Minemyer
FierceHealthcare, November 13, 2019

Blues plans are launching a high-performance network nationwide.

The Blue Cross Blue Shield Association (BCBSA) revealed this week that its member plans would offer Blue HPN beginning in January 2021. The network will be available in 55 markets across the U.S.

Jennifer Atkins, vice president of network solutions at BCBSA, told FierceHealthcare that the goal in launching the network was to build on the plans’ existing value-based and patient-centered models.

There was strong interest in the individual markets for such a network, she said. About 70% of members in BCBSA plans are enrolled in a value-based contract.

Employers are taking a more “activist” role in healthcare, and part of that effort includes greater uptake of options such as direct contracting and high-performance networks to drive lower costs without pushing additional cost sharing for employees.

Atkins said that existing value-based contracts deliver an average of 10% in total cost savings and that the BCBSA members expect a high-performance network to grow that number further. With 74 million members in its base, Atkins said the Blues plans believe they can reach the “critical mass” necessary to gather quality providers.

In developing the networks, the plans will take a “best of local” approach that allows each plan to meet the needs of its markets under a shared set of standards. Quality metrics focus on offering the appropriate care, promoting adherence and boosting outcomes, and Blue HPN allows for individual plans to build in their own metrics to fit regional needs.

A key concern in a narrow-network plan is that members may not have a full grasp of what’s covered, which could put them at greater risk of unexpected medical bills that they cannot afford.

“We have been working hard to ensure that when we’re communicating to employees though employer that picked the high-performance network so that they can be confident that they’re receiving the best care at best price,” Atkins said.

https://www.fiercehealthcare.com…

Blue High Performance Network:
https://www.bcbs.com…

Comment:

By Don McCanne, M.D.

One problem with employer-sponsored plans today is that cost sharing, especially high-deductibles, has been pushed to the limit. By making patients pay more out of pocket at the time of service, health care has been made less affordable and patients may forgo beneficial health care services because of these out-of-pocket costs. Employers have been recognizing these adverse consequences and thus are looking for alternative means of controlling health care spending.

Instead of pushing cost sharing even higher, BlueCross BlueShield Association is embarking on an ambitious national plan to establish a narrow “high-performance” network in selected markets nationally. Although they are marketing these networks to employers as being high performance, to achieve cost savings they actually are contracting for lower rates by promising health care providers greater exclusivity, thus reducing competition for those in the networks by keeping the provider networks narrow.

This is typical of the highly undesirable tradeoffs that are inevitable in a market of private health plans. In this case, patients lose their choices of physicians and hospitals in exchange for avoiding further increases in their out-of-pocket spending. But they may also be exposed to surprise medical bills because of care unavoidably provided out of network.

Contrast this with a well designed, single payer model of Medicare for All. Patients have free choice of their health care professionals and institutions, while financial barriers to accessing health care are removed. Of course there are endless other benefits such as guaranteed coverage for everyone for life, efficiencies through reduction in administrative waste, public administration of pricing, and care finally becomes affordable for each individual by the use of equitable (progressive) tax policies to fund the universal risk pool.

Blue Cross and Blue Shield plans are not inherently evil; it is our public officials who are evil when they insist that we continue with the fragmented, dysfunctional system of private and public plans when they have before them a model that would work well for everyone and they continue to reject its enactment and implementation, when their obligation is to inform the public on the moral imperative of single payer Medicare for All – a public that is much more influenced by sound bites than by policy science (what’s that?).

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‘I live on the street now’: how Americans fall into medical bankruptcy

Having health insurance is often not enough to save Americans from massive debts when serious illness strikes

It’s been over a dozen years since Susanne LeClair of West Palm Beach, Florida was first diagnosed with cancer and she’s been fighting ever since. Now she, like many other Americans facing life-threatening illness, is bankrupt despite having health insurance.

Before her first cancer-related surgery, LeClair was told by the hospital they accepted her employer-based health insurance.

“I paid my $300 copay. After the surgery, I started receiving all these invoices and came to find out the only thing covered was my bed because the hospital was out of network,” said LeClair. “My bills were hundreds of thousands of dollars, so I had no choice but to file bankruptcy.”

LeClair is on the verge of having to file for bankruptcy a second time due to the mounting medical debt she has accrued for additional cancer-related surgeries, regular appointments, medications and supplies related to her recovery, despite having health insurance and paying as much as she can out of pocket for copays, deductibles and premiums to maintain insurance.

“My medical bills are at $52,000. I’ve done everything from credit cards to consolidation loans, I just keep simply paying one credit card with another interest-free one until I can pay the next one,” LeClair added. “It’s the side of cancer most people don’t understand or know about and it’s never-ending. It just keeps adding up and adding up and before you know it you’re back in debt that you can’t believe again.”

Bankruptcy can also make it difficult to find employment given that many employers will disqualify a candidate with a bankruptcy filing found from a background check.

According to a study published in February 2019, about 530,000 bankruptcies filed annually are because of debt accrued due to a medical illness. The study found that even the Obama administration’s landmark Affordable Care Act (known as Obamacare) has failed to change the proportion of bankruptcies caused by medical debts, with poor health insurance cited as one of the main culprits.

Republicans and Democrats are currently at loggerheads over Trump administration plans to further weaken Obamacare by making it easier for states to opt out of certain requirements and offer cheaper plans that could further exacerbate the situation. And health insurance has emerged as one of the signature issues of the 2020 election, and the fight for the Democratic presidential nomination with senators Bernie Sanders and Elizabeth Warren promising a total overhaul and Joe Biden and others pledging milder reforms. What all sides admit is that the current system is broken.

“Health insurance that we have today is a defective product,” said Dr David Himmelstein, distinguished professor of public health at City University of New York’s Hunter College and a lecturer in medicine at Harvard Medical School.

“A lot of people, a little over 60%, are filing bankruptcy at least in part because of medical bills. Most of them are insured. It’s clear that despite health insurance, there are many, many people incurring costs not being covered by their insurance,” said Himmelstein. “Medical debt is incredibly common, it’s the main cause of calls from collection agencies, and the vast majority of people with it have insurance,” said Himmelstein, lead author of the study Medical Bankruptcy: Still Common Despite the Affordable Care Act.

One out of every six Americans has an unpaid medical bill on their credit report, amounting to $81bn in debt nationwide, while about one in 12 Americans went without any medical insurance throughout 2018. Even as many Americans struggle to afford health insurance coverage in the first place, those that have it are not insulated from facing massive debt due to medical bills.

“I have insurance through my job but it has a high premium and high deductible. I have to pay $450 a month. When you think about living paycheck to paycheck, $450 is a lot of money. I’m barely making it. Some bills don’t get paid every month,” said Mary Cross of Detroit, Michigan, who has filed for bankruptcy twice since early 2013 when she was admitted to the hospital for pneumonia, required lung surgery and was diagnosed with sarcoidosis, an inflammatory disease.

“I’m currently struggling to stay afloat now due to having surgery this past January,” added Cross, 51. “I’ve been getting constant calls from the billing department at the hospital where I had surgery.”

In Savannah, Georgia, a 35-year-old man who requested to remain anonymous to avoid being associated with a bankruptcy, recently found himself homeless and jobless due to prolonged hospital stays and hundreds of thousands of dollars in medical debt.

A type 1 diabetic for years, he had to reduce his work hours for a cellular retail store when trouble regulating his blood sugar resulted in a toe amputation in April 2019.

“I had to cut my work hours so bills were harder to pay. But in July 2019 I was admitted to the hospital again and I was fired from my job because I was in the hospital. I lost my insurance. They amputated my leg, which means I still can’t work,” he said.

When he lost his job due to the prolonged hospital stay and leg amputation, his employer offered Cobra, a health insurance program for employees who lose their job or have a reduction in work hours, but he couldn’t afford it. He is currently working on trying to file bankruptcy to release the medical debt he’s accrued from amputations this year and he lost his house in October 2019 as a result.

“I have amassed over $400,000 in medical bills I need to pay, and still have at least six months before I get a disability hearing. So I owe over $400,000 in medical bills, have lost my house and I live on the street now, with no end in sight,” he said.

Just outside of Chicago, Illinois, Jessica Hillman filed for bankruptcy in 2016 due to medical debt accrued from battling a seizure disorder, despite having health insurance coverage for the majority of her treatment.

“I had thousands of dollars in various medical debt which made the majority of my claim. The last bill I got that really pushed me toward the bankruptcy was for a routine lab test that my insurance refused to approve because of a billing mistake. That bill was about a thousand dollars,” Hillman said. “I couldn’t work and had no way to pay these.”

At the time, Hillman was receiving several collection notices in the mail for past hospital stays and tests amounting to several thousand dollars, often having no knowledge of the bills that health insurance didn’t cover until receiving the collection notices.

“One of the biggest hurdles you face as a patient is just the sheer confusion of the process. You think you just show up and present your card, sometimes pay a copay, and that’s it. You don’t expect all these plan limitations and authorizations,” Hillman added. “What are you going to do if your authorization gets denied? You don’t really have a choice to not go get care. All these processes that are in the finest of fine print. And sometimes it feels like you are literally paying for nothing.”

https://www.theguardian.com…

Dr. Adam Gaffney: Private health insurance restricts patients’ freedom

Fox News Rundown Podcast, November 14, 2019

Health care is expected to be a big issue in the 2020 race for the White House. Democratic presidential candidates Bernie Sanders and Elizabeth Warren have pushing for a “Medicare for All” plan. Republicans and moderate Democrats say it won’t work.

Dr. Adam Gaffney, President of Physicians for a National Health Program, explains why he and other doctors are supportive of “Medicare For All.”

“Right now, the private insurance business model is basically built around restricting freedom,” he says. “If you have a private insurance plan, you can only go to the doctors or hospitals that are in network.” A single-payer program, on the other hand, would offer patients free choice of virtually any medical provider in the U.S.

Dr. Gaffney’s excerpt begins at the 14:02 mark.

https://omny.fm…

Millions know someone who died after not getting treatment

Millions in U.S. Lost Someone Who Couldn't Afford Treatment

By Dan Witters
Gallup, November 12, 2019

Highlights

  • 34 million adults know someone who died after not getting treatment
  • 58 million adults report inability to pay for needed drugs in past year
  • Little progress seen by Trump administration in limiting rising drug costs

More than 13% of American adults — or about 34 million people — report knowing of at least one friend or family member in the past five years who died after not receiving needed medical treatment because they were unable to pay for it, based on a new study by Gallup and West Health. Nonwhites, those in lower-income households, those younger than 45, and political independents and Democrats are all more likely to know someone who has died under these circumstances.

These results are not meant to quantify the number of people who have died after not being able to pay for medical treatment, including prescription drugs, but rather the number of people who report knowledge of a death under such circumstances. In all, the Centers for Disease Control and Prevention estimate that about 2.8 million persons died in 2017 in the U.S. across all causes.

Dovetailing with these results is a rising percentage of adults who report not having had enough money in the past 12 months to “pay for needed medicine or drugs that a doctor prescribed” to them. This percentage has increased significantly, from 18.9% in January 2019 to 22.9% in September. In all, the 22.9% represents about 58 million adults who experienced “medication insecurity,” defined as the inability to pay for prescribed medication at least one time in the past 12 months. The increase reflects a marked rise among women of over five percentage points to 27.5%, widening the gender gap to over nine points when compared with the 18.1% rate for men.

Bottom Line

The substantial number of Americans who know someone who has died after not receiving treatment because of their inability to pay for it, coupled with the rise in the percentage who have not had enough money to pay for their prescriptions, underscores the urgency of the U.S. healthcare cost crisis. These realities starkly highlight the significant practical implications of drug prices on U.S. residents, as well as the effects of healthcare policy action — or inaction.

Only 7% of U.S. adults report that the Trump administration has accomplished “a great deal” on the issue, and voters are clearly expecting more from their elected officials than what has been accomplished in the past three years.

https://news.gallup.com…

Comment:

By Don McCanne, M.D.

People are dying because of their inability to pay for health care. Although there is a lot of political noise on the subject, the inertia is overwhelming. It’s not that we do not understand the policy solutions that would make health care affordable for everyone, we do. A single payer model of Medicare for All would work just fine. Rather it’s that we are allowing the political noise to drown out the pleas for help. Are we just going to walk away?

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Drug co-payments can be hazardous to your health

Effect on Treatment Adherence of Distributing Essential Medicines at No Charge: The CLEAN Meds Randomized Clinical Trial

By Navindra Persaud, MD; Michael Bedard, MD; Andrew S. Boozary, MD; et al
JAMA Internal Medicine, October 7, 2019

Abstract

Importance: Nonadherence to treatment with medicines is common globally, even for life-saving treatments. Cost is one important barrier to access, and only some jurisdictions provide medicines at no charge to patients.

Objective: To determine whether providing essential medicines at no charge to outpatients who reported not being able to afford medicines improves adherence.

Design, Setting, and Participants: A multicenter, unblinded, parallel, 2-group, superiority, outcomes assessor–blinded, individually randomized clinical trial conducted at 9 primary care sites in Ontario, Canada, enrolled 786 patients between June 1, 2016, and April 28, 2017, who reported cost-related nonadherence. Follow-up occurred at 12 months. The primary analysis was performed using an intention-to-treat principle.

Interventions: Patients were randomly allocated to receive free medicines on a list of essential medicines in addition to otherwise usual care (n = 395) or usual medicine access and usual care (n = 391).

Main Outcomes and Measures: The primary outcome was adherence to treatment with all medicines that were appropriately prescribed for 1 year. Secondary outcomes were hemoglobin A1c level, blood pressure, and low-density lipoprotein cholesterol levels 1 year after randomization in participants taking corresponding medicines.

Results: Among the 786 participants analyzed (439 women and 347 men; mean [SD] age, 51.7 [14.3] years), 764 completed the trial. Adherence to treatment with all medicines was higher in those randomized to receive free distribution (151 of 395 [38.2%]) compared with usual access (104 of 391 [26.6%]; difference, 11.6%; 95% CI, 4.9%-18.4%). Control of type 1 and 2 diabetes was not significantly improved by free distribution (hemoglobin A1c, −0.38%; 95% CI, −0.76% to 0.00%), systolic blood pressure was reduced (−7.2 mm Hg; 95% CI, −11.7 to −2.8 mm Hg), and low-density lipoprotein cholesterol levels were not affected (−2.3 mg/dL; 95% CI, −14.7 to 10.0 mg/dL).

Conclusions and Relevance: The distribution of essential medicines at no charge for 1 year increased adherence to treatment with medicines and improved some, but not other, disease-specific surrogate health outcomes. These findings could help inform changes to medicine access policies such as publicly funding essential medicines.

Trial Registration: ClinicalTrials.gov identifier: NCT02744963

From the Discussion

In our multicenter randomized trial, distributing a comprehensive set of essential medicines at no charge improved adherence. Free distribution also lowered systolic blood pressure and there was a suggestion of better diabetes control, although results did not reach statistical significance. There was no effect on low-density lipoprotein cholesterol levels. There was no increase in potentially inappropriate prescribing and there was no substantial difference in serious adverse events. Participants receiving free medicine distribution were more likely to report being able to make ends meet; the hypothesis that medicine access allows people to afford other necessities can be tested in future studies.

Many patients did not see improvements in surrogate outcomes despite free distribution of medicines, emphasizing that cost is only one of several contributors to nonadherence and that medicines are just one part of care.

The setting and design of the trial allows inferences about the causal effects of essential medicine access to be drawn because all participants had access to publicly funded health care services. The study population included people with a range of income levels and sources and different ethnicities who lived in urban and rural settings.

https://jamanetwork.com…

Even a Modest Co-Payment Can Cause People to Skip Drug Doses

By Aaron E. Carroll
The New York Times, November 11, 2019

There’s a logic to out-of-pocket medical payments. They’re supposed to make patients think twice before spending money on unnecessary health care.

When it comes to drugs, however, they’re often preventing people from getting necessary care.

(Cites extensive studies confirming reduced compliance with patient cost sharing.)

Canada’s single-payer system is sometimes held up as the preferred “other” model to the American status quo. But its drug coverage isn’t so good compared with the rest of the world. Pharmaceutical coverage is not part of Canada’s Medicare system, and differs from province to province. Still, Canadians do better than Americans.

Insurance isn’t enough, it seems clear. In 2015, researchers published a study in the Journal of General Internal Medicine that looked at medication adherence and cost-saving strategies of those who have Medicare. About 40 percent of this population took actions to try to cut their costs.

Cost sharing is supposed to lower spending without sacrificing quality. It was not meant to prevent patients who need drugs from receiving them.

NYT Reader Comment:

By Don McCanne, M.D.

Another recent study in Canada showed that patients receiving medications at no charge had significantly higher adherence to treatment (JAMA Internal Medicine, October 7, 2019).

A health care financing system should make it easier for patients to receive essential care they should have. Cost sharing is a barrier to care and should be eliminated. A well designed single payer model of Medicare for All would do just that.

https://www.nytimes.com…

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Influential chief executives of health systems are bringing us more managed care

Who Influences Health Care in the United States? A Study of Trends From 2002 to 2018

By Adam L. Logeman, MS, Oscar Ponce, MD, Neri Álvarez-Villalobos, MD, Victor M. Montori, MD, MSc
Mayo Clinic Proceedings, November 2019

The health care system in the United States is capable of both health care excellence and pricing people out of care. Key individuals can exert influence on public and private discourse, policies, and actions that are responsible for health care’s current state and envision a path forward. Since 2003, the periodical Modern Healthcare has published a yearly ranking of the 100 most influential people in US health care. The list is compiled with readership input and vetted by the periodical’s editorial board using proprietary criteria; the selection is also opaque as to what (ie, health care or clinical policy and the practice or the business of care) or who (ie, policymakers, employers, payers, clinicians, and patients) is subject to their influence. Because it receives wide reporting and limited critique, this list stands as a useful longitudinal account of who others perceive to be in a position to influence health care.

Using the published yearly list and the reported characteristics of the persons listed, we sought to determine the relative ranking over time, covering the period 2002 to 2018, of executives and administrators, academics and frontline advocates, and government officials.

There were 1700 persons named from 2002 to 2018, a minority of them women (range over the period, 17% to 28%). Most influencers are top executives from nonprofit health care provider organizations; their proportion has increased from 23% in 2002 to 72% in 2018, with an apparent substantial upward inflection in this trend since 2009. This predominance appears to be at the expense of academics, advocates, and government officials.

We found that the perceived influence over US health care of chief executives of health systems is increasing. To the extent that the ranking validly reflects influence, the sharp rise in the influence of chief executive officers at the expense of representatives of patients or health professionals may underscore the increasing industrialization of health care. It is not possible to find patients, patient advocates, clinicians, or clinician advocates at the top of this list. This trend placing health care influencers within C-suites, accountable to boards mostly comprising other corporate leaders, may explain the rise of business language and thinking—for example, high-value health care.

Our findings suggest that patients and clinicians are neither defining what health care is nor deciding how it should evolve. Urgently, they must find and use their collective voices to turn away from industrial health care and move decidedly toward careful and kind patient care for all.

https://www.mayoclinicproceedings.org…

To Control Costs Expand Managed Care and Managed Competition

By Alain Enthoven, PhD; Victor R. Fuchs, PhD; Stephen M. Shortell, PhD, MPH, MBA
JAMA, November 7, 2019

The US health care financing and delivery system serves the public poorly. It costs far more than in any other country, does not produce better health outcomes, and leaves millions uninsured.

Over the years, managed care, defined as patient-centered coordinated care provided under payment incentives that reward achieving cost and quality measures, and managed competition, a market designed to create incentives for managed care organizations (MCOs) to reduce cost and improve quality and patient satisfaction, have demonstrated a potential to control costs without any sacrifice of quality.

Managed care increases efficiency of care delivery within individual health plans. Managed competition creates a structure within which health care plans compete with one another. The 2 are complementary and synergistic, and have several advantages over reforms that require government-initiated transformation of all medical care. These models offer the possibility of controlling costs without government price controls.

Managed Care

Managed care, a concept that addresses both payment and delivery, has a long history, beginning with Kaiser Permanente in the 1940s and including passage of the Health Maintenance Organization Act of 1973 and current interest in risk bearing ACOs. Managed care, fully or partially implemented, is now a widespread form of health care in most parts of the country.

2019 data suggest that more physician organizations are owned or strongly affiliated with a specific hospital/health system, reducing to some extent the overlap of physician networks.

Managed Competition

The competitors are health care financing and delivery plans based on managed care or traditional open-ended fee-for-service systems.

For managed competition to succeed, it must lead to the transformation of US health care from traditional, open-ended, uncoordinated fee-for-service systems to efficient MCOs.

From the Conclusions

When an economic or health care crisis comes, cost control will have priority, but crisis solutions are rarely the wisest. Managed care and managed competition are not panaceas. As is true of all types of medical care interventions, clinical or organizational, not every individual attempt will succeed; however, managed care and managed competition have a good record of success in controlling costs and maintaining quality without resorting to price controls, the principal alternative.

https://jamanetwork.com…

Comment:

By Don McCanne, M.D.

The most influential people in U.S. health care? It’s not the patients. It’s not the clinicians. It is not the academics, advocates, nor government officials. According to the Modern Healthcare survey, it’s the top executives of health care provider organizations, or leaders of “industrial health care” (forget about “medical”).

And what about the managed care revolution that failed to adequately control high health care spending and left in place the health care injustices that are so prevalent today? The deafening echo perpetuated through recent decades is intensifying in its call for yet more managed care, now often labeled as ACOs or value-based care. And what do we hear from the health care academics? Net savings performance still varies widely and quality performance is still highly variable (Health Affairs Blog, October 25, 2019). It is not working.

And just to confirm that not much has changed, the Old Guard (Enthoven et al) tell us that we need to continue to expand this model to control costs in order to avoid government price controls. What? Costs have continued their upward spiral in the private commercial insurance market (in spite of transient brief slowing) yet have been much better controlled under the government-run Medicare program. Tens of millions remain uninsured and many more remain underinsured while patients are losing their choices of physicians and hospitals. Again, managed care is not serving us well.

The private sector is not going to voluntarily bring most people under the safe umbrella of health care. When the private industry has already tapped those backed by adequate resources, only government policies can pull the rest in. Only the government can ensure that absolutely everyone is included, that financial and other barriers to access are removed, that all essential services are covered, and that the system is affordable for each of us through a universal financing system funded through equitable taxes. None of these are functions of managed care.

We need to discharge the private managed care managers and replace the system with our own public stewards. As the authors of the Mayo Clinic Proceedings article state, “patients and clinicians must find and use their collective voices to turn away from industrial health care and move decidedly toward careful and kind patient care for all.”

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Half of Medicare beneficiaries with serious illness face financial hardship

Financial Hardships Of Medicare Beneficiaries With Serious Illness

By Michael Anne Kyle, Robert J. Blendon, John M. Benson, Melinda K. Abrams, and Eric C. Schneider
Health Affairs, November 2019

Abstract

In a national survey, seriously ill Medicare beneficiaries described financial hardships resulting from their illness—despite high beneficiary satisfaction with Medicare overall and the fact that many have supplemental insurance. About half reported a serious problem paying medical bills, with prescription drugs proving most onerous.

Conclusion

Medicare insurance is broadly popular, but seriously ill beneficiaries who most need financial protection report widespread problems affording care and financial instability.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

Medicare should be especially advantageous for beneficiaries with serious illness, but about half reported a serious problem paying medical bills.

Although “Medicare for All” initially referred to the vastly superior single payer model of reform, the label has been corrupted. For some it refers to merely adding a Medicare-like public option to our dysfunctional system of health care financing. For others it means that your insurance through work will be taken away from you, and, to compound problems, your taxes will go up.

Regardless of labels, it is imperative that the public understands that the single payer model would provide affordable, comprehensive health care for absolutely everyone. No other model, whether or not labeled “Medicare for All,” comes close. That begins by understanding that we are not proposing to continue with the inadequate traditional Medicare program, but we would be replacing it with a vastly improved version, whether labeled “Single Payer Improved Medicare for All” or whatever.

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