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Gruber and Sommers tell us what we have learned from 10 years of ACA

Gruber and Sommers tell us what we have learned from 10 years of ACA

The Affordable Care Act’s Effects on Patients, Providers and the Economy: What We’ve Learned So Far; NBER Working Paper 25932

By Jonathan Gruber and Benjamin D. Sommers
National Bureau of Economic Research, June 2019

Abstract

As we approach the tenth anniversary of the passage of the Affordable Care Act, it is important to reflect on what has been learned about the impacts of this major reform. In this paper we review the literature on the impacts of the ACA on patients, providers and the economy. We find strong evidence that the ACA’s provisions have increased insurance coverage. There is also a clearly positive effect on access to and consumption of health care, with suggestive but more limited evidence on improved health outcomes. There is no evidence of significant reductions in provider access, changes in labor supply, or increased budgetary pressures on state governments, and the law’s total federal cost through 2018 has been less than predicted. We conclude by describing key policy implications and future areas for research.

From the Conclusion

Disentangling which aspects of the ACA have the largest impacts will be critical as policymakers consider both selective restrictions and expansions of the law’s provisions. The effect of the individual mandate repeal and potential barriers to coverage such as Medicaid work requirements have been the focus of recent political discussions, while early forays into health policy among Democratic presidential contenders often focus on making exchange plans more affordable. Understanding the effects not just of having any health insurance but the particular type of coverage also has important implications for health care quality, costs, and patient outcomes. A better understanding of coverage heterogeneity is particularly critical as state and federal policymakers propose a wide range of solutions, such as a public option on the insurance marketplace, moving more Medicaid beneficiaries to private coverage, and – most dramatically – “Medicare-for-All” in various configurations. Ongoing studies of these issues are warranted to continue to inform changes to the ACA and the U.S.’s health insurance system more broadly in the coming years.

https://www.nber.org…

Comment:

By Don McCanne, M.D.

Jonathan Gruber and Benjamin Sommers are certainly highly qualified to describe what a decade of the Affordable Care Act has done for health care in the United States. The most important change has been to increase the numbers of Americans who are insured, predominantly through the Medicaid program, along with an improvement in health care access that being insured provides. The remaining improvements are fairly negligible when compared to the need that existed ten years ago and the need that still exists.

The authors tell us that we need ongoing studies of potential solutions such as “a public option on the insurance marketplace, moving more Medicaid beneficiaries to private coverage, and – most dramatically – ‘Medicare-for-All’ in various configurations.” So just what studies do we need?

  • Presumably we want everyone to be included. Current studies have shown that, in spite of the increase, we have fallen far short of universality. So when we set up a system that automatically includes everyone, what study do you need to find out if everyone ends up being included? Well, the health policy academics don’t have to do a study of that one since anyone who is discovered to not be enrolled is automatically enrolled on the spot.
  • The financial burden of underinsurance has grown worse since deductibles are increasing. So what study do you need to find out how much of a financial burden the patients would face when out-of-pocket health care spending is eliminated (as with HR 1384, Jayapal)? Well, that lets the policy academics off the hook again since there is no underinsurance if there are no medical bills for cost-sharing that has already been eliminated.
  • Insurance premiums are a burden for working families who do not qualify for government subsidies. Single payer Medicare for All legislation would eliminate regressive insurance premiums and replace them with progressive taxes that would make health care affordable for everyone. What study do you need to show paying less in taxes would cost the family less than paying more in insurance premiums and other out-of-pocket costs? Do we really even need to ask that question?
  • Provider networks, which are a tool to benefit the private insurers, take away from patients choices in their health care while potentially exposing them to higher costs because of surprise bills and out-of-network care. What study do we need of out-of-network care when there is only one universal network for the entire nation, and everyone is automatically included in the network?
  • Our unique American health care financing system has already been demonstrated to waste a tremendous amount of funds on administrative excesses, and the Affordable Care Act added even more administrative requirements. It has been shown in other nations that these administrative excesses are not necessary, and, by design, would be dramatically reduced by enacting and implementing single payer Medicare for All. We wouldn’t need the academic policy community to tell us that waste would be drastically reduced, but it might be informative for them to do another study showing us how many hundreds of billions of dollars we would be saving by recovering that waste – savings that could be spent on health care instead.
  • With regional planning and separate capital budgets we could improve capacity in regions of need thereby improving access to care in areas that are currently underserved, while avoiding excess capacity that can result in overutilization. Do we really need a study to show us that spending money where it is needed better meets the need?

“Ongoing studies of these issues are warranted to continue to inform changes to the ACA…” Really? The overwhelming evidence is that this decade with the Affordable Care Act has demonstrated that it has largely been a failure in achieving universality, elimination of financial hardship from medical bills, affordability for individuals and society, equity, portability, accessibility, administrative efficiency, and a failure of our health policy community to advance reform that would clearly benefit all of America.

That doesn’t mean that Gruber, Sommers and their colleagues in health policy should be out of a job. Look at price and volume in health care – the two mathematical determinants of spending. For instance, when a new drug comes on the market with a $2 million price tag for a single dose, wouldn’t it be helpful to know if it is priced properly? When a preventive measure is being used by millions of individuals, wouldn’t it be helpful to know if it is really effective in preventing what it is alleged to prevent? Surely they can devise a multitude of studies that are designed to help… guess what… the patient!

We’ve had enough studies that are designed to help insurers and passive investors in the medical-industrial complex when they shouldn’t even be in the picture anymore. Kenneth Arrow, who showed that health care markets do not work for patients, was awarded the Nobel Prize. Maybe there are more Nobels for the health policy community if they will only apply their science to the betterment of health for all of us.

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‘Medicare for All’? American Medical Association says no, drawing protest in Chicago.

By Lisa Schencker
Chicago Tribune, June 10, 2019

Doctors gathered in Chicago for the American Medical Association’s annual meeting this week are increasingly finding themselves at the uncomfortable center of a national debate over “Medicare for All.”

A group of doctors, nurses and medical students protested the meeting, criticizing the association’s opposition to Medicare for All — the idea of expanding Medicare to cover all Americans. And on Monday, the doctors at the meeting heard a speech by Seema Verma, head of the federal Centers for Medicare & Medicaid Services, a Trump appointee who devoted a chunk of her talk to what she sees as problems with the proposal.

She told the audience, to applause, that Medicare for All would lead to higher taxes, lower payments for doctors and rationing of health care, among other things.

“We are deeply committed to helping those who need it, but while doing that, we must put the patients and their doctors in the driver’s seat to make decisions about their care, not the government,” Verma said.

So far the AMA has stood by its opposition to Medicare for All, also sometimes referred to as a single-payer system or universal health care, even as it’s become a hot topic ahead of the 2020 presidential race. Democratic candidate Sen. Bernie Sanders, I-Vt., unveiled a bill earlier this year to move to a single-payer health care system. About 56 percent of Americans surveyed earlier this year by the Kaiser Family Foundation said they would favor all Americans getting their insurance from a single government plan.

Supporters say they’re weary of the growing costs of health insurance, provided by private insurers, and restrictions often placed by insurers on which doctors can be seen and what will be covered. Those opposed to the concept, such as the AMA, say choice is key to health care improvements, and they worry about the government’s ability to effectively administer and fund such a huge system.

“The AMA is absolutely in favor of having every American have health care that needs to be of good quality and affordable,” AMA President Dr. Barbara McAneny said in an interview. The AMA supports the Affordable Care Act, also known as Obamacare, which mandated that all Americans have health insurance and barred discrimination based on preexisting conditions, among other things. “We just aren’t certain that Medicare for All is the right vehicle.”

McAneny said the association shares the frustration many feel with the current health care system, saying, “We cannot continue to spend this quantity of money and create bankruptcies just because someone gets sick.”

But the association believes choice in health care is a better way to go than Medicare for All. McAneny worries about what might happen to a government-run health care system during government shutdowns and about whether it would pay enough to sustain medical care. Now, government health insurance programs Medicare and Medicaid tend to reimburse doctors less than private insurers.

McAneny runs a cancer clinic in New Mexico, where most of her patients are on government health care programs. “I struggle to keep that practice breaking even,” she said. “If I did not have the higher rates of commercial payers to make up the shortfall of what I’m funded for Medicare rates, I would end up having to close that practice and leave a lot of people without service.”

Still, proponents of Medicare for All call the association’s stance antiquated. The group Physicians for a National Health Program protested the association Saturday over its position, shouting “AMA, get out of the way!”

That group contends that without private insurance, hospitals and doctors wouldn’t have to spend as much on administration, freeing up dollars for care. It also wants the AMA to stop being a member of a group that opposes single-payer health care called Partnership for America’s Health Care Future, which includes as members the Blue Cross and Blue Shield Association and the insurance industry’s main lobbying group.

The physicians’ group also notes that many doctors support the concept, pointing to a 2017 survey by physician search firm Merritt Hawkins that found 56 percent of doctors surveyed either strongly or somewhat supported a single-payer health care system.

“It makes the AMA seem awfully out of touch not only with the public but with the physicians they represent,” said Dr. Philip Verhoef, a physician at University of Chicago Medicine, and a member of the national board of Physicians for a National Health Program.

Chicago physician Peter Orris would also like to see the AMA reverse course, saying he believes that Medicare for All would remove unnecessary administrative costs from the system.

Still, Orris remains a member of the AMA despite his differing views from the group. Orris is a professor of occupational and environmental medicine at the University of Illinois at Chicago and a practitioner at the health system’s hospital.

“How are you going to bring everybody along there unless you’re engaging in that debate?” Orris said.

https://www.chicagotribune.com…

Protesters Rally, Disrupt Opening Session at AMA Meeting

Activists urge the association to support Medicare for All

By Joyce Frieden, Washington Editor and Shannon Firth, Washington Correspondent
MedPage Today, June 8, 2019

To chants of “AMA, get out of the way!,” a coalition of several hundred doctors, nurses, medical students, community organizers, and patients rallied outside the American Medical Association‘s (AMA) House of Delegates annual meeting to demand that the organization support a Medicare for All single-payer health system.

“We are here for those who cannot be here today,” Claudia Fegan, MD, national coordinator of Physicians for a National Health Program (PNHP), said as the group began gathering at the headquarters of the Blue Cross and Blue Shield Association, an organization of Blue Cross and Blue Shield insurers. “We are here for those who cannot afford their care. Twenty-nine million people are still uninsured and even the insured have deductibles so high they cannot afford their medications.”

The group also heard from Talisa Hardin of National Nurses United, a labor union for nurses, who criticized the AMA for its “aggressive” lobbying tactics. “The AMA is violating one of its most ethical principles: ‘Do No Harm,’ by being on the wrong side of history,” she said. “We want the AMA to publicly show its support for Medicare for All.”

Jennifer Epps-Addison, co-executive director of the Center for Popular Democracy, a grass-roots lobbying organization, led the group in chants of “Everybody In, Nobody Out!” She explained that her husband was diagnosed with multiple sclerosis a few years ago, and even though she has good health insurance, it costs the family $800 per month in premiums, and still more in other out-of-pocket costs. “This current healthcare system not only doesn’t work for low-income and no-income people, but it doesn’t work for the middle class families who are struggling to get by either,” she said. “My family is one job transition away from risking my husband’s life. That ain’t right.”

After the speakers finished, the group marched from the Blue Cross building to the Hyatt Regency Hotel, where the AMA was meeting. One of the marchers was David Mair, MD, a psychiatrist from Minneapolis and a member of PNHP, who said the AMA “needs to get with the 21st century. I was in the AMA as a student in 2000, and then I started looking at [how] we needed to get coverage for everybody.. I realized after doing much research that the obvious answer was single-payer, and I learned that the AMA was opposed to it.”

The reason the AMA isn’t getting on board with Medicare for All is that “they’re afraid of getting less money [as individual physicians],” Mair told MedPage Today. “The overall cost to run the business would go down [because] you’d have to have less admin staff, fewer prior authorizations, all the nonsense paperwork we have to do now. It’s still possible the pay would come down a little bit, but I think if all the doctors were united and they had the same payer, they could make the case [for higher] reimbursement rates, but they don’t want to bite the hand that feeds them.”

Outside the Hyatt Regency, the assembled marchers heard from other speakers, including Peter Lorenz, a medical student at the Chicago Medical School at Rosalind Franklin University here. “The first step of medical education is to take the Oath of Geneva, a pledge that the health of my patient is my first consideration. I cannot fulfill this oath in a society whose healthcare resources are so unequally distributed, resulting in a ‘pay-to-live’ system that benefits those with means and condemns those without.”

“Just across the river in Streeterville, a primarily affluent and white neighborhood, the life expectancy is 90 years,” he said. “Nine miles away in Englewood, primarily African American and low-income, the life expectancy is a full 30 years less … We have to work together to build a healthcare system that doesn’t perpetuate these injustices. We need Medicare for All.”

While the rally was going on outside, a smaller group of about 30 physicians disrupted the meeting’s opening session. They marched to the front of the room, held up a large banner reading “AMA: Support Medicare for All” along with several signs in the shape of gravestones with messages like “Here lies an infant whose mother couldn’t afford healthcare” and “Here lies your friend waiting for insurance approval.”

Over a dozen activists sat or lay on the ground in front of the stage, and a few stood on the stage by the podium, while activists in wheelchairs chanted and sang along with the group. A few of the activists also shared stories of patients who were harmed by their lack of health insurance. After 10 or 15 minutes, the activists exited peacefully, flanked by a couple of hotel staff; the activists were singing and chanting “Ain’t going to let nobody turn us around” as they left.

During the protest, Sue Bailey, MD, speaker of the AMA House of Delegates — who on Saturday was voted the organization’s president-elect for the coming year — called for order and ultimately a short recess. She reminded the protesters that just as they had a right to speak, the AMA also had a right to convene its meeting.

This is not the first time the AMA meeting has contended with protesters. In 2009, Tea Party activists demonstrated outside the AMA’s meeting to urge the organization not to support the Affordable Care Act, which the AMA later voted to support.

In her speech to the delegates as outgoing president, Barbara McAneny, MD, said she was “proud that the AMA is taking on insurance companies to reform prior authorization, helping a dozen states remove prior authorization for medication-assisted therapy to get timely treatment for a substance use disorder.”

“Our nation’s largest health insurance plans made billions last year,” she said. “Do we want a health system that simply fills insurer’s pockets or one that allows us to deliver our best care to patients?”

https://www.medpagetoday.com…

American Medical Association opposes ‘Medicare for All.’ Students, nurses and activists want to change that

By Tami Luhby
CNN, June 8, 2019

The American Medical Association is coming under increasing fire for opposing “Medicare for All.”

Energized by the growing attention on universal health care in the 2020 presidential campaign and in Congress, medical students, nurses and other activists are expected to rally Saturday at the AMA’s annual meeting in Chicago to urge its leadership to change its position.

Nearly two dozen groups — including those representing doctors, nurses, medical students and other health care workers — are participating in the campaign, organizers say.

The influential association has long opposed a government-run health care system, such as the Medicare for All proposal championed by Vermont Sen. Bernie Sanders, an independent running for the Democratic presidential nomination. It is also a member of the Partnership for America’s Health Care Future, a coalition of health industry groups seeking to quash any momentum behind Medicare for All.

The rally comes as the AMA doubles down on its opposition to universal health care. After being pressed to review its position by its medical students caucus at last year’s meeting, the association recently reaffirmed its commitment to strengthening the Affordable Care Act and making coverage more affordable, in part by increasing the eligibility and amount of federal subsidies for premiums and out-of-pocket expenses.

“Instead of abandoning the ACA and threatening the stability of coverage for those individuals who are generally satisfied with their coverage, the council believes that now is the time to invest not only in fixing the law, but improving it,” the AMA said in a report issued last month.

The association backs the idea that every American deserves quality, affordable health care insurance and that the current situation for patients is “unacceptable,” AMA President Barbara McAneny said in a statement Friday.

Still, the report recommended that the group not support single payer proposals. Among the concerns: a cut in reimbursement rates that could affect the number of doctors willing to participate.

Supporters of universal health care, however, want the AMA to “get out of the way,” said Marti Smith, a Midwest director of National Nurses United, one of the leading advocacy groups backing Medicare for All. The association is focused more on the industry than its patients, she charged.

The next generation of doctors has been particularly vocal in its support for universal health care.

Amanda Snead, who is finishing her first year at the University of Illinois at Chicago’s medical school, said the experience has been eye opening. She’s heard from people who couldn’t leave marriages or jobs because they needed to keep their health insurance.

AMA’s stance is why Snead has joined the Students for a National Health Program, which advocates for a single-payer plan, instead of the association. She’s concerned the current system will interfere with her ability to practice medicine.

“A lot of insurers take the autonomy out of physicians’ hands,” she said. “I want to be able to make the best medical decisions for my patients.”

https://www.cnn.com…

AMA Get Out of the Way!

On June 8, 2019, PNHP joined forces with Students for a National Health Program (SNaHP), National Nurses United, Jane Addams Senior Caucus, Center for Popular Democracy, Democratic Socialists of America, and other social justice organizations to demand the American Medical Association leave the corporate-funded “Partnership for America’s Health Care Future” and end its long-standing opposition to single-payer Medicare for All.

Why health profession students are fighting the AMA

Why we're fighting the American Medical Association

The AMA protects corporate interests, not doctors and patients – and now it’s trying to stop Medicare for All

By Jonathan Michels, Will Cox, Alankrita Siddula and Rex Tai
The Guardian, June 6, 2019

This Saturday, nurses, physicians, and medical students plan to walk out of their clinics and on to the streets of Chicago to confront the American Medical Association at the organization’s annual meeting. Health providers know that the outrageous costs and shameful inequality of American medicine are no accident – and that their patients’ lives are at stake.

The AMA claims to represent the interests and values of our nation’s doctors. But it has long been the public relations face of America’s private health insurance system, which treats healthcare as a commodity. This approach has resulted in some of the worst health outcomes in the industrialized world: the highest rate of infant mortality, the highest number of avoidable deaths, and health spending that eats up nearly 18% of America’s GDP.

The AMA is a major reason why 28 million Americans still don’t have health insurance. Despite recent polls showing that a majority of doctors support the single-payer system Medicare for All, which would fully insure all Americans, the AMA is leading the fight against universal coverage.

By money spent, the AMA is the nation’s third largest lobbying organization of the last 20 years, behind only the US Chamber of Commerce and the National Association of Realtors. By deploying powerful lobbying and misleading media campaigns, the AMA has opposed or hijacked nearly every health reform proposal of the last century, from Social Security to Medicare to the Affordable Care Act.

The AMA has also been a relentless opponent of universal healthcare. In 1949, the group waged an unscrupulous war against President Truman’s proposed national health insurance program, spending millions of dollars to have a political-consulting firm mislabel single-payer healthcare as “socialized medicine”. In 1961, the group doubled down on fearmongering when they hired Ronald Reagan to record an advertisement warning Americans that the passage of Medicare, an imperfect but popular health program for seniors, was a “short step to all the rest of socialism”.

The AMA, however, is finding it increasingly difficult to keep healthcare providers and patients scared of single payer.

Despite industry claims that Americans are “satisfied” with their private health plans, insured patients are saddled with exorbitant co-pays, premiums, and deductibles that keep them from actually getting the care they need. A single illness or injury pushes many Americans into bankruptcy. According to a recent Gallup poll, Americans borrowed a whopping $88bn last year simply to pay for medical expenses. So much for private insurance.

Most Americans – 70% – now favor the creation of a publicly financed but privately delivered single-payer health insurance program, better known as Improved and Expanded Medicare for All. Americans are desperate for affordable healthcare, a system that prioritizes patients over commerce, centers clinical decisions in the hands of physicians, and results in lower costs and better outcomes.

In February, Representative Pramila Jayapal, along with 106 co-sponsors, unveiled the Medicare for All Act of 2019 (HR 1384), while Senator Bernie Sanders’ revamped Medicare for All Act enjoys support from most of the leading Democratic presidential candidates. Even former President Barack Obama recently admitted that his signature health initiative – the Affordable Care Act – is no substitute for single payer.

Faced with soaring public support for Medicare for All, this past summer the AMA joined the “Partnership for America’s Health Care Future”, a benign-sounding corporate group which represents the pharmaceutical and private insurance industries and aims to “change the conversation around Medicare for All”. In order to protect their own economic interests, the “Partnership” is waging a well-funded campaign to turn elected officials away from single-payer by rallying Democrats around the ACA and preventing the Democratic party from including Medicare for All in its 2020 platform.

The campaign is merely the latest example of how the AMA uses the prestige of its white-coated members to push for market-based health reforms that maintain the status quo of our fractured health system: one in which some Americans have a lot, others have a little, and some are left with absolutely nothing.

Medical students and professionals have had enough. This Saturday’s protest is only one example. Last year, the Medical Student Section of the AMA put pressure on their leadership with a resolution demanding the organization suspend its decades-long opposition to single-payer. Single-payer activism is growing on medical school campuses across the nation, perhaps a preview of what the next generation of doctors will expect.

The public agrees with the evidence that Medicare for All is the answer to our broken health system. Until the AMA’s priorities change, it will remain an obstacle to the good of our patients.

Jonathan Michels is a premedical student at the University of North Carolina at Greensboro and a student board member of Physicians for a National Health Program (PNHP), an organization that advocates for an improved and expanded Medicare for All health system.

Will Cox is a longtime healthcare worker and social justice organizer and serves on the board of the North Carolina chapter of PNHP.

Alankrita Siddula is a medical student at Rush University in Chicago and a member of Students for a National Health Program (SNaHP).

Rex Tai is a medical student at the University of Illinois at Chicago. He is a midwest regional delegate for SNaHP and has a background organizing for criminal justice reform and harm reduction in opioid treatment.

The online version has 16 links to references supporting the statements made here:
https://www.theguardian.com…

Comment:

By Don McCanne, M.D.

Although there are many fine people in the AMA (I’m a life member), when it comes to health policy, the reactionaries have dominated, placing the medical-industrial complex in a dominant role over the patients. But there is hope. As these students demonstrate, the coming generation of health care professionals will be supporting the primacy of the patient. That should help clear the way for the enactment and implementation of single payer Medicare for All so that then we will have health care justice for all.

Everybody in! Nobody out!

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

Doctors to tell American Medical Association: Support Medicare for All or “get out of the way”

Hundreds of doctors, nurses, medical students, and health care activists to rally at AMA annual meeting in Chicago

FOR IMMEDIATE RELEASE, June 7, 2019
Contact: Clare Fauke, Physicians for a National Health Program, clare@pnhp.org

  • WHAT: Demonstration for Medicare for All: “Tell the AMA to Get Out of the Way!”
  • WHO: Hundreds of doctors, nurses, seniors and other supporters of improved Medicare for All
  • WHEN: Saturday, June 8, 1:30-3:00 p.m.
  • WHERE: 1:30-2:00 p.m. – Rally at Blue Cross Blue Shield headquarters, 300 E. Randolph; 2:00-2:30 p.m. – March to the AMA Meeting at the Hyatt Regency, 151 E. Wacker; 2:30-3:00 p.m. – Final Rally outside AMA meeting

CHICAGO — Wearing their scrubs and white coats, hundreds of doctors, nurses, medical students, and health care activists will march on the annual meeting of the American Medical Association (AMA), demanding they drop their opposition to improved Medicare for All and withdraw from the anti-single payer lobbying group Partnership for America’s Health Care Future.

The demonstration will begin at 1:30 p.m. at the headquarters of private insurer Blue Cross Blue Shield (300 E Randolph), where health professionals will speak out against the greed and administrative waste of the insurance industry. Protesters will then march to the AMA annual meeting at the Hyatt Regency (151 E Wacker) to shine a light on the group’s anti-single payer agenda.

Even though a majority of American doctors now support improved Medicare for All, the AMA has for decades opposed any type of single-payer reform. In 2018, the AMA further angered doctors by joining the Partnership for America’s Health Care Future, a lobbying group that includes pharmaceutical and health insurance companies, and that actively campaigns against both Medicare for All and members of Congress that support single-payer legislation.

“The AMA claims to represent the values of physicians, but their policies put profits ahead of patient care,” said Dr. Adam Gaffney, president of Physicians for a National Health Program (PNHP), a group of 23,000 doctors who support single-payer Medicare for All. “It’s time for the AMA to leave the Partnership for America’s Health Care Future and join the majority of physicians who support improved Medicare for All.”

While single-payer supporters rally in the streets outside the conference, the Medical Student Section of the AMA plans to file a resolution demanding the organization rescind all policies that prohibit it from supporting or even considering single-payer reform.

Besides physicians and medical students, the demonstration includes a broad coalition of single-payer supporters, such as National Nurses United, People’s Action, Jane Addams Senior Caucus, Democratic Socialists of America, The Center for Popular Democracy, Public Citizen, Social Security Works, United Electrical Workers, National Economic and Social Rights Initiative, Healthcare-NOW!, and Progressive Doctors.

“For too long, the AMA has been a roadblock to change in our deadly health care system, where patients have to make impossible choices, like paying for medical bills or paying for food,” said Jean Ross, RN, president of National Nurses United, the largest union of registered nurses in the country. “Enough is enough! Nurses will stand in strong solidarity with doctors, students, patients, and the 70 percent of people in America who support Medicare for All.”

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.

John Geyman’s ‘Struggling and Dying Under Trumpcare’

Struggling and Dying Under Trumpcare: How We can Fix This Fiasco

By John Geyman, M.D.
Copernicus Healthcare

From the Preface

There are four key issues involved in the future of U.S. health care:

  1. Who is the health care system for – profiteering corporate stakeholders, their shareholders and Wall Street investors – or patients, families, and taxpayers?
  2. Is health care just another commodity for sale in our largely for-profit market-based system – or essential services based on medical necessity?
  3. Is health care a human right or a privilege based on ability to pay?
  4. What ethic should prevail in health care – a business “ethic” maximizing revenue to providers or a service ethic based on needs of patients and their families?

This book has four goals:

  1. To identify and define issues concerning health care reform across the political spectrum in the upcoming 2020 election cycle;
  2. To expose disinformation and demagoguery for what it is;
  3. To focus on the real stakes for the American people regardless of political ideology; and
  4. To help educate policy makers, legislators, and the electorate concerning the real issues and likely outcomes of alternative approaches to health care reform.

Common Sense: The Case For and Against Medicare For All

By John Geyman, M.D.

This Common Sense pamphlet, written in the style of Thomas Paine, “offer(s) simple facts, plain arguments, and common sense about the current crisis in health care in this country and urgent need for reform.”

“This pamphlet is targeted to legislators in Congress who will be involved in this new debate over health care, grassroots activists, and the general public seeking to better understand the issues.”

https://www.amazon.com…

Comment:

By Don McCanne, M.D.

A bizarre twist of American exceptionalism is that we have by far the most expensive health care system in the world, and yet it is one of the poorest performing of well financed systems. Particularly egregious are the poor health outcomes of not only many of those who remain uninsured but also the tens of millions who are insured but their coverage fails them in time of medical need. John Geyman explains what is wrong, what the political failures are that led to this fiasco, and most importantly, what we can do to finally bring us a high performance system that is affordable and accessible for each and everyone of us.

(The mission of PNHP is to educate physicians, other health workers, and the general public on the need for a comprehensive, high-quality, publicly-funded health care program, equitably accessible to all residents of the United States. PNHP does not endorse any political party or candidate, but we recommend that all politicians, regardless of political affiliation, support the goal of our mission.)

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

Why we’re fighting the American Medical Association

The AMA protects corporate interests, not doctors and patients – and now it’s trying to stop Medicare for All

By Jonathan Michels, Will Cox, Alankrita Siddula, and Rex Tai
The Guardian, June 6, 2019

This Saturday, nurses, physicians, and medical students plan to walk out of their clinics and on to the streets of Chicago to confront the American Medical Association at the organization’s annual meeting. Health providers know that the outrageous costs and shameful inequality of American medicine are no accident – and that their patients’ lives are at stake.

The AMA claims to represent the interests and values of our nation’s doctors. But it has long been the public relations face of America’s private health insurance system, which treats healthcare as a commodity. This approach has resulted in some of the worst health outcomes in the industrialized world: the highest rate of infant mortality, the highest number of avoidable deaths, and health spending that eats up nearly 18% of America’s GDP.

The AMA is a major reason why 28 million Americans still don’t have health insurance. Despite recent polls showing that a majority of doctors support the single-payer system Medicare for All, which would fully insure all Americans, the AMA is leading the fight against universal coverage.

By money spent, the AMA is the nation’s third largest lobbying organization of the last 20 years, behind only the US Chamber of Commerce and the National Association of Realtors. By deploying powerful lobbying and misleading media campaigns, the AMA has opposed or hijacked nearly every health reform proposal of the last century, from Social Security to Medicare to the Affordable Care Act.

The AMA has also been a relentless opponent of universal healthcare. In 1949, the group waged an unscrupulous war against President Truman’s proposed national health insurance program, spending millions of dollars to have a political-consulting firm mislabel single-payer healthcare as “socialized medicine.” In 1961, the group doubled down on fearmongering when they hired Ronald Reagan to record an advertisement warning Americans that the passage of Medicare, an imperfect but popular health program for seniors, was a “short step to all the rest of socialism.”

The AMA, however, is finding it increasingly difficult to keep healthcare providers and patients scared of single payer.

Despite industry claims that Americans are “satisfied” with their private health plans, insured patients are saddled with exorbitant co-pays, premiums, and deductibles that keep them from actually getting the care they need. A single illness or injury pushes many Americans into bankruptcy. According to a recent Gallup poll, Americans borrowed a whopping $88bn last year simply to pay for medical expenses. So much for private insurance.

Most Americans – 70% – now favor the creation of a publicly financed but privately delivered single-payer health insurance program, better known as Improved and Expanded Medicare for All. Americans are desperate for affordable healthcare, a system that prioritizes patients over commerce, centers clinical decisions in the hands of physicians, and results in lower costs and better outcomes.

In February, Representative Pramila Jayapal, along with 106 co-sponsors, unveiled the Medicare for All Act of 2019 (HR 1384), while Senator Bernie Sanders’ revamped Medicare for All Act enjoys support from most of the leading Democratic presidential candidates. Even former President Barack Obama recently admitted that his signature health initiative – the Affordable Care Act – is no substitute for single payer.

Faced with soaring public support for Medicare for All, this past summer the AMA joined the “Partnership for America’s Health Care Future”, a benign-sounding corporate group which represents the pharmaceutical and private insurance industries and aims to “change the conversation around Medicare for All”. In order to protect their own economic interests, the “Partnership” is waging a well-funded campaign to turn elected officials away from single-payer by rallying Democrats around the ACA and preventing the Democratic party from including Medicare for All in its 2020 platform.

The campaign is merely the latest example of how the AMA uses the prestige of its white-coated members to push for market-based health reforms that maintain the status quo of our fractured health system: one in which some Americans have a lot, others have a little, and some are left with absolutely nothing.

Medical students and professionals have had enough. This Saturday’s protest is only one example. Last year, the Medical Student Section of the AMA put pressure on their leadership with a resolution demanding the organization suspend its decades-long opposition to single-payer. Single-payer activism is growing on medical school campuses across the nation, perhaps a preview of what the next generation of doctors will expect.

The public agrees with the evidence that Medicare for All is the answer to our broken health system. Until the AMA’s priorities change, it will remain an obstacle to the good of our patients.

Jonathan Michels is a premedical student at the University of North Carolina at Greensboro and a student board member of Physicians for a National Health Program (PNHP), an organization that advocates for an improved and expanded Medicare for All health system.

Will Cox is a longtime healthcare worker and social justice organizer and serves on the board of the North Carolina chapter of PNHP.

Alankrita Siddula is a medical student at Rush University in Chicago and a member of Students for a National Health Program (SNaHP).

Rex Tai is a medical student at the University of Illinois at Chicago. He is a midwest regional delegate for SNaHP and has a background organizing for criminal justice reform and harm reduction in opioid treatment.

https://www.theguardian.com…

Doctors call on AMA to drop ‘Medicare for All’ fight

A grassroots coalition that supports a single-payer system will rally against the American Medical Association and private health insurers in Chicago this weekend.

By Stephanie Goldberg
Crain’s Chicago Business, June 6, 2019

A coalition of doctors, nurses and medical students are calling on the American Medical Association to drop its fight against “Medicare for All.”

The physicians group is among associations that oppose a single-payer system, which would discontinue Medicaid and private health insurance—squeezing hospital profits and threatening the existence of many health insurers.

However, groups like Physicians for a National Health Program and National Nurses United say many health care providers actually support proposals to expand Medicare. They—along with other associations, health care workers and advocacy groups—will protest the AMA’s opposition of “Medicare for All” in Chicago on Saturday.

At least 100 people are expected to gather for the demonstration, which starts at 1:30 p.m. outside Blue Cross & Blue Shield of Illinois’ headquarters at 300 E. Randolph Street, and ends outside the Hyatt Regency Chicago at 151 E. Wacker Dr., where the AMA is holding its annual meeting.

The rally seems to have more momentum than any other single-payer protest in the last 10 years, said Dr. Philip Verhoef, a national board member of Physicians for a National Health Program, which has about 1,000 members in Illinois. He said several different groups had the idea to stage a rally during the AMA’s annual meeting, and they decided to come together to support the cause.

Starting the demonstration at Blue Cross is a “gesture to say, ‘this is the problem,’ ” added Verhoef, who is also an assistant professor of medicine and pediatrics at University of Chicago and an ICU doctor at UChicago Medicine. “Private health insurance is what has driven health care prices, inequity and waste in this country.”

The grassroots coalition is calling on the AMA to drop its fight against “Medicare for All” and withdraw from the Partnership for America’s Health Care Future, an industry coalition fighting proposals to expand Medicare. The Blue Cross Blue Shield Association is also a member.

In addition to opposing “Medicare for All,” the AMA fought the formation of the program in the 1960s. However, it supported the Affordable Care Act in 2009.

“The status quo for our patients is unacceptable, and policymakers should continue taking steps to improve coverage, affordability, and expand the safety net,” AMA President Dr. Barbara L. McAneny said in a statement. “AMA policy says patients and physicians should have a range of public and private coverage options and benefit from freedom of choice and competition, which can be achieved by building on our current system, with the goal of providing coverage to all Americans.”

Blue Cross & Blue Shield of Illinois echoes the sentiment, saying in a statement the company “believes that everyone should have access to quality, affordable health care in a system built on choice, competition and innovation. We will continue to advocate for policies that support that goal in a sustainable way.”

Verhoef said some single-payer critics believe physician autonomy would be lost under “Medicare for All,” while highly paid doctors and specialists may be concerned their income would decrease under such a system.

It comes down to equity, said Verhoef.

“We have an incredibly inequitable system right now because we have (nearly) 30 million people who are uninsured” and even more who are underinsured, Verhoef said. “They don’t get the care they deserve. (“Medicare for All”) is a way to level the playing the field and give everyone comprehensive health care.”

Talisa Hardin, a representative of National Nurses United and a registered nurse in the burn unit of University of Chicago Medical Center, said she supports a single-payer system because the current system is “not designed to support and promote health.”

To the AMA, Verhoef says: “You’re not representing the majority of Americans and, quite frankly, the majority of physicians who all argue that single payer is the best solution.”

https://www.chicagobusiness.com…

Care for America’s elderly and disabled people relies on immigrant labor

By Leah Zallman, Karen E. Finnegan, David U. Himmelstein, Sharon Touw, and Steffie Woolhandler
Health Affairs, June 2019

Abstract

As the US wrestles with immigration policy and caring for an aging population, data on immigrants’ role as health care and long-term care workers can inform both debates. Previous studies have examined immigrants’ role as health care and direct care workers (nursing, home health, and personal care aides) but not that of immigrants hired by private households or nonmedical facilities such as senior housing to assist elderly and disabled people or unauthorized immigrants’ role in providing these services. Using nationally representative data, we found that in 2017 immigrants accounted for 18.2 percent of health care workers and 23.5 percent of formal and nonformal long-term care sector workers. More than one-quarter (27.5 percent) of direct care workers and 30.3 percent of nursing home housekeeping and maintenance workers were immigrants. Although legal noncitizen immigrants accounted for 5.2 percent of the US population, they made up 9.0 percent of direct care workers. Naturalized citizens, 6.8 percent of the US population, accounted for 13.9 percent of direct care workers. In light of the current and projected shortage of health care and direct care workers, our finding that immigrants fill a disproportionate share of such jobs suggests that policies curtailing immigration will likely compromise the availability of care for elderly and disabled Americans.

From the Introduction

As the US elderly population grows, health care workforce shortages (which already limit care) are expected to increase in the coming decades. The Institute of Medicine projects that 3.5 million additional health care workers will be needed by 2030. Currently, immigrants fill health care workforce shortages, providing disproportionate amounts of care overall and particularly for key shortage roles such as rural physicians. Immigrant health care workers are, on average, more educated than US-born workers, and they often work at lower professional levels in the US because of lack of certification or licensure. They work nontraditional shifts that are hard to fill (such as nights and weekends), and they bring linguistic and cultural diversity to address the needs of patients of varied ethnic backgrounds.

The size of the elderly population is expected to double by 2050, raising concern that long-term care workers will be in particularly short supply. Direct care workers—nursing, psychiatric, home health, and personal care aides—are the primary providers of paid hands-on care for more than thirteen million elderly and disabled Americans. These workers help elderly and disabled people live at home (the preferred setting for most people) by providing assistance with daily tasks such as bathing, dressing, and eating. They also help elderly and disabled people in nursing or psychiatric facilities when living at home is not possible and during transitions home after hospitalization.

Workers prepared to fill these roles are already in short supply, and the Health Resources and Services Administration projects a 34 percent rise in the demand for direct care workers over the next decade, equivalent to a need for 650,000 additional workers. Projected shortages are compounded by high turnover and retention challenges, which create ongoing obstacles to maintaining a sufficient labor supply for long-term care.

Recent years have seen a steep decline in the number of unauthorized immigrants entering the country. The administration of President Donald Trump has taken steps to further reduce the flow of immigrants and has proposed legislation to reduce the number of legal immigrants with a focus on “skilled immigrants,” which could sharply reduce the number of low-wage immigrant workers.

Discussion

The US health care system as a whole is dependent on the work of over three million immigrants, who account for 18.2 percent of all health care workers. More than one in four direct care workers are immigrants, including nearly one in three direct care workers in home health agencies. Immigrants also account for a disproportionate share of housekeeping and maintenance personnel in nursing homes.

Our study adds to the literature on immigrants’ role in the nonformal direct care sector by including workers who are privately hired to support elderly and disabled people. We found that workers in the nonformal sector provide care to hundreds of thousands of people living at home or in other nonmedical settings such as senior housing. Such care likely reduces the need for (and expense of) institutional care.

Our findings have important implications for the care of elderly and disabled people. In light of current shortages, high turnover rates, low retention rates, growing demand for direct care workers, and immigrants’ already disproportionate role in filling such jobs, policies that curtail immigration are likely to compromise the availability of care. Moreover, the anti-immigrant rhetoric and policies that restrict immigration threaten the health and well-being of immigrants who are entrusted with the care of the nation’s elderly and disabled people.

Our study also adds to a growing literature that highlights immigrants’ support for the health care of the US born. We have previously documented that immigrants pay tens of billions of dollars more annually in taxes to Medicare and in premiums to private insurers than Medicare or private insurers pay out on their behalf, effectively subsidizing the care of US-born people. Immigrants also make major contributions to the health professions: One in four US physicians has been trained in a foreign medical school, including 38.6 percent of all US internists, 43.6 percent of cardiologists, and 50.7 percent of geriatricians. Our study highlights immigrants’ contribution to the everyday care of elderly and disabled people.

Addressing the direct care worker shortage will require a multifaceted approach, including better wages, benefits, and education and training programs to draw people into the labor force while reducing turnover. However, curtailing immigration will almost certainly move us in the wrong direction, worsening the shortage and the availability of high-quality care for elderly and disabled Americans.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

Health policy frequently interacts with other public policies, in this case with immigration policy. This study shows the very important role that immigrants have played in providing health care and long-term care, especially for elderly and disabled people.

Further, there has been a shortage in direct care workers and that is likely to worsen with the anticipated increase in the numbers of disabled elderly, and with the immigration policies that our current administration is putting into place. For our health, we need to support these workers through better wages and benefits, which we can do through a Single Payer Medicare for All program. but it will also be imperative that we get immigration policies right.

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Mitchell Katz endorses single payer

New York Health Act Testimony

By Mitchell Katz, M.D., President and Chief Executive Officer, New York City Health + Hospitals
New York State Hearing, Joint Senate and Assembly Committees on Health, May 28, 2019

Good morning Chairpersons Gottfried and Rivera and members of the Assembly and Senate Committees on Health. I am Mitch Katz, M.D., President and Chief Executive Officer of the New York City Health + Hospitals (“Health + Hospitals”). On behalf of Health + Hospitals and the de Blasio Administration, thank you for the opportunity to provide testimony in support of the New York Health Act.

It is well established that health insurance coverage plays a critical role in enhancing one’s access to needed care and maintaining or improving health status. There is strong evidence that insurance coverage is associated with having a consistent source of care and being able to afford needed care, both of which are critical for achieving better health outcomes. Not having insurance also increases health disparities across race, ethnicity and socioeconomic status. Health insurance plays a major role in access to primary care and evidence-based preventive health services, which can help people avoid or delay the onset of disease, slow or prevent the progression of diseases, lead productive lives and reduce costs. In fact, studies have shown that lack of health insurance may increase the likelihood of mortality.

Health insurance coverage is also important for the city’s economy and job markets, as it directly supports health care providers, including hospitals, community health centers, nursing facilities, and health insurance plans. Expanding access to health insurance coverage and implementing a single payer system would support NYC Health + Hospitals mission to provide high quality health care services to all New Yorkers regardless of their ability to pay. Health + Hospitals is the largest public health care system in the nation and serves over a million patients each year, of which nearly 400,000 are uninsured.

Since the Affordable Care Act (ACA) was enacted in 2010, the uninsured rate in New York City across all ages has dropped significantly. During the most recent open enrollment period, a record 1 million New Yorkers, 57% of whom were New York City residents, enrolled in health insurance through the state’s ACA exchange; almost three quarters of those individuals signed up for Essential Plan. Overall, New York’s ACA exchange saw a 70,000 (7%) increase in Essential Plan and qualified health plan enrollment from the previous year , despite the fact that enrollment through the federally facilitated exchange declined by approximately 4% during the same period. Unfortunately, coverage gaps remain; over 1.1 million New Yorkers, including the estimated 600,000 New York City residents that remain uninsured.

A single payer health system would provide coverage to these uninsured and underinsured New Yorkers. The New York Health Act would create a comprehensive system of access to health insurance to provide a health plan available to every New York State resident. The program does not require participants to pay any premium or out-of-pocket costs, and provides all benefits currently included in Medicaid, Medicare, Child Health Plus and other state programs. This new system will ensure access to critical care for those who need it most, and will increase positive health care outcomes for all New Yorkers. We have read about concerns expressed by labor about the New York Health Act, and we are confident that the bill sponsors can address the concerns raised.

A single payer system would also make major strides to decrease segregation of care based on insurance type. Research has shown that many private practices do not accept Medicaid ; other studies suggest that Medicaid is generally accepted at hospital clinics, but not necessarily in the faculty practices of the same hospitals. The difference in rates paid by Medicaid when compared to private insurance is a contributor to this inequity, which would be eliminated with a single payer system.

As a primary care doctor, what is most important is care. A single payer system would allow me to spend more time on patient care than checking formularies. The current system makes me check formularies of each insurance company rather than providing prescriptions that I know work for my patients. It would also alleviate administrative burdens that safety net hospitals face. Health + Hospitals is currently fighting to make sure insurance companies pay us back when they have underpaid us in the past for care provided to patients.

The continued effort to undermine or eliminate the ACA is a threat to all New Yorkers and especially to Health + Hospitals patients. The threat of Federal Disproportionate Share Hospital payments cuts which will be devastating to Health + Hospitals, the proposed public charge rule and immigration policy changes harm our efforts to reach new patients and provide them the care they need. Despite these risks, Health + Hospitals will not be deterred from serving our patients across our health system.

As the Trump Administration continues its assault on the ACA and Medicaid, it is our job to ensure that everyone, regardless of their age, employment status, household income, immigration status or health status, has access to health care. The New York Health Act would guarantee this access for every New York State resident.

The City of New York strongly supports the New York Health Act. Thank you for the opportunity to join the growing chorus of voices in support of a single payer health care system.

Thank you to the Chairs of the Assembly and Senate Health Committees for your tremendous support of Health + Hospitals and I look forward to taking your questions.

(Thanks to New York Assembly Health Chair Richard Gottfried – author of the New York Health Act – for sending this draft of Mitch Katz’s testimony.)

Comment:

By Don McCanne, M.D.

Although today’s selection is standard testimony on behalf of the single payer model of health reform, it is highly authoritative because of the status of Mitchell Katz. He implemented the Healthy San Francisco program which established “universal” coverage in that city (under then mayor Gavin Newsom). He then led the Los Angles County Department of Health Services during implementation of the Affordable Care Act, transforming it into the Los Angeles County Health Agency – the nation’s second largest public health system. Now he is CEO of NYC Health + Hospitals – the largest public health care system in the United States.

Dr. Katz has received accolades for his efforts to improve health delivery under these public health systems, using all resources at his disposal in the most effective manner possible. This has been particularly important considering the safety-net role of these institutions. Yet 600,000 New Yorkers served by the system remain uninsured. It does not require a visionary like Dr. Katz to imagine what he could do if everyone were enrolled in a single payer system.

Although Dr. Katz’s comments are specifically in support of the New York Health Act, they can be extrapolated to apply to a national Single Payer Medicare for All. Without even asking, I know Dr. Katz would certainly concur.

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