By Ezekiel J. Emanuel and Victor R. Fuchs
The New York Times, September 12, 2019

Fallacy No. 2: Medicare for All is unaffordable.

The key to evaluating the cost of Medicare for All is to distinguish between increasing spending on health care and shifting expenditures from private insurance to the federal government.

True, Medicare for All would increase federal health care spending. But that is not the same as increasing total health care spending, which was over $3.5 trillion last year. Instead, Medicare for All would move money from one column (private health insurance spending) to another (federal health spending); it does not automatically increase total costs.

A recent study by the Mercatus Center at George Mason University — a free-market center generally hostile to government programs — estimates that for the 10 years between 2022 and 2031 the total national health costs for Senator Bernie Sanders’s Medicare for All plan would actually be $50.1 trillion. That would be $2 trillion less than if we let the system operate as it currently does. However, Mercatus researchers doubt that the Sanders’s plan would ultimately save trillions because they believe Congress would have to increase Medicare rates paid to hospitals and physicians to get the legislation enacted. They may be right — or wrong. But that is a different argument — a prediction about the politics of enacting laws — than that Medicare for All would inherently increase total health care spending.

We have our doubts about Medicare for All. But unaffordability is not a reason to oppose it. Whether it’s our current arrangement or a future Medicare for All, the per capita cost of our health care system already far exceeds that of any other industrialized country — including those with single-payer systems. When you hear a health care price tag in the trillions, know that the existing system has already brought us there.

Ezekiel J. Emanuel is an oncologist and a vice provost at the University of Pennsylvania. Victor R. Fuchs is an emeritus professor of economics at Stanford University and former president of the American Economics Association.

https://www.nytimes.com…

The New England Journal of Medicine, March 24, 2005, “Health Care Vouchers — A Proposal for Universal Coverage” by Ezekiel J. Emanuel, M.D., Ph.D., and Victor R. Fuchs, Ph.D.

The best health care reform is already in place

By Laurence Kotlikoff
The Hill, September 8, 2019

As with the previous Democratic debates, this week’s debate in Houston will likely start with our country’s forever question: How can we provide health insurance to all without bankrupting the country?

The Republican Party’s answer is to define basic health insurance as no health insurance. The party yearns for, and is suing in the courts, to restore the halcyon pre-ObamaCare days when 50 million Americans were uninsured and insurance companies could deny coverage at will.

This stance isn’t going to fly with the Party’s rank and file, whose own future health care and that of friends and relatives is at stake. But, hey, political self-immolation seems all the rage.

Vision two is Senator Sanders’ traditional Medicare (Parts A, B, and D) for All. Actually, it’s a far more generous version than traditional Medicare, which features co-pays, co-insurance, limits on catastrophic coverage and significant monthly premiums. As a result, millions of participants are forced to purchase Medigap coverage. Under BernieCare, there are no co-pays (except for prescription drugs) and no limits on coverage. Bernie care includes lab work, maternity, vision and dental care, and long-term care for the disabled.

Employers would, to their joy, be banned from the health care business. But their workers will be able to keep their doctors and use the same hospitals, who will simply send their bills to Medicare. Indeed, setting aside requisite tax hikes, BernieCare is far more generous than most employer-provided plans.

BernieCare, which Senator Elizabeth Warren (D-Mass.) and several other Democratic presidential candidates endorse, works great in theory. And it may in practice. The biggest bottom line is the share of GDP spent on health care. Other developed countries are delivering excellent universal health care at well south of 14 percent of GDP. We’re at 18 percent of GDP and growing. And they are all doing it with a healthy dose of central government control.

If it’s a choice between our current system and BernieCare, I’d go with BernieCare in a heartbeat. Yes, there are lots of concerns — people overusing the system, costs that far exceed the senator’s estimates, government price control over what is a fifth of the economy, doctors opting out of medicine because of limits on their reimbursements and long waiting lines.

But 14 percent of U.S. GDP can surely buy a truly first-class health care system for all. Also bear in mind that medicine in our country is already largely government run but done so with maximum inefficiency, leaving 30 million uninsured and far more underinsured.

BernieCare surely beats “Don’tCare” — the Trump-McConnell answer. But is there another reform that makes more sense?

Yes. “Medicare Part C for All.” This is the brain child of John Goodman, the father of Health Saving Accounts. I pushed for this solution in The Healthcare Fix. Goodman recently discussed the plan in the Wall Street Journal.

Medicare Part C is also called the Advantage Plan. Some 22 million Medicare participants – one in three – have opted for Medicare Advantage over traditional Medicare.

Laurence Kotlikoff is a professor of economics at Boston University (BU), a fellow of the American Academy of Arts and Sciences, a research associate of the National Bureau of Economic Research, and a fellow of the Econometric Society. He served on President Ronald Reagan’s Council of Economic Advisers.

https://thehill.com…

The MIT Press, September 2007, “The Healthcare Fix” by Laurence J. Kotlikoff (proposes vouchers for health insurance)

Comment:

By Don McCanne, M.D.

It has been fascinating to observe the insights on single payer Medicare for all of some of the nation’s more prominent economists who have not already been in the single payer camp. They seem to understand the clear benefits of the model, and yet they regress to supporting their own preferred but lesser models of reform, very often a model using variations of subsidized vouchers for purchase of private plans, as the authors of today’s excerpts support.

Even the Affordable Care Act was based partly on the voucher concept with the establishment of the ACA insurance exchanges. There is currently a push to use vouchers (“premium support”) to expand coverage through private Medicare Advantage plans. If we ever do approach having truly universal coverage, it will likely be the results of the contest between Medicare Advantage vouchers and a single payer model of an improved Medicare for all. A recent Quote of the Day discussed why this Medicare Advantage for All model is such a terrible idea.

Yes, it has been fascinating to see the insights of so many economists on the single payer model, yet it has been terribly frustrating to see that many if them continue to reject this obviously superior model.

Some years ago at Stanford University I was on a panel with Victor Fuchs in which he presented his voucher proposal and I presented the single payer approach. After the session was over, he approached me and asked me if I would like to work with him and Ezekiel Emanuel on their voucher model. I asked him if he would like to work with us on the single payer model. We both laughed, but, sadly, the impasse is not at all funny.

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By Ashley Kirzinger, Audrey Kearney, and Mollyann Brodie
Kaiser Family Foundation, September 12, 2019

Majorities of Democrats and Independents favor Medicare-for-all and public option, most Republicans oppose either proposal

Do you favor or oppose having a national health plan, sometimes called Medicare-for-all?

Democrats
51% – Strongly favor
26% – Somewhat favor
11% – Somewhat oppose
10% – Strongly oppose

Independents
27% – Strongly favor
26% – Somewhat favor
14% – Somewhat oppose
31% – Strongly oppose

Republicans
11% – Strongly favor
8% – Somewhat favor
10% – Somewhat oppose
69% – Strongly oppose

Do you favor or oppose having a government-administered health plan, sometimes called a public option?

Democrats
57% – Strongly favor
30% – Somewhat favor
5% – Somewhat oppose
5% – Strongly oppose

Independents
36% – Strongly favor
36% – Somewhat favor
8% – Somewhat oppose
17% – Strongly oppose

Republicans
15% – Strongly favor
26% – Somewhat favor
14% – Somewhat oppose
39% – Strongly oppose

Public divided on whether Medicare-for-all and public option are similar or different plans

Do you think a national Medicare-for-all plan and a public option government-administered health plan are…?

10% – Very similar
37% – Somewhat similar
29% – Somewhat different
15% – Very different
10% – Don’t know/Refused

Half say they have heard some about Medicare-for-all but large shares say they haven’t heard much about either Medicare-for-all or a public option

How much, if anything, have you heard about a national Medicare-for-all plan?

25% – A lot
26% – Some
26% – A little
22% – Nothing at all
1% – Don’t know/Refused

How much, if anything, have you heard about a government-administered health plan, sometimes called a public option?

14% – A lot
22% – Some
26% – A little
38% – Nothing at all
1% – Don’t know/Refused

https://www.kff.org…

Comment:

By Don McCanne, M.D.

According to this new poll, Democrats support Medicare-for-all (“a national health plan”), Independents are split, and Republicans are opposed. Also, Democrats and Independents both support a public option (“a government-administered health plan”), and Republicans are split. However, the public is confused as to whether Medicare-for-all and a public option are similar or different, and half have not heard much about Medicare-for-all and even more have not heard much about a public option.

It seems as if individuals do have an opinion on Medicare-for-all and on a public option even though many are confused as to what they are. The fact that the pollsters referred to one as “a national health plan” and the other as “a government-administered health plan” likely leaves many of those polled with little understanding of the refinements distinguishing the two models.

Features that people might be interested in include the following:

• Everyone is automatically covered for life
• Affordability is assured through equitable taxes based on ability to pay
• Financial barriers such as high deductibles are eliminated
• Choices of physicians and hospitals are assured through elimination of insurer networks
• Hundreds of billions of dollars in administrative waste is recovered

Of course, these are features of the single payer model of Medicare for all and none would apply by merely adding a public option to our fragmented financing system of a multitude of public and private insurance programs.

When will the pollsters finally ask the following questions?

• Should everyone be covered or just some of us?
• Should insurance be automatic forever or should it depend on life circumstances?
• Should payments into the system be made affordable based on income, or should many be left out because they can’t afford the premiums?
• Should high deductibles and surprise medical bills be used to deprive individuals of health care that they should have?
• Should patients have choices of their physicians and hospitals or shall we continue to allow private insurers to restrict choices to their networks?
• Should we continue to tolerate wasting about half a trillion dollars in administrative excesses, or should we redirect those funds that so that we can pay for care for those currently uninsured or underinsured?

In other words, do we want a health care system that we can afford that takes care of all of us, or do we want to merely add a public option and a couple of tweaks to ACA that leaves our overpriced, highly dysfunctional system in place? People really need to understand the differences between Medicare-for-all (single payer version) and a public option. Let’s see that they do.

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

By Angèle Malâtre-Lansac
Health Affairs Blog, August 28, 2019

Editor’s Note: In addition to Angèle Malâtre-Lansac, this post was conceived of and written by the 2018-2019 Harkness Fellows on health care policy and practice listed at end of this post.

Each year, the Commonwealth Fund selects an international cohort of Harkness Fellows in health care policy and practice, consisting of mid-career researchers, policy makers, and practitioners with leading positions in their countries, who come to the US to study the health care system, work with renowned US health policy experts, and provide input to US health care and research, drawing on insights from their own international contexts.

Reflections on health care in the US are commonplace: In our view, what is less common are observations and reflections from health experts from seven other countries on US health care. What are the most surprising aspects of the US system through the lenses of 10 observers from Australia, France, Germany, the Netherlands, New Zealand, Norway, and England?

No Such Thing As The US Health Care System

The United States undeniably provides some of the best health care and is one of the most innovative nations in the world. Financial investments in health and medical research are the envy of us all. Pockets of excellence can be seen in so many places. However, one of our first realizations is that there is no such thing as a single, unified, and coordinated US health care system — but rather a complicated and fragmented health care marketplace. Variations between US states, communities, and health insurance plans are in many cases greater than the differences between our countries. There are many reasons for this, but key among them are our countries’ shared principle of universal health coverage (both within single and multi-payer systems) and our usually nationally negotiated prices.

The diversity across US states is striking to us, particularly in terms of access to, and quality of, health care services. Perhaps, most surprising from our international perspective is the importance of political differences as a unique determinant of regional variations in health care performance. The ongoing debate over the Affordable Care Act (ACA) and the state-based variation in implementation of the ACA are vivid examples of this diversity and polarization within health care.

While there can be many benefits to diversity and choice, particularly in terms of tailoring services and resources to meet the specific needs of different populations and to ensure appropriate care, too much of a good thing can create problems. As an example, the sheer number of options individuals need to review and decide upon when considering a private health insurance plan or selecting a provider creates complexity, decision fatigue, and frustration.

Health Care As A Privilege, Not A Right

In our countries, there is a broad consensus on the role of the government in health care, as there is in education. Health care is considered a fundamental right. In the US, the federal government does not assume full responsibility for ensuring the right to health care for its citizens. The predominant narrative here frames health as a privilege. This plays out in many ways, but perhaps most notably it is advanced by proponents of work requirements for Medicaid, premised on the idea that access to health care is something to be earned. And yet, many US people cherish Medicare, a government program that provides universal coverage for people ages 65 years and older.

In addition, although we hear a lot of discussion about the costs of care, it is surprising how little of the conversation is on the costs of care not delivered. Approximately 28.5 million Americans have no health insurance, and it’s well known that being uninsured negatively affects your health and is costly. There are costs for the individuals; for the families who rely on those individuals for financial and other forms of support; for the businesses whose employees are absent, unproductive, or retire early; for the health care system, which ends up providing more expensive reactive care; and for society at large.

Another stark difference between the US and our own countries is the high level of financial burden placed on its people. Prominent in the US health care system are the high-deductible health plans driven by the idea that cost-sharing obligations will encourage people to prioritize high-value care and reduce health care spending. Yet, recent evidence suggest that populations on such plans delay or skip essential care entirely and as a consequence, experience adverse effects.

The Price Problem

On average, the US spends twice as much as other Organization for Economic Cooperation and Development countries on health care without evidence of superior care or health outcomes. In fact, life expectancy is declining in the US while health care costs continue to rise. Grossly inflated drug and device prices, overall health care costs, and surprise billing are big challenges. Substantial administration and advertising costs are a further unintended consequence of the primacy placed on individual choice. Quite simply, everything is more expensive in the United States than it is in our countries.

Drug prices in the US are three to six times higher than in many European countries, despite decades of calls for change. Our countries use Health Technology Assessment (HTA)—a multidisciplinary approach that considers the clinical, economic, legal, ethical, and organizational aspects of new technologies such as drugs, devices, and procedures. The core principle is to determine the added value of new technologies compared to existing alternatives to inform authorities responsible for coverage and reimbursement decisions. Unlike in our countries, there is no single agency tasked with addressing this issue in the US.

The Accountability Problem

In an article recently published in the New England Journal of Medicine, “The Not-My-Problem Problem,” Lisa Rosenbaum provides a persuasive account of the unintended consequences of diffusion of responsibility in a highly fragmented US health care system. According to the World Health Organization’s Health System Framework, well-functioning health care systems share several characteristics, including leadership and governance, factors that play essential roles in achieving the goals of health systems, regardless of how health systems are organized and designed.

In the US, governance is often unclear, and there is no shared understanding of what each actor in the health care system is accountable for (and to whom). At the end of the day, the entire system seems beholden to one thing: the “bottom line.” The lack of a commitment to universal coverage, as well as the many different stakeholders and multiplicity of intermediaries in the supply chain, might explain this phenomenon.

These lessons may not come as a great surprise to the many policy makers and researchers who have long studied and aspired to improve health care in the US. Our hope is that, by highlighting the challenges that stand out most acutely to us as outsiders, this international perspective may provoke thoughtful discussion about how to achieve better health outcomes. Addressing those great challenges is like tackling climate change — it’s both crucial and painful. Taking the necessary steps toward a greater good first requires agreement on what that looks like. The opportunity of the upcoming presidential campaign will undoubtedly make it possible to bring a new vision for the future of US health care.

Author’s Note

Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and should not be attributed to the Commonwealth Fund or its directors, officers, or staff.

2018-2019 Harkness Fellows on health care policy and practice from the Commonwealth Fund:

Angèle Malâtre-Lansac, France
Mary Docherty, UK
Unni Gopinathan, Norway
Cornelia Henschke, Germany
Prakash Jayakumar, UK
Nadine Kasparian, Australia
Grégoire Mercier, France
Huseyin Naci, UK
Andrew Old, New Zealand
Laura Shields-Zeeman, Netherlands

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

This perspective is very helpful to us because it represents the views of highly qualified health policy experts from other nations who have come to the United States to study our system. The objective view they present can be invaluable in our own assessment of our health care system as we consider what can be done to improve it.

Considering our unique culture and politics, it is very difficult to see how we could effectively address the issues discussed short of enacting and implementing a single payer model of an improved Medicare that covered everyone. The sooner, the better.

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

By Tara Bannow
Modern Healthcare, September 7, 2019

The problem of overlap in the CMS’ various payment initiatives, including ACOs and bundled-payment programs, can introduce confusion and frustration when it comes to determining which program gets credit for those patients’ care. The CMS wants to avoid double-rewarding for savings on an individual patient’s care, such as if the patient is in an ACO and received qualifying care from a Bundled Payments for Care Improvement Advanced provider. So when it comes down to reconciling who is credited for the savings, things get tricky. And they’re bound to get even more complicated as the CMS adds alternative payment models to the mix.

New research highlights just how sweeping the problem is. More than 1 in every 4 patients receiving care under the CMS’ flagship bundled-payments program, the Bundled Payments for Care Improvement initiative, were also attributed to its flagship ACO program, the Medicare Shared Savings Program, in 2016, according to an August study in the Journal of Hospital Medicine. Conversely, 1 in every 10 MSSP patients received care at a BPCI participating hospital in 2016.

The CMS attempted to clarify things in June when it announced that starting in 2020, providers participating in BPCI Advanced will take precedence over all MSSP beneficiaries—meaning, their savings will be carved out from the ACO’s savings. Currently, this is only the case for certain MSSP beneficiaries, those categorized under the program’s basic track.

On a practical level, the June announcement means if John Doe is a patient in an MSSP ACO, and is admitted to a BPCI Advanced hospital with a clinical episode, such as congestive heart failure, that episode of care will be attributed to the BPCI Advanced provider, said Gina Bruno, vice president of value-based care with naviHealth.

The CMS is also trying to calculate a way to compensate aligned ACOs for their contributions to those patients’ care, Bruno said. “ACOs, especially those that work with BPCI Advanced providers will say, ‘Well, wait a minute. John Doe has been our patient for a period of time. We have a team that follows up with him. We play a part in managing his chronic disease. How do we get credit for our contributions to his outcomes?’ ”

Therein lies the trickiness of overlap. Experts say providers who contributed to a patient’s care often wind up feeling as though they didn’t get the commensurate reward.

“There is a risk of expending resources to support patients who ultimately are not attributed to the model to which that operating expense was aligned,” Bruno said.

At least five CMS payment models could overlap with one another: MSSP, BPCI Advanced, CJR, the advanced primary-care medical home model Comprehensive Primary Care Plus and the Oncology Care Model, said David Muhlestein, chief research officer with Leavitt Partners.

“If everybody is getting credit for it, you could potentially pay the same bonus payment five times,” he said. “Or if everybody does really poorly, all of them would pay the same penalty payment.”

There’s also a broader societal problem with overlap. It makes it difficult for the CMS Innovation Center to study whether its payment model experiments are actually saving money and improving patient outcomes. In that respect, the CMS is between a rock and a hard place, Muhlestein said.

“If they want to test many different programs to find out what works currently and not have overlap, you kind of can’t,” he said.

https://www.modernhealthcare.com…

Comment:

By Don McCanne, M.D.

While the policy community is ignoring the truly effective model of Single Payer Medicare for All, they remain fixated on accountable care organizations (ACOs) and alternative payment models (APMs). Not only has the initial experience with these models been relatively disappointing, the patients may be simultaneously enrolled in multiple models, often without their knowledge, creating confusion as to which entity should be receiving payment or assessed a penalty for falling short on parameters of care.

As David Muhlestein of Leavitt Partners states, “If they (CMS) want to test many different programs to find out what works currently and not have overlap, you kind of can’t.”

Yesterday’s Quote of the Day made the point that we don’t need more policy studies to figure out how we can fix the system. We merely need to enact and implement the single payer model of an improved Medicare for all.

https://pnhp.org…

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By Austin Frakt
The New York Times, September 9, 2019

Rigorous evaluations of health policy are exceedingly rare. The United States spends a tremendous amount on health care, but very little of it learning which health policies work and which don’t.

Evaluations of health policy have rarely been as rigorous as clinical trials. A small minority of policy evaluations have had randomized designs, which are widely regarded as the gold standard of evidence and commonplace in clinical science.

Because randomized health policy studies are so rare, those that do occur are influential. The RAND health insurance experiment is the classic example. This 1970s experiment randomly assigned families to different levels of health care cost sharing. It found that those responsible for more of the cost of care use far less of it — and with no short-term adverse health outcomes (except for the poorest families with relatively sicker members).

The results have influenced health care insurance design for decades. In large part, you can thank (or curse) this randomized study and its interpretation for your health care deductible and co-payments.

Problems can also plague rollouts that are voluntary and not randomized. Programs showing promise suffer from diminishing participation as health care organizations drop out. The innovation center’s pioneer accountable care organization program offered health care organizations the opportunity to earn bonuses in exchange for accepting some financial risk, provided they meet a set of quality targets. It started with 32 participants in 2012. Although studies showed it reduced spending and at least maintained, if not improved, quality, only nine remained by 2016 when the program ended.

Beginning in April 2016, Medicare randomly assigned 75 markets to be subject to bundled payments for knee and hip replacements, and 121 markets to business as usual. But the innovation center didn’t maintain the design, announcing in November 2017 that hospitals could leave it. This will greatly limit what can be learned from the program.

Just as in clinical care, there are examples of incorrect thinking based on low-rigor studies that more rigorous ones later overturn. For example, many low-quality studies suggest that wellness programs reduce employers’ health care costs as they improve health outcomes. But when the programs have been subject to randomized controlled trials, none of these findings hold up.

Hospital cost shifting — the idea that shortfalls from Medicare or Medicaid cause hospitals to charge higher prices to private insurers — can also seem commonplace from studies without rigorous designs. But when subject to more careful evaluation, the phenomenon is almost never observed.

It’s hard to rid ourselves of ideas that are little more than wishful thinking or to end policies that don’t work.

NYT Reader Comment:

By Don McCanne, M.D.

Health policy research is potentially beneficial, but it should not distract us from adopting policies that do not require research to know whether or not they work.

Currently much research is directed to studying value over volume, yet the preliminary results have been disappointing, and the response has been to call for more such studies. This is actually harmful when it deters us from adopting policy changes that would be inherently effective. Current research on alternative payment models is largely wasting resources, partly through an increase in useless administrative complexity.

On the other hand, we can enact and implement policies that would automatically include everyone, sharply reduce the profound administrative waste of private insurers and the burden they place on the system, make health care affordable for everyone by financing the system with equitable progressive taxes, and improve access by removing financial barriers to care. You do not need a complex policy study to see whether or not those goals would be realized. They are inherent in a well designed, single payer model of an improved Medicare that covered everyone.

Policy research is fine, but let’s not walk away from common-sense solutions just because the policy community hasn’t done the research yet, when no such research is required.

https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

The granddaddy of health policy research is the RAND health insurance experiment (RAND HIE) which supposedly showed that cost sharing decreased the use of health care without increasing adverse health outcomes (though that’s not quite true, at least for patients with hypertension). Yet commonly ignored is the fact that this study was confined to healthy workers and their young healthy families. That, in effect, excluded most of the 20 percent of individuals who use 80 percent of our health care. Thus the study has intrinsic validity for healthy individuals, but it does not have extrinsic validity for individuals receiving most of the health care in the United States.

Though this study showed that young, healthy people remained healthy (no surprise there), it was nevertheless used to advance the principles of consumer-driven health care – requiring high deductibles to keep people away from health care that they may not need. So today we have high deductibles that keep sick people away from the health care that they should have simply because the policy community ignored the fact that the RAND HIE does not have extrinsic validity. So this greatest health policy experiment of all time has had a detrimental impact on health care in America – the opposite of what policy science should be bringing us.

So what studies do we need to establish health care justice for all?

If we want everyone included, what study would show us how we can do that? Well, you don’t need a study. Simply include everyone.

If we want to reduce the high costs of the profound administrative waste of the private insurers and the burden they place on the health care professionals and institutions, what study would you need to figure out how to do that? How would a study help when what we need to do is simply eliminate the private insurers, substituting a universal, publicly financed and publicly administered program?

What study would you need to make sure that each person can afford his or her share of our national health expenditures? Again, you do not need a study. Simply fund the universal risk pool based on ability to pay by implementing equitable, progressive tax policies.

What study would you need to update the RAND HIE that would remove financial barriers to essential health care services? Again, it doesn’t take a study to conclude that you simply remove the barriers such as high deductibles.

What study would you need to return to the patient choices in health care professionals and institutions beyond the restrictive networks established by the private insurers? By now you’ve gotten the message. Simply eliminate the networks along with the private insurers that established them.

It’s time to reconnoiter and regroup. Let’s chase to the sidelines those in the policy community who just don’t get it and let them watch us fix our system. We don’t need more endless policy studies to figure out how to do that.

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By Michael Hiltzik
Los Angeles Times, September 4, 2019

You’ve got to hand it to Sen. Bernie Sanders for his ability to keep hot-button issues in the forefront of the presidential race.

The latest example is his assertion, made at least twice in the last month, that medical bills drive 500,000 Americans into bankruptcy every year. The Washington Post’s fact-checker column examined the numbers and concluded that Sanders deserved “three Pinocchios” for the statement, which means the Post found it “mostly false” and that Sanders was, basically, lying.

The Post blundered, as the authors of the study on which Sanders based his claim point out. In the real world, Sanders’ assertion that “500,000 Americans will go bankrupt this year from medical bills” is “mostly true.” Medical bankruptcy is an American scandal, and possibly even more common than he or the study’s authors calculate.

“At this point everyone agrees that many thousands of Americans suffer medical bankruptcies each year, but there’s still scholarly debate over exactly how many,” Himmelstein and Woolhandler wrote in response to the Post fact-checking. “Economists and business school professors (including some funded by the health insurance industry) generally offer lower estimates, and medical and legal researchers find higher numbers.”

Unquestionably, the individual burden of medical costs in the U.S. can be unsupportable and, in the richest country in the world, should be unnecessary. Sanders and Warren are right to point the finger at a dysfunctional healthcare financing system. Those who say things aren’t that bad are wrong; it’s worse. Debating whether the number of Americans forced into bankruptcy by medical debt is 500,000 or some other figure is nitpicking, and woefully beside the point. What everyone knows is that the threat is bad enough, and it can strike at anyone.

www.latimes.com…

Sanders’s flawed statistic: 500,000 medical bankruptcies a year

By Salvador Rizzo
The Washington Post, August 28, 2019

This fact check has been updated with a rebuttal response

Sanders’s statements — “500,000 people go bankrupt every year because they cannot pay their outrageous medical bills” and “500,000 Americans will go bankrupt this year from medical bills” — are unambiguous. He’s saying medical debts caused those 500,000 bankruptcies. However, correlation is not causation, and the study he’s citing doesn’t establish causation for all 500,000 bankruptcy cases.

One of the authors sent us rough estimates showing that Sanders might be on target, but those numbers deserve scientific scrutiny before they can be taken as fact.

The omissions and twists are significant enough to merit Three Pinocchios for Sanders.

www.washingtonpost.com…

Medical Bankruptcy is Real, Even if the Washington Post Refuses to Believe it

By David U. Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H

The Washington Post has broken new ground, calling a presidential candidate a liar for citing a statistic from research published in the world’s leading public health journal. The Post’s Fact Checker column labeled Bernie Sanders a “three pinocchio” level liar for saying that 500,000 Americans are bankrupted by medical bills each year. Sanders’ statement relied on research that we and three colleagues published in the American Journal of Public Health (AJPH). Dozens of politicians and publications (including the Post itself!) have cited that study as a reliable source.

Our AJPH study was part of an ongoing research effort by the Consumer Bankruptcy Project (CBP). For decades, the CBP has been surveying debtors about the causes (including medical ones) and consequences of their bankruptcy. In our 2019 research, 37.0% of bankrupts “very much” agreed that medical bills were an important factor, while another 21.5% “somewhat agreed”. Many others cited lost wages due to illness, and overall, two-thirds cited illness-related bills, income loss or both. As we wrote in the AJPH, that’s “. . . equivalent to about 530 000 medical bankruptcies annually.” That figure is in line with estimates based on our earlier CBP studies (carried out with then-Harvard law professor Elizabeth Warren and sociologist Deborah Thorne), which were published in leading medical and policy journals.

But even the 530,000 figure is an underestimate of the number of people affected by medical bankruptcies. Most bankruptcies involve more than one person – an average of about 2.7 people, often including a spouse/partner and children. That means that the 750,000 bankruptcies last year involved more than 2 million people. And even if you use the most restrictive definition of medical bankruptcy – i.e. including only debtors who “very much” agreed that medical bills were a cause of their bankruptcy – Sanders’ 500,000 figure is, if anything, too low. The right number is more like three quarters of a million.

And our studies aren’t the only indicator that many American families suffer a crushing burden of medical bills. A Nobel Prize winner was forced to sell his medal to pay medical bills. More than 250 000 people sought to raise funds for medical bills through GoFundMe campaigns last year. According to the Consumer Financial Protection Bureau, medical bills account for more than half of all unpaid bills sent to collection agencies. And in a New York Times/Kaiser Foundation survey, more than one quarter of respondents said they or someone in their household had a problem paying medical bills, and of them, 11% said they’d declared bankruptcy due, at least in part to medical bills.

So why did the Fact Checker claim that Sanders told a whopper? That claim rests on an econometric study that found only a modest uptick in bankruptcy filings among persons hospitalized in California between 2003 and 2007. But that study appeared tailor made to undercount medical bankruptcies. As we and Elizabeth Warren noted in our response to it in the New England Journal of Medicine, it excluded most people who were frequently hospitalized (a group that’s at high risk of medical bankruptcy); it assumed that anyone not hospitalized could not suffer medical bankruptcy (even though people who aren’t hospitalized in the course of a year account for four-fifths of all out-of-pocket medical bills); that no one is bankrupted by bills for a child’s or partners’ care; and that potentially bankrupting illnesses never start before the moment of hospitalization – an assumption contradicted by the study’s own data.

Yet despite these flaws, the economists behind the study insisted (and the Post believed) that their math was a more reliable indicator of what caused financial ruin than the testimony (and court records that we’ve used as cross-check) from the thousands of debtors surveyed and interviewed by the CBP.

At this point everyone agrees that many thousands of Americans suffer medical bankruptcies each year, but there’s still scholarly debate over exactly how many; economists and business school professors (including some funded by the health insurance industry) generally offer lower estimates, and medical and legal researchers find higher numbers. We’d be happy to see the Post report the facts and nuances of that debate. But instead it’s chosen a side and labeled those on the other side – researchers, public figures who cite their research, and the debtors who shared their painful stories – “liars.”

David U. Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H. are both Distinguished Professors of Public Health, City University of New York at Hunter College and Lecturers in Medicine at Harvard Medical School, and the founders of Physicians for a National Health Program.

www.berniesanders.com… 

Comment:

By Don McCanne, M.D.

The United States is unique in supporting a health care financing system that results in financial hardship for millions of people due to medical bills. Many of those individuals end up in personal bankruptcy whether those bills were a contributor or a “cause” of the bankruptcy.

For many years now, the bankruptcy statistics have been debated, not based on whether medical bills cause financial hardship or contribute to bankruptcy – they clearly do and on a massive scale. Rather, the debate has been over the definition of “cause” when used to estimate the number of bankruptcies “caused” by medical bills. Those who wish to discredit the bankruptcy studies seem to disregard medical debt as “a” cause of bankruptcy and insist that only medical debt as “the” (presumably sole) cause of bankruptcy be counted in the statistics.

David Himmelstein and Steffie Woolhandler, in their response above, set the record straight. Medical debt in the United States is a horrendous problem that creates much hardship, and it is totally unnecessary.

All we need to do is to separate the health care financing system from the delivery of health care. We can finance the entire health care system with equitable taxes that are affordable for each of us without creating any personal financial hardship. Then when individuals need health care they can get it without the necessity of paying insurance premiums nor deductibles, copayments or coinsurance as a condition for accessing health care.

A Single Payer Medicare for All system would ensure health care for everyone without exposing them to financial hardship nor personal bankruptcy due to medical debt. The media and policy community should stick to the issues that actually impact our health care rather than distracting us with their pinocchio mischief.

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By Munira Z. Gunja and Sara R. Collins
The Commonwealth Fund, August 28, 2019

In 2018, an estimated 30.4 million people were uninsured, up from a low of 28.6 million in 2016. Coverage gains have stalled in most states and have even eroded in some. In addition, more people have reported problems getting health care because of cost. To examine why so many people remain uninsured, we use data from the 2018 Commonwealth Fund Biennial Health Insurance Survey.

• Uninsured Working-Age Adults Disproportionately Low-Income, Latino, and Under Age 35
• Nearly Half of Uninsured Adults May Be Eligible for Marketplace Subsidies or Medicaid
• One-Third of Uninsured Adults Who Did Not Visit Marketplace to Get Coverage Cited Affordability Concerns
• One-Third of Adults Who Lost Coverage and Were Previously Covered Through the Individual Market Cited Affordability Concerns
• Majority of Adults Who Had Lost Coverage and Were Previously Covered by Medicaid Said They Were No Longer Eligible
• More Adults Had Difficulty Finding Affordable Coverage in the Individual Market in 2018 vs. 2016

Policy Recommendations:

• Expand Medicaid without restrictions.
• Lift the 400-percent-of-poverty cap on eligibility for marketplace tax credits.
• State or federal reinsurance.
• Reinstate outreach and navigator funding for the 2020 open-enrollment period.
• Ban or place limits on short-term health plans and other insurance that doesn’t comply with the ACA.
• Make premium contributions for individual market plans fully tax deductible.
• Fix the so-called family coverage glitch.
• Inform people about their options.
• Reduce churn in Medicaid.
• Extend the marketplace open-enrollment period.

www.commonwealthfund.org…

Comment:

By Don McCanne, M.D.

In spite of enactment and implementation of the Affordable Care Act, 30 million people remain uninsured and tens of millions remain underinsured. In spite of spending twice the average of other wealthy nations, access to health care and affordability of care remain a uniquely American problem.

The Commonwealth survey quantifies these problems, and then they propose incremental tweaks that would expand access and improve affordability, but they would do so at a cost of increasing our already excessive administrative complexity and increasing further our very high level of spending. Further, they would not eliminate the problems of access and affordability as many would still fall short of qualifying for public programs or of being able to pay for private programs.

Yet many recommend that we build on ACA and add a public option (Medicare buy-in) as another choice. The options listed by Commonwealth are those that would build on ACA, and yet we see that they are costly and increase administrative complexity while falling far short of the goals of universality, accessibility, and affordability. Adding the option of buying a public plan does not work for the great majority of those who would remain uninsured simply because the plan would not be affordable for them.

The single payer model of Medicare for All would recover hundreds of billions of dollars in administrative waste while automatically making health care affordable and accessible for absolutely everyone.

Enough with the deficient tweaks. Let’s go directly to a system that would work for all of us: Single Payer Medicare for All.

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