By Merrill Goozner
Modern Healthcare, March 16, 2018

Healthcare providers and insurers are gearing up to oppose Medicare for All. No surprise there. Insurers can’t look kindly on legislation that would put them out of business. And providers are deathly afraid of losing the high rates from private insurers that cross-subsidize government-funded patients.

But at the same time as they mobilize to defeat M4A, shouldn’t they be outlining what they support?

Here’s what M4A advocates want to achieve. The first is universal coverage. Sadly, we’re again moving away from this basic human right due to actions by the Trump administration to undermine the Affordable Care Act. They want lower prices. Insurance premiums for employers and out-of-pocket expenses for individuals and families continue to rise faster than wages or economic growth.

Finally, they want an end to the frustration engendered by a system that erects roadblocks between physicians and patients. These range from insurer rules requiring prior authorization to seemingly arbitrary limits on what doctors can perform or prescribe.

Is M4A the only way to solve these problems? Of course not. When it comes to covering the uninsured, the ACA worked just fine. Massachusetts, the first state to implement an ACA-like program, had an uninsured rate of 2.5% in 2017. That’s not the 0% of most Organisation for Economic Co-operation and Development countries, but pretty close.

Politics are at the root of the ACA’s failures—not its Rube Goldberg design. The Supreme Court allowed states to opt out of the Medicaid expansion. And when the GOP-controlled Congress eliminated the individual mandate, key to making rates on the exchanges affordable, it reduced sign-ups, raised premiums and stopped the expansion dead in its tracks.

How about service prices? M4A would set prices at Medicare rates, which are well below private insurance rates but higher than Medicaid rates (both Medicaid and the Children’s Health Insurance Program are eliminated in Sen. Bernie Sanders’ M4A bill). But that’s not where most of its savings come from.

According to a sympathetic analysis from the University of Massachusetts at Amherst, half of M4A’s savings come from reducing provider and insurer administrative overhead. Another quarter comes from lower drug prices.

But these are one-time savings that will do little to stop the upward spiral of hospital and physician costs, which account for two-thirds of all spending. That’s where we get to the third issue supposedly addressed by M4A: the administrative hassles and limits imposed on obtaining care.

These aren’t eliminated by an expanded public system. They simply transfer the policing of waste, fraud and abuse from private hands to public hands and change the motivation from padding profits to protecting taxpayers. In the past, Medicare has done a better job than private payers for one simple reason: it can impose price controls. Providers have responded by shifting much of the shortfall to their private-paying patients.

There are alternatives for achieving M4A’s goals. They include private companies offering exchange policies with well-defined coverage rules and strict limits on out-of-pocket costs; all-payer rate-setting or global budgets to slow the rate of price increases; merging Medicaid with Medicare (leaving long-term services and supports to the states), which would give private employers and families rate and tax relief; and establishing all-stakeholder oversight councils to develop medically appropriate utilization rules.

There’s more. The point is that in the post-Trump era, the U.S. will once again begin moving toward a healthcare system that is universal and affordable with high-quality care for everyone.

A multipayer approach could be like Germany and Switzerland, which rely on private insurers that are regulated to a much greater extent than currently exists in the U.S. Or it will be a single-payer system like Canada, Great Britain or France. Each delivers better results at a lower cost than the U.S.

I’m agnostic on which way to go. I’m still waiting for providers and insurers to articulate their vision.

---

Comment posted at Modern Healthcare:

By Don McCanne, M.D.

Put all the facts on the table and there should be no room left for agnosticism. A well designed, single payer, improved Medicare for all system does the following:

• It is truly universal in that everyone is included automatically, for life.
• It dramatically reduces profound administrative waste, recovering enough funds to pay for care for the currently uninsured and underinsured.
• It addresses the problem of excessive prices by using publicly administered global budgeting and price negotiation, covering legitimate costs while eliminating gouging.
• It improves equitable allocation of our health care resources through central planning and separate budgeting of capital improvements. Everyone would have reasonable access to care.
• It makes the financing of health care equitable by replacing premiums and cost sharing with progressive taxes based on ability to pay. The financing of the universal health care risk pool is totally separated from the delivery of health care such that nobody is ever denied care because of the inability to pay for it.
• Publicly administered programs are much more effective in reducing the trajectory of health care costs to sustainable levels (compare Canada’s spending curve to ours), ensuring that, well into the future, health care will be affordable for each of us and for society as a whole.
• Our current system has twice the average per capita costs of other wealthy nations while we fall short on universality, effectiveness, equity, resource allocation, access, and quality. The Affordable Care Act left this extremely inefficient system in place, so building on it or compounding its complexity with the addition of a public option (expanding Medicare to the few who can afford it) cannot begin to correct the profound, expensive dysfunctions in our system.

Do we want a public service model designed to take care of patients, or shall we continue with a private business model designed to enrich the vested interests? There should be no question that it is time to end equivocation and get on with enacting and implementing a model that actually would work: Single Payer Medicare for All.

https://www.modernhealthcare.com…

---

Comment:

By Don McCanne, M.D.

With the surge in popularity of the single payer Medicare for All model of reform, there understandably has been a groundswell of opposition by stakeholders who stand to lose and by ideologues on the right. The media is busy providing what they profess to be balanced reporting on this activity. Unfortunately, they seem to have bought the concept that Medicare for All is only an “aspiration” that can be dismissed because it doesn’t mesh with the machinations of the political system in this country. Thus they concentrate on the status of the Affordable Care Act and the supposedly politically feasible public option in the form of Medicare for the few who can afford to purchase it, as if this represents the only realistic pathway to reform.

I have followed Merrill Goozner’s journalistic efforts for quite a few years and know him to be a person of integrity. I understand why he mentions systems in other nations that work better than ours that are not single payer systems, thus concluding that Medicare for all is not the only way to go. I have to admit that I do get a little edgy when he says that he remains agnostic as to whether we should use a multi-payer system or a single payer system because he is “still waiting for providers and insurers to articulate their vision.”

Well, the realistic vision of health care nirvana has already been articulated in the single payer, improved Medicare for all model advanced by Physicians for a National Health Program and other organizations. Just a few features that make this model an imperative are listed in the response to Goozner’s editorial above. There should be no room left for agnosticism. The vision of single payer Medicare for All is based on solid health policy science.

It’s time to move forward with fine tuning the Jayapal Medicare for All bill in the House and the Sanders Medicare for All bill in the Senate. As the politics realign, we should be able to complete the legislative process by early 2021, and finally have heath care for all, effective January 1, 2022. Or maybe we should aim for July 1, 2021.

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

By Keren M. Escobar, Dorian Murariu, Sharon Munro, Kevin M. Gorey
Journal of Public Health Research, March 11, 2019

Abstract

This study tested the hypothesis that socioeconomically vulnerable Canadians with diverse acute conditions or chronic diseases have health care access and survival advantages over their counterparts in the USA. A rapid systematic review retrieved 25 studies (34 independent cohorts) published between 2003 and 2018. They were synthesized with a streamlined meta-analysis. Very low-income Canadian patients were consistently and highly advantaged in terms of health care access and survival compared with their counterparts in the USA who lived in poverty and/or were uninsured or underinsured. In aggregate and controlling for specific conditions or diseases and typically 4 to 9 comorbid factors or biomarkers, Canadians’ chances of receiving better healthcare were estimated to be 36% greater than their American counterparts (RR=1.36, 95% CI 1.35-1.37). This estimate was significantly larger than that based on general patient or non-vulnerable population comparisons (RR=1.09, 95% CI 1.08-1.10). Contrary to prevalent political rhetoric, three studies observed that Americans experience more than twice the risk of long waits for breast or colon cancer care or of dying while they wait for an organ transplant (RR=2.36, 95% CI 2.09-2.66). These findings were replicated across externally valid national studies and more internally valid, metropolitan or provincial/state comparisons. Socioeconomically vulnerable Canadians are consistently and highly advantaged on health care access and outcomes compared to their American counterparts. Less vulnerable comparisons found more modest Canadian advantages. The Affordable Care Act ought to be fully supported including the expansion of Medicaid across all states. Canada’s single payer system ought to be maintained and strengthened, but not through privatization.

From the Introduction

Canadians and Americans rate health care a top concern. They seem naturally to wonder if health care policies are greener on the other side of their unfenced 5,000-kilometer border. Some Americans − particularly concerned with health care inaccessibility among the uninsured − have called for a more Canada-like single payer system. In contrast, some Canadians − concerned with health care shortages − have called for a more American-like system with more private options. Aiming to contribute critical evidence to these debates, our research group has focused on the health care of people living in poverty. We assume that this magnifies human and policy significance.

From the Discussion

This study found that Canadians with any number of acute health conditions or chronic diseases are significantly more advantaged on health care access and outcomes compared to their counterparts in the USA. It estimated that the chances of Canadians receiving indicated treatments and surviving were 13% greater than Americans. That estimate was more unequivocal and larger than previous review estimates that were based on less internally valid research designs. We advanced and found much support for a meta-analytic country by socioeconomic status interaction. This clearly demonstrated that Canadian advantages were significantly larger among those living in poverty or those who were otherwise socioeconomically vulnerable such as the uninsured or inadequately insured.

Among patients who lived in high poverty neighborhoods, it was estimated that the chances of Canadians receiving indicated treatments and surviving were 36% greater than Americans. That estimate was essentially unequivocal across all the reviewed studies and was larger than a previous meta-analytic estimate based on less prevalently poor neighborhoods. Recalling that such a 36% differential is implicated across most common health conditions and diseases over the lives of millions of impoverished Canadians and Americans, its population-level significance is clear. In addition to accounting for socioeconomic factors most of these primary studies also accounted for key personal and contextual case-mix differences between Canada and the USA, notably disease severity and health care service endowments in diverse large to small urban or rural places. We consider the robustness of the observed Canadian advantage to be our review’s most provocative scholarly and policy-significant finding.

As with primary research, we think that the interpretation of significant interaction effects or important effect modifications ought to take precedence in synthetic research. Therefore, we think four more interpretive adjuncts are in order. First, larger Canadian advantages were replicated among socioeconomically vulnerable patients with acute conditions and chronic diseases, representing a multiplicative Canadian advantage among those living in poverty with chronic diseases. Such patients probably had multiple experiences with their respective health care system over several years. In other words, it seems that the longer patients were in contact with their respective Canadian or American health care systems, the larger were their respective advantages or disadvantages. Second, three studies included four assessments of wait-lists, estimating that the exemplary risks of experiencing relatively long waits for adjuvant cancer care or of dying while waiting for a liver transplant were much greater in the USA (RRs ranged from 1.89 to 2.99, precision-weighted RR=2.36, 95% CI 2.09-2.66) than in Canada. This evidence stands in stark contrast to prevalent contemporary political rhetoric. Third, all this field’s synthetic evidence strongly suggests a dose-response relationship between socioeconomic vulnerability and Canadian advantages. It seems, therefore, that Canada’s single payer healthcare system causally provides much better health care than does the USA’s multiple payer system that still leaves millions uninsured or inadequately insured. The Canadian health care system’s most pronounced evidence-based advantages are clearly among those who live in poverty who consistently experience much better health care compared to impoverished Americans. In short, the more socioeconomically vulnerable a person is the more protective a single payer health care system is likely to be.

The fourth interpretive adjunct arose serendipitously in our systematic search for eligible studies. We retrieved 8 within-Canada studies of socioeconomic factors and cancer care. Though ineligible for this review, these studies were very interesting. One observed a modest indirect low-income-care association. Five others observed similar trends, but were not statistically significant and two others were null. The pooled precision-weighted estimate was minuscule (RR=0.97, 95% CI 0.95-0.99). We identified more than 100 such within-USA studies nearly all of which observed the well-known, large American socioeconomic-care gradient. Six studies that were included in this review, but that also observed typically very low-income or poverty associations with cancer care in both Canada and the USA allowed for a controlled, precision-weighted synthetic comparison. A large disadvantage of being poor was observed in the USA (RR=0.73, 95% CI0.71-0.75) while no such association was observed in Canada (RR=0.99, 95% CI 0.96-1.02), z=14.44, P<0.05. Such within-country observations clarify the between-country comparisons. Given the intimate relationship between low socioeconomic status and health insurance inadequacy in the USA, but not in Canada, the pattern resolutely identifies inadequate health insurance coverage in the USA as the primary explanation for this study’s findings. It clearly indicts the USA for the largely inadequate health insurance coverage it provides its underclass, including those who live in poverty or near poverty as well as the periodically unemployed or underemployed middle-class. Most regrettably, this indictment holds true in post-Affordable Care Act America. For example, at the time of this writing, 14 states still had not fulfilled the Act’s legislative intent to expand Medicaid.

Conclusions

This field’s research now seems rigorous enough to support confident judgements about the relative effectiveness of Canadian versus American health care, especially among the most socioeconomically vulnerable. Socioeconomically vulnerable Canadians are consistently and highly advantaged on health care access and outcomes compared to their American counterparts. Less vulnerable comparisons found more equivocal and more modest Canadian advantages. The Affordable Care Act ought to be retained, indeed fully supported, including the envisioned expansion of Medicaid across all states. When politically achievable, however, single payer health care would better ensure truly equitable access and outcomes among America’s diverse population. Canada’s single payer system ought to be maintained and strengthened where needed, but not through the addition of private tiers.

Significance for Public Health

This study estimated that socioeconomically vulnerable Canadians’ chances of receiving better health care were 36% greater than their American counterparts and this estimate was larger than that based on general patient comparisons (9%). One may wonder about the public health significance of such relative risks/protections. Attributions of risk/protection among populations are a function of three factors of which relative risk is only one. The size of the population and the prevalence of exposure to risks are also important. In this instance, the entire USA population is at relatively greater risk of receiving lower quality care, its more prevalent low-income and inadequately insured populations more so. Applying our findings to population parameters and attributable risk formulations we estimated that without reform, over the next generation more than 50 million Americans will be treated less optimally and die earlier than had they enjoyed a single-payer health care system like Canada’s.

https://www.jphres.org…

---

Comment:

By Don McCanne, M.D.

Socioeconomically vulnerable residents of the United States fare much worse medically under our health care system than do socioeconomically vulnerable Canadians under their health care system. The authors of this meta-analysis estimate, “over the next generation more than 50 million Americans will be treated less optimally and die earlier than had they enjoyed a single-payer health care system like Canada’s.”

Solution? Single Payer Improved Medicare for All – Now!

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

By Lane Koenig, PhD, Asha Saavoss, Samuel Soltoff, Berna Demiralp, PhD, Jing Xu, PhD
KNG Health Consulting, LLC, March 12, 2019

In this study, we model the effects of the Medicare-X Choice Act on coverage and healthcare spending. Although not as expansive as Medicare-for-All, Medicare-X Choice would allow any individual to voluntarily enroll in a public plan offered on each health exchange.

Key Findings

We find that national enrollment in the public plan would be 40.7 million in 2024 and would increase slightly to 42.3 million by 2033 (Table ES1). Under Medicare-X Choice, the number of uninsured and the commercially insured on the non-group market would fall by 5.5 and 12.6 million in 2024, respectively, while enrollment in employer-sponsored insurance (ESI) would fall by 22.6 million. About ninety percent of the enrollment in the public plans would comprise individuals who were either covered under ESI or on a commercial non-group plan in the baseline. While most of the enrollment in the public plan comes from those previously with ESI, the public plan take-up rate is highest (67%) among those with commercial non-group insurance.

We estimate considerable reductions in healthcare spending of 7 percent under Medicare-X Choice over the 10-year period from 2024 to 2033 (Table ES2). Spending on individuals who are uninsured in the baseline is projected to increase by 9 percent in 2024, however, increased spending on the uninsured would be more than offset by spending reductions among those who are enrolling in the public plan but previously insured through private insurance. While hospital- based services represent 47 percent of total baseline healthcare spending, these services would account for roughly 67 percent of the reduction in total spending. Overall, we estimate that hospitals would experience a 10-percent reduction in payments among the relevant population.

Conclusions

Medicare-X Choice would result in significant changes in the health insurance landscape, with 36.5 million people leaving private coverage for the new government-run public option, and 5.5 million individuals without insurance gaining coverage. While we estimate material reductions in the number of uninsured, most of those choosing coverage under a public plan would come from those currently covered under a commercial non-group plan or ESI. We estimate reductions in total healthcare spending due to reduced payments to providers, given the large differences in prices between Medicare and commercial insurers. For hospitals and other providers, the introduction of Medicare-X Choice would reduce revenue without commensurate reductions in costs. Although the increase in the number of insured individuals would increase revenue from the formerly uninsured, higher spending from this group would not be enough to offset the lost revenue from shifts between private and public insurance coverage.

For hospitals, the introduction of a public plan that reimburses providers using Medicare rates would compound financial stresses already faced by the sector, potentially impacting access to care and provider quality. CBO projects that between 40 and 50 percent of hospitals could have negative margins by 2025 under current law. Given that Medicare pays hospitals below their costs (e.g., the Medicare Payment Advisory Commission estimates that Medicare inpatient margins will be -11 percent in 2018), Medicare-X Choice would be expected to increase the number of hospitals with negative margins. While hospitals may attempt to shift some costs to commercial insurers, the ability to do this under a public plan may be limited because of the study’s projected significant take-up by those in the non-group market. Policymakers should have a clear understanding of potential effects on patient access, provider payment, the commercial insurance market, and ESI (desired as well as unintended) when considering proposals to expand Medicare coverage.

https://fah.org…

---

Comment:

By Don McCanne, M.D.

This study was prepared for the American Hospital Association and the Federation of American Hospitals. They wanted to see the potential impact of a Medicare-for-some model of reform, choosing as an example the Medicare-X Choice Act of Sen. Michael Bennet and Sen. Tim Kaine. They show that the shift of enrollees from employer-sponsored plans and commercial non-group plans into the public option Medicare-X plan, which would have payment rates set at Medicare levels, would reduce hospital net revenues without commensurate reductions in costs, even though the impact is partially offset by the newly insured.

Although the report is mostly about hospitals (understandably so considering the sponsors of the study), the report does show that not only would payments to hospitals decline by 10 percent, continuing over a decade, but payments to physicians also would decline by 8 percent (page 10, Table 4).

More importantly, and not mentioned in this study, is that the Medicare-X Act and all other Medicare-for-some Acts would leave in place most of the critical flaws in our health care financing system – flaws that would be corrected by enacting and implementing a well designed, Single Payer Medicare for All program. The authors suggest that instead we should strengthen existing components of the Affordable Care Act, but that won’t do it. We really desperately need to enact Single Payer Medicare for All.

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

By Diane Archer
The Hill, March 11, 2019

If you’re following the health care debate, you’ve already heard quite a bit about “Medicare for all,” the proposal to improve and expand Medicare, the government health insurance program for older adults and people with disabilities, to all Americans. As proposed by Sen. Bernie Sanders (I-Vt.) and others, Medicare for all provides all Americans the right to use physicians and hospitals of their choice anywhere in the country, eliminates premiums, deductibles and co-payments, and is projected to drive down national health care spending by $2 trillion to $5 trillion over the next 10 years.

For most Americans, this sounds like a pretty good idea. And it looks even better when compared against the failures of our commercial health insurance system. Commercial insurance forces Americans to spend nearly twice as much on health care as our peers in Europe and Japan for significantly worse health care outcomes. Commercial insurance creates an estimated $500 billion a year in administrative waste, enables excessive and irrational provider rates, and forces one in four Americans under 65 to forgo necessary health care because they cannot afford their out-of-pocket costs.

Nonetheless, a number of thoughtful commentators and well-intentioned politicians are telling us that Medicare for All is not a practical approach to health care reform – that it’s just not doable given the political context and the country’s long history with employer-based health insurance. These self-described “pragmatists” would offer Medicare as an additional option alongside commercial insurance, proposing a Medicare buy-in or Medicare for some.

By any measure, Medicare for some would deliver very little for the American people. At best, it would capture a fraction of the health care savings created under Medicare for all. It would not address the unaffordable premiums, deductibles and coinsurance that keep millions of Americans from getting needed health care. And it would leave tens of millions of Americans uninsured or underinsured.

So, too, Medicare for some does not address the most basic questions about our health care system: Why do we trust health insurers to determine the doctors and hospitals we can see? Why should a knee replacement cost anywhere between $16,000 and $61,000? Why should Americans pay twice as much for prescription drugs as our peers in Europe and Japan? And, why should our health coverage depend on where we work?

The “pragmatists” argue that we have to live with this crazy system because Americans want “choices” in health care, and most are not willing to give up their current insurance. As a result, they say, the best we can do today is to support Medicare for some and hope for real reform in the future. However sincere or politically fashionable, this view makes no sense.

Let’s get real: Commercial insurance is the biggest threat to health care choices and our freedom to receive the health care we need. Employers choose our insurers, and the insurers restrict the providers we can use, the treatments we can receive, and the prescription drugs we can take. Every year, we can be forced to change provider networks, benefits, out-of-pocket costs and, often, insurers. If we change jobs, every aspect of our health insurance changes. And, we are left to fend for ourselves if we leave the job market.

No one loves Aetna, Anthem or any other insurance company. What we love – and what we need – is the freedom to get care from the doctors we want to see at a price we can afford. Medicare for all guarantees all Americans access to health care, with freedom to see the doctors we want, throughout our lives, wherever we live, wherever we work and whenever we are out of work. That’s about as pragmatic as it gets.

Maybe the “pragmatists” are concerned that we lack the votes in Congress to pass Medicare for all or that the commercial interests with a stake in maintaining the status quo are too powerful to overcome. That might be right. The health care industry is flush with cash, and insurers use campaign contributions to wield substantial influence in Congress. As we learned in 2009 and 2010, the health insurance industry will fight hard to retain its place in the health care system.

But fixing our broken commercial health insurance system is too important to leave to the politicians or to the insurance industry. The American people deserve a frank conversation about how we can guarantee access to health care as a right in this country. That conversation does not begin with Medicare for some. It begins – and ends – with Medicare for all.

Diane Archer is a senior adviser at Social Security Works. She is founder and president of Just Care USA, an independent digital hub covering health and financial issues facing boomers and their families and promoting policy solutions. Archer is the past board chair of Consumer Reports and serves on the Brown University School of Public Health Advisory Board.

https://thehill.com…

---

Comment:

By Don McCanne, M.D.

Diane Archer says it. The conversation on affordable health care for all does not begin with Medicare for some. It begins – and ends – with Medicare for all.

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

BlueCross BlueShield Association, Issue Brief, March 2019

Many individuals who have significant medical conditions and need extensive and often costly care depend on the individual market for coverage.

Unfortunately, individual market premiums are often unaffordable for people who do not qualify for financial assistance, and coverage options for these people remain limited. For many, the cost of coverage and care is out of reach, with many purchasers required to pay more than 15 percent of their income for health insurance so they can obtain the medical care they need.

The individual market is a critical source of coverage for people from all walks of life, and it should be strengthened to make coverage more affordable while protecting those with pre-existing conditions. To achieve this, BCBSA recommends that policymakers take three critical steps:

1. Revise federal assistance to help more people afford coverage

• Congress should adjust tax credits to make coverage more affordable and boost enrollment among younger people.
• Congress should adjust the current tax credit structure to help those who are ineligible for tax credits today.
• Congress should improve cost-sharing protections to help lower-income people access medical care.

2. Enact policies to lower costs and remove financial barriers to accessing care

• Congress should establish a sustained federal funding system to support the cost of caring for those with significant medical needs.
• Congress should provide relief from the health insurance tax.
• Congress should modernize health plans that are linked with health savings accounts (HSAs).

3. Improve outreach to encourage people to obtain and maintain insurance

• Exchanges should provide enhanced outreach to ensure that people enroll in coverage.
• Exchanges should provide information on coverage status to states to improve outreach efforts and simplify enrollment.
• Policymakers should continue to allow consumers to automatically renew coverage.

https://s3.amazonaws.com…

---

Comment:

By Don McCanne, M.D.

The support for single payer Medicare for All stems from the recognition that too many people are not being served well by our current dysfunctional health care financing system, resulting in impaired access to health insurance and health care and exposure to financial hardship. The vested interests that would lose by changing to a single payer public financing system have had initial success in shifting the media toward bemoaning the loss of private insurance that would occur under single payer. This Issue Brief from BlueCross BlueShield Association is important because it explains how the private insurance industry would address the problems of access and affordability facing the insurance beneficiary.

The basic problem is straightforward. Health care has now become so expensive that each beneficiary’s proportionate share of risk – the premium – that would fund a common risk pool now exceeds the financial resources available to the typical working family. It has long been understood that the government must cover the deficit. Earlier, Medicare for retirees with their limited incomes, and Medicaid for individuals living in poverty, filled in the largest gaps. Once insurance premiums exceeded the abilities of average-income families to pay them, more government intervention was required, and that resulted in enactment of the Affordable Care Act with its insurance premium and cost sharing subsidies plus its expansion of Medicaid.

Now it is widely recognized that not even the Affordable Care Act is meeting the needs. People well informed on health policy understand that the single payer model has become the obvious solution that would ensure affordable health care for all, but some are ideologically opposed, willing to sacrifice the suffering of others in order to reduce the role of government, and others are opposed because of the impact on the vested interests, especially the private insurers and the profiteers such as the pharmaceutical firms.

So it is understandable that traditional insurers such as Blue Cross and Blue Shield would want policies enacted that would not only salvage their industry but would also further nurture them. A quick look at their proposals leads to an obvious conclusion: They do not propose policies that would control future health care spending; instead they support proposals that would infuse more government money – our taxes – into their industry.

By providing more public support to the insurers, we would be perpetuating their very costly administrative excesses, while not receiving anything of substance from them in return for us increasing further our already too high national health expenditures. But, you say, more people would be insured? Taking money from the federal government, carving out a portion for themselves, and then passing the rest on to the actual health care delivery system is not providing us with value for our tax dollars that they keep.

This is where the media is failing us. A single payer Medicare for All program would meet our goals of universality, effectiveness, efficiency, equity, and affordability for each of us and for the nation as a whole. Simply throwing more money at the current, fragmented, dysfunctional system will perpetuate most of our problems, not to mention that it is the most expensive model of reform. If the media is going to cover reform, it is imperative that they understand fully the policy science behind it.

Although some in the media parrot the policy principles behind reform, it is difficult to believe that they understand the issues in depth when you listen to them whine about the potential loss of our revered private plans, especially the employer-sponsored plans. Really? We need to protect that industry when the result is to spend even more money while perpetuating unnecessary financial hardship, physical suffering and even premature death? Start whacking the media (figuratively) when they deserve it. Enough of their crescendo of journalistic crap about our precious private insurance industry.

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

By J. Frank Wharam, Fang Zhang, Jamie Wallace, Christine Lu, Craig Earle, Stephen B. Soumerai, Larissa Nekhlyudov, and Dennis Ross-Degnan
Health Affairs, March 2019

Abstract

The effects of high-deductible health plans (HDHPs) on breast cancer diagnosis and treatment among vulnerable populations are unknown. We examined time to first breast cancer diagnostic testing, diagnosis, and chemotherapy among a group of women whose employers switched their insurance coverage from health plans with low deductibles ($500 or less) to plans with high deductibles ($1,000 or more) between 2004 and 2014. Primary subgroups of interest comprised 54,403 low-income and 76,776 high-income women continuously enrolled in low-deductible plans for a year and then up to four years in HDHPs. Matched controls had contemporaneous low-deductible enrollment. Low-income women in HDHPs experienced relative delays of 1.6 months to first breast imaging, 2.7 months to first biopsy, 6.6 months to incident early-stage breast cancer diagnosis, and 8.7 months to first chemotherapy. High-income HDHP members had shorter delays that did not differ significantly from those of their low-income counterparts. HDHP members living in metropolitan, nonmetropolitan, predominantly white, and predominantly nonwhite areas also experienced delayed breast cancer care. Policies may be needed to reduce out-of-pocket spending obligations for breast cancer care.

From the Discussion

This study found that both vulnerable and less vulnerable women experienced delays in breast cancer diagnostic testing, early-stage diagnosis, and chemotherapy initiation following an employer-mandated switch to high-deductible health plans. Although magnitudes of delays among women in the three income categories were not statistically different at a 95 percent level of certainty, the graduated duration of the delays in the expected direction suggests true differences. For example, HDHP enrollment was associated with delays in chemotherapy initiation of 8.7 months among low-income women, 8.1 months among middle-income women, and 5.7 months among high-income women. We also detected delayed breast cancer care among HDHP members living in metropolitan, nonmetropolitan, predominantly white, and predominantly nonwhite areas.

These results suggest that HDHP-associated delays in breast cancer care are only partially related to patients’ sociodemographic characteristics and that women across the income spectrum might experience high out-of-pocket spending obligations as a barrier to breast cancer care. The delay of approximately five to seven months in early-stage breast cancer diagnosis among women across the sociodemographic spectrum could imply suboptimal breast cancer outcomes.

High-income women have greater ability to afford out-of-pocket expenses than low-income women do, so our finding that high-income women experienced substantial delays in breast cancer care was unexpected.

Our findings raise concerns that in coming years a majority of commercially insured women of all sociodemographic levels could experience delayed breast cancer care.

Conclusion

Both vulnerable and less vulnerable women who were switched to high-deductible health plans experienced delays in breast cancer diagnostic testing, early-stage diagnosis, and chemotherapy initiation, compared to women remaining in low-deductible health plans. Such delays could lead to adverse long-term breast cancer outcomes affecting a substantial proportion of commercially insured women who develop breast cancer. Policy makers, health insurers, and employers should consider implementing value-based features in HDHPs to encourage successful transitions through key stages of the cancer care pathway. This could take the form of increased HSA contributions or “population-tailored” exclusions of essential care so that women would pay minimal amounts for services such as breast diagnostic testing.

https://www.healthaffairs.org…

---

Comment:

By Don McCanne, M.D.

We have serious problems with our health care financing system – a system that costs twice the average per capita of other wealthy nations yet falls miserably short in performance. In the meantime, the policy community busies itself with fixes that have clearly failed to bring our expensive system up to the standards of other nations. One of those fixes is high-deductible health plans.

Deductibles have fallen short as a policy tool, yet the policy community still insists that they have to be of benefit since they would make patients better health care shoppers by exposing them to more of the costs of their care. Their policy diagnosis is that, for deductibles to work, patients are going to have to feel more financial pain. Thus they have been increasing the deductibles to reach that threshold where pain occurs.

The policy community is quite smug now because moving to higher deductibles is working, according to their terms. People are limiting or delaying care because of these deductibles, thus meeting the goal of reducing health care spending. Or, in our terms, is it really working? Is it smart health care shopping if the financial exposure causes patients to delay diagnosis and treatment of breast cancer? Should women be waiting to be sure that they really need this care by seeing if they develop further invasive or metastatic disease? Just asking that question depresses and even nauseates me. Yet this study confirms through a “natural experiment” that women are delaying breast cancer care when they are shifted to plans with high deductibles.

As an individual obsessed with the study of health policy as it applies to our health care system, I am disappointed to see that the authors suggest implementing “value-based” features – perhaps increasing contributions to health savings accounts – as a means to reduce the stress of out-of-pocket spending for breast cancer. Not only is this a feeble response, it ignores the fact that these consumer-driven policies negatively impact the care of all serious medical problems, not just breast cancer.

We need a fundamental restructuring of our health care financing system. Right now with all of the talk about single payer Medicare for All it is almost impossible to avoid knowing what form that restructuring should take. A well-designed, single payer Medicare for All program, free at the point of service, would make essential health care accessible and affordable for absolutely everyone. And yet too many of today’s politicians and many in the policy community seem to think that an extreme measure would be to allow individuals to buy a Medicare plan as they exist today that would cover on the average only about half of health care costs, but don’t dare take away our private insurance (that relies on high deductibles and other perversities). Or rather, many say, we should just limit ourselves to building on the highly deficient Affordable Care Act.

Excuse me, but I have to barf.

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