PNHP

Saving Veterans’ Health Care

Saving Veterans’ Health Care

Readers object to a plan to privatize the V.A. system.

By Andrew Coates, M.D.
The New York Times, Letters, Feb. 11, 2019

To the Editor:

Re: “V.A. Rule Would Broaden Access to Private Health Care for Some Veterans” (news article, Jan. 31):

The Department of Veterans Affairs has begun to shift tremendous resources, measured in billions, away from publicly provided — and therefore publicly accountable — medical and surgical care.

Precisely the wrong direction!

What is the big problem at the publicly run veterans hospitals and clinics? Cynically underfund a great public service and then advertise only its failures, while ignoring its fundamental and irrefutable successes.

The V.A. should not be torn down, but defended and expanded — on history, on principle and especially on its superlative health outcomes. Instead of privatization, we should demand expansion of the V.A.

We desperately need a national health program. We should see in the V.A. system a foundation for a national health service, able to offer excellent and accountable care for everyone in the United States.

Dr. Andrew Coates is an assistant professor of medicine and psychiatry at Albany Medical College and a past president of Physicians for a National Health Program.

https://www.nytimes.com…

Single-payer would save trillions

By Johnathon Ross, M.D., M.P.H.
Toledo (Ohio) Blade, Letters, February 9, 2019

In response to a letter about the cost of single-payer healthcare (“Medicare for All cost said to be $32 trillion,” Jan. 27), polls show that many people are confused about what Medicare for all would cost. I hope that the following is helpful to the author and other readers.

The Mercatus Institute at George Mason University and the Political Economy Research Institute at the University of Massachusetts-Amherst have published cost estimates of Sen. Bernie Sanders’ bill. Both studies were as conservative as possible. They project significant savings over 10 years, while covering an additional 28 million people and improving coverage for 32 million, eliminating co-pays and deductibles, and allowing complete choice of doctor and hospital.

Mercatus estimates that we will need $32 trillion of new tax dollars to replace insurance premiums and out-of-pocket payments like co-pays and deductibles. This may seem like a shocking amount of new taxes but total national health spending would still be $2 trillion less over the same period of time. The PERI group estimates we would save about $6 trillion.

Both studies show large administrative savings from simplified billing for doctors, global budgets for hospitals, savings from negotiations for better prices for drugs and equipment, and from the elimination of the administrative waste.

Dr. Johnathon Ross is a past president of Physicians for a National Health Program.

https://www.toledoblade.com…

Eighty-seven million adults are inadequately insured

Health Insurance Coverage Eight Years After the ACA

By Sara R. Collins, Herman K. Bhupal, and Michelle M. Doty
The Commonwealth Fund, February 7, 2019

The greatest deterioration in the quality and comprehensiveness of coverage has occurred among people in employer plans. More than half of Americans under age 65 — about 158 million people — get their health insurance through an employer, while about one-quarter either have a plan purchased through the individual insurance market or are enrolled in Medicaid. Although the ACA has expanded and improved coverage options for people without access to a job-based health plan, the law largely left the employer market alone.

Since the ACA, Fewer Adults Are Uninsured, but More Are Underinsured

Compared to 2010, when the ACA became law, fewer people today are uninsured, but more people are underinsured. Of the 194 million U.S. adults ages 19 to 64 in 2018, an estimated 87 million, or 45 percent, were inadequately insured.

There also has been some improvement in long-term uninsured rates. Among adults who were uninsured at the time of the survey, 54 percent reported they had been without coverage for more than two years, down from 72 percent before the ACA coverage expansions went into effect.

More Adults Are Underinsured, with the Greatest Growth Occurring Among Those with Employer Coverage

Of people who were insured continuously throughout 2018, an estimated 44 million were underinsured because of high out-of-pocket costs and deductibles. This is up from an estimated 29 million in 2010. The most likely to be underinsured are people who buy plans on their own through the individual market including the marketplaces. However, the greatest growth in the number of underinsured adults is occurring among those in employer health plans.

Fewer Adults Report Not Getting Needed Care Because of Costs, but Gains Have Stalled in Recent Years

In 2014, the year the ACA’s major coverage expansions went into effect, the share of adults in our survey who said that cost prevented them from getting health care that they needed, such as prescription medication, dropped significantly. But there has been no significant improvement since then.

Inadequate Coverage Is Associated with More Cost-Related Problems Getting Needed Care

The lack of continued improvement in overall access to care nationally reflects the fact that coverage gains have plateaued, and underinsured rates have climbed. People who experience any time uninsured are more likely than any other group to delay getting care because of cost. And among people with coverage all year, those who were underinsured reported cost-related delays in getting care at nearly double the rate of those who were not underinsured.

Fewer Adults Have Difficulty Paying Their Medical Bills, but the Improvement Has Stalled

There was modest but significant improvement following the ACA’s coverage expansions in the proportion of all U.S. adults who reported having difficulty paying their medical bills or said they were paying off medical debt over time. However, those gains have stalled.

Inadequate Coverage Is Associated with More Problems Paying Medical Bills

Inadequate insurance coverage leaves people exposed to high health care costs, and these expenses can quickly turn into medical debt. More than half of uninsured adults and insured adults who have had a coverage gap reported that they had had problems paying medical bills or were paying off medical debt over time. Among people who had continuous insurance coverage, the rate of medical bill and debt problems is nearly twice as high for the underinsured as it is for people who are not underinsured.

From the Conclusion

U.S. working-age adults are significantly more likely to have health insurance since the ACA became law in 2010. But the improvement in uninsured rates has stalled. In addition, more people have health plans that fail to adequately protect them from health care costs, with the fastest deterioration in cost protection occurring in the employer market. The ACA made only minor changes to employer plans, and the erosion in cost protection has taken a bite out of the progress made in Americans’ health coverage since the law’s enactment.

Health care costs are primarily what’s driving growth in premiums across all health insurance markets. Employers and insurers have kept premiums down by increasing consumers’ deductibles and other cost-sharing, which in turn is making more people underinsured.

WHY ARE INSURED AMERICANS SPENDING SO MUCH OF THEIR INCOME ON HEALTH CARE COSTS?

Several factors may be contributing to high underinsured rates among adults in individual market plans and rising rates in employer plans:

1. Although the Affordable Care Act’s reforms to the individual market have provided consumers with greater protection against health care costs, many moderate-income Americans have not seen gains. The ACA’s essential health benefits package, cost-sharing reductions for lower- income families, and out-of-pocket cost limits have helped make health care more affordable for millions of Americans. But while the cost-sharing reductions have been particularly important in lowering deductibles and copayments for people with incomes under 250 percent of the poverty level (about $62,000 for a family of four), about half of people who purchase marketplace plans, and all of those buying plans directly from insurance companies, do not have them.

2. The bans against insurers excluding people from coverage because of a preexisting condition and rating based on health status have meant that individuals with greater health needs, and thus higher costs, are now able to get health insurance in the individual market. Not surprisingly, the survey data show that people with individual market coverage are somewhat more likely to have health problems than they were in 2010, which means they also have higher costs.

3. While plans in the employer market historically have provided greater cost protection than plans in the individual market, businesses have tried to hold down premium growth by asking workers to shoulder an increasing share of health costs, particularly in the form of higher deductibles. While the ACA’s employer mandate imposed a minimum coverage requirement on large companies, the requirement amounts to just 60 percent of typical person’s overall costs. This leaves the potential for high plan deductibles and copayments.

4. Growth in Americans’ incomes has not kept pace with growth in health care costs. Even when health costs rise more slowly, they can take an increasingly larger bite out of incomes.

https://www.commonwealthfund.org…

Trump Versus the Socialist Menace

By Paul Krugman
The New York Times, February 7, 2019

After all, voters overwhelmingly support most of the policies proposed by American “socialists,” including higher taxes on the wealthy and making Medicare available to everyone (although they don’t support plans that would force people to give up private insurance — a warning to Democrats not to make single-payer purity a litmus test).

https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

Many politicians today are walking away from Single Payer Medicare for All – a system that would make health care affordable for everyone. Many suggest instead that we merely need to add one more option to our fragmented system of financing health care. So how is the system that they want to protect working?

Of just the U.S. adults alone – the 194 million aged 19 to 64 in 2018 – an estimated 87 million, or 45 percent, were inadequately insured. The greatest growth in underinsured has been in the insurance market that supposedly we were protecting – the employer-sponsored health plans that are required to cover only 60 percent of the typical person’s overall costs.

This is shocking! The financial protection supposedly afforded by private employer-sponsored plans is deteriorating. Yesterday’s Quote of the Day revealed that the incidence of medical bankruptcy has not declined since the implementation of the Affordable Care Act.

And yet there is a surge in the call to protect private insurance from being displaced by a single payer Medicare for All system. As only one of hundreds of examples, Paul Krugman writes that people don’t support plans that would force them to give up private insurance – “a warning to Democrats not to make single-payer purity a litmus test.”

When you look at all of the other proposals designed to avoid the enactment of a single payer Medicare for All system, none of them address adequately this deterioration in the financial protection that should be an essential feature of private insurance. Yet if you redesign private plans so they do provide that protection, the premiums would be so high that much greater public subsidies would be required – subsidies that the politicians will tell us we can’t afford.

They don’t get it. Our current fragmented, dysfunctional, administratively wasteful system is by far the most expensive model of financing health care, while taking away choice of doctors and hospitals and forcing on individuals excessive out-of-pocket costs that have resulted in inadequate coverage for 87 million adults. Eighty-seven million!

All of that would go away with the least costly system of providing comprehensive coverage for everyone: Single Payer Medicare for All.

Remember when they tell us that people want their private plans protected from Medicare for All, 87 million adults are potentially exposed to financial hardship, and most of them don’t even realize it since they have not yet faced major medical expenses. But what is insurance for? Prepaid medical care through the social insurance program of Single Payer Medicare for All will show you what it’s for. Eighty-seven million fewer adults that would have to worry about the potential of debt from medical bills.

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

Medical Bankruptcy: Still Common Despite the Affordable Care Act

By David U. Himmelstein, M.D.; Robert M. Lawless, J.D.; Deborah Thorne, Ph.D.; Pamela Foohey, J.D.; and Steffie Woolhandler, M.D., M.P.H.
AJPH, March 2019

In surveys conducted by researchers with the Consumer Bankruptcy Project in 2001 and 2007, a majority of recently bankrupt debtors implicated medical bills or illness-related work loss as causes of their bankruptcy, findings that President Obama used to argue for passage of the Affordable Care Act (ACA). The ACA both expanded and upgraded health insurance coverage, banning preexisting illness exclusions, imposing a cap on out-of-pocket spending, and mandating coverage for essential benefits. Although these reforms might attenuate the risk of medical bankruptcy, increasing medical costs and stagnant incomes could have the opposite effect.

We sought to assess the incidence of medical bankruptcy in the current era using methods similar to those employed by the Consumer Bankruptcy Project in its 2001 and 2007 surveys.

The share of debtors reporting a medical contributor before the ACA’s January 1, 2014 implementation (65.5%) and after implementation (67.5%) was similar (P = .37). Both of these figures are close to the 62.1% estimate from the 2007 survey, and in a difference-in-differences analysis we found no evidence that trends differed between states that did versus did not accept the ACA’s Medicaid expansion (P = .76). The responses regarding individual items in the current survey are also similar to those in 2007, when 57.1% of debtors cited medical bills as contributors to their bankruptcy and 40.3% cited income loss due to illness.

Medical bankruptcy has garnered public attention because it resonates with the abuse that Americans—including many middle-class Americans—suffer at the hands of our health care finance system. Despite gains in coverage and access to care from the ACA, our findings suggest that it did not change the proportion of bankruptcies with medical causes.

Moreover, medical costs continue to outpace incomes, 29 million remain uninsured, and many of those with health insurance face unpredictable and unaffordable out-of-pocket costs as copayments and deductibles ratchet up. And few Americans have adequate disability coverage, leaving them vulnerable to illness-related income loss that amplifies the financial distress caused by medical bills.

Although death is inevitable, good public policy can ensure that financial suffering from illness is not.

https://ajph.aphapublications.org…

Comment:

By Don McCanne, M.D.

The Affordable Care Act did not change the proportion of bankruptcies with medical causes. “The share of debtors reporting a medical contributor before the ACA’s January 1, 2014 implementation (65.5%) and after implementation (67.5%) was similar.”

A well designed single payer Medicare for All program would essentially eliminate medical bills as a contributing cause to bankruptcy though we would still need more effective programs that would replace lost income due to illness – income that would be required to meet basic needs.

The Affordable Care Act has not provided enough financial protection for those with health care needs, and merely adding to the insurance market another public option, as many politicians are suggesting, will do essentially nothing to reduce the scourge of medical bankruptcy. We need to enact and implement Single Payer Medicare for All if we want to seriously address this problem.

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

Medicare for All is an improved free-market solution

By Ed Weisbart, M.D.
St. Louis Post-Dispatch, Feb. 7, 2019

I am a capitalist and physician who believes competition within a market can drive up quality and drive down cost. That’s why I believe single-payer Medicare for All is an improved market solution and the best road forward for American health care.

Think about it. The market today pits doctors like me against other doctors, each in search of the most lucrative insurance contracts we can get. After all, by necessity, we’re running a de facto retail business, and if we can sign on with an insurer that pays us a few bucks more for the same amount of work, it’s pretty hard to turn down.

From time to time, you may have seen those little notices in your doctor’s office listing insurance networks with which your doctor no longer participates. You quickly scan that list, see that your insurance company isn’t on it, and forget about it. After all, you don’t think it really affects you. It does.

What that notice actually means is that your physician’s practice has signed a contract with a new insurer that pays more than some of their other insurers do, and that new contract promises an influx of better-paying patients. To make room for these new patients, we doctors leave networks that aren’t as economically advantageous. We’re just responding to the ever-changing market and making business decisions.

This is an unfair and inhumane use of the market. It makes me sick that someone’s economic value determines whether physicians take care of them. This is a terrible side effect of the for-profit health care market.

It’s also incredibly wasteful. A recent study from Milliman showed that the average American physician spends $99,000 per year just dealing with insurance companies. That’s money that must be made up, and it eventually comes back to you and your employer in higher premiums.

Imagine, instead, that you live in a country where every person is worth the same economic value to any physician. Imagine that you could go to any doctor you choose and the payment automatically follows you. Imagine that you never have to check to see if your doctor is “in network” and that no one can tell you have to change doctors. Imagine that you — and only you — control your own health care decisions.

In other words, imagine you live in a country with single-payer, improved Medicare for All. Instead of hundreds of insurance companies, imagine the United States has one single payer — Medicare — and it includes coverage for prescription drugs, dentistry, eyeglasses and more — all without any co-pays or deductibles.

That’s precisely the country we would have with the Medicare for All Act of 2019, which Rep. Pramila Jayapal, D-Wash., is currently proposing.

Intuitively, one automatically assumes the costs of such a pipe-dream solution would be prohibitive, but the counterintuitive facts say the opposite: Single-payer, improved Medicare for All would cost less than the current, wasteful system. Twenty-eight independent economic analyses have come to the same conclusion: Medicare for All would reduce what our nation spends on health care.

Most of the studies predict dramatic savings — at a minimum, enough to eliminate the need for co-pays and deductibles, while adding coverage for dentistry, eyeglasses and hearing aids, and giving us access to virtually every doctor. Even a Koch-brothers-funded study a few months ago concluded that Medicare for All would save the nation trillions of dollars over 10 years.

A 2018 analysis from the University of Massachusetts estimated a 12 percent increase in overall utilization of health care services but a 9 percent drop in total administrative costs, a 40 percent drop in the 15 percent we spend on pharmaceuticals, a 2.8 percent drop created by developing uniform rates, and a 1 percent drop by reducing fraud and other waste. Overall, the 12 percent increase is more than balanced by a 19 percent cost savings, dropping our 2017 health care spending from $3.24 trillion to $2.93 trillion.

In a nation that shut down a government over a $5.7 billion wall proposal, saving $331 billion in health care is huge.

I support Rep. Jayapal’s Medicare for All Act of 2019 because it applies the free market to the delivery side of health care — in favor of patients — because doctors should be competing for patients, not for insurance contracts.

Medicare for All is pragmatic, doable and necessary — because our current system is broken. It stands to reason that if we can find a way to pay for health care that’s far too expensive, then we can certainly afford health care that’s less expensive.

Dr. Ed Weisbart is a family physician in Olivette, Mo. and chairs the Missouri chapter of Physicians for a National Health Program.

https://www.stltoday.com…

Cost Savings from Improved Medicare for All

Health care costs are increasing dramatically for American businesses, with no end in sight. This depresses wages, makes employees reluctant to use their health insurance, and puts companies at a competitive disadvantage. Improved Medicare for All would generate significant savings for both businesses and workers.

Featuring MCS Industries CEO and Business Initiative for Health Policy founder Richard Master, and University of Massachusetts Amherst Professor Gerald Friedman.

New medical bankruptcy study: Two-thirds of filers cite illness and medical bills as contributors to financial ruin

Researchers found no evidence that the ACA reduced the proportion of bankruptcies driven by medical problems; insurance offered little protection to middle-class Americans.

FOR IMMEDIATE RELEASE: February 7, 2019

Contacts: David U. Himmelstein, M.D., dhimmels@hunter.cuny.edu; Steffie Woolhandler, M.D., M.P.H., steffie_woolhandler@hms.harvard.edu; Clare Fauke, 312-782-6006, clare@pnhp.org

Medical problems contributed to 66.5% of all bankruptcies, a figure that is virtually unchanged since before the passage of the Affordable Care Act (ACA), according to a study published yesterday as an editorial in the American Journal of Public Health. The findings indicate that 530,000 families suffer bankruptcies each year that are linked to illness or medical bills.

The study, carried out by a team of two doctors, two lawyers, and a sociologist from the Consumer Bankruptcy Project (CBP), surveyed a random sample of 910 Americans who filed for personal bankruptcy between 2013 and 2016, and abstracted the court records of their bankruptcy filings. The study, which is one component of the CBP’s ongoing bankruptcy research, provides the only national data on medical contributors to bankruptcy since the 2010 passage of the ACA. Bankruptcy debtors reported that medical bills contributed to 58.5% of bankruptcies, while illness-related income loss contributed to 44.3%; many debtors cited both of these medical issues.

These figures are similar to findings from the CBP’s medical bankruptcy surveys in 2001 and 2007, which were authored by three researchers in the current study (Himmelstein, Thorne, and Woolhandler), and then-Harvard law professor Elizabeth Warren. As in those earlier studies, many debtors cited multiple contributors to their financial woes.

The current study found no evidence that the ACA reduced the proportion of bankruptcies driven by medical problems: 65.5% of debtors cited a medical contributor to their bankruptcy in the period prior to the ACA’s implementation as compared to 67.5% in the three years after the law came into effect. The responses also did not differ depending on whether the respondent resided in a state that had accepted ACA’s Medicaid expansion. The researchers noted that bankruptcy is most common among middle-class Americans, who have faced increasing copayments and deductibles in recent years despite the ACA. The poor, who were most helped by the ACA, less frequently seek formal bankruptcy relief because they have few assets (such as a home) to protect and face particular difficulty in securing the legal help needed to navigate formal bankruptcy proceedings.

Relative to other bankruptcy filers, people who identified a medical contributor were in worse health and were two to three times more likely to skip needed medical care and medications.

Dr. David Himmelstein, the lead author of the study, a Distinguished Professor at the City University of New York’s (CUNY) Hunter College and Lecturer at Harvard Medical School commented: “Unless you’re Bill Gates, you’re just one serious illness away from bankruptcy. For middle-class Americans, health insurance offers little protection. Most of us have policies with so many loopholes, copayments and deductibles that illness can put you in the poorhouse. And even the best job-based health insurance often vanishes when prolonged illness causes job loss – just when families need it most. Private health insurance is a defective product, akin to an umbrella that melts in the rain.”

In the article, the authors note that “medical bills frequently cause financial hardship, and the U.S. Consumer Financial Protection Bureau reported that they were by far the most common cause of unpaid bills sent to collection agencies in 2014, accounting for more than half of all such debts.”

The study’s senior author Dr. Steffie Woolhandler, an internist in the South Bronx, Distinguished Professor at CUNY/Hunter College and Lecturer in Medicine at Harvard commented: “The ACA was a step forward, but 29 million remain uncovered, and the epidemic of under-insurance is out of control. We need to move ahead from the ACA to a single-payer, Medicare for All system that assures first-dollar coverage for everyone. But the Trump administration and Republicans in several states are taking us in reverse: cutting Medicaid, threatening to gut protections for the more than 61 million Americans with pre-existing conditions, and allowing insurers to peddle stripped-down policies that offer no real protection.”

Study co-author Robert M. Lawless, the Max L. Rowe Professor of Law at the University of Illinois College of Law noted: “In the Supreme Court’s words, bankruptcy is a fresh start for the ‘honest but unfortunate debtor.’ Our study shows that for many bankruptcy debtors, the misfortune continues to come from the way we pay for health care. Bankruptcy may provide a fresh start, but it comes at a high financial and emotional cost for those who file. Filing for  bankruptcy can stop the financial bleeding that the health care system imposes, but curing that system’s ills is the only lasting solution.”

“Medical Bankruptcy: Still Common Despite the Affordable Care Act.” David U. Himmelstein, Robert M. Lawless, Deborah Thorne, Pamela Foohey, and Steffie Woolhandler. American Journal of Public Health, March 1, 2019 (online Feb. 6, 2019). DOI: 10.2105/AJPH.2018.304901

Deborah Thorne of the University of Idaho and Pamela Foohey of Indiana University Bloomington also were co-authors of the study. Drs. Himmelstein and Woolhandler founded Physicians for a National Health Program (www.pnhp.org), a nonprofit research and education organization whose more than 22,000 members support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.

Hospital prices grew faster than physician prices in hospital-based care

Hospital Prices Grew Substantially Faster than Physician Prices for Hospital-Based Care in 2007–14

By Zack Cooper, Stuart Craig, Martin Gaynor, Nir J. Harish, Harlan M. Krumholz, and John Van Reenen
Health Affairs, February 2019

Abstract

Evidence suggests that growth in providers’ prices drives growth in health care spending on the privately insured. However, existing work has not systematically differentiated between the growth rate of hospital prices and that of physician prices. We analyzed growth in both types of prices for inpatient and hospital-based outpatient services using actual negotiated prices paid by insurers. We found that in the period 2007–14 hospital prices grew substantially faster than physician prices. For inpatient care, hospital prices grew 42 percent, while physician prices grew 18 percent. Similarly, for hospital-based outpatient care, hospital prices grew 25 percent, while physician prices grew 6 percent. A majority of the growth in payments for inpatient and hospital-based outpatient care was driven by growth in hospital prices, not physician prices. Our work suggests that efforts to reduce health care spending should be primarily focused on addressing growth in hospital rather than physician prices. Policy makers should consider a range of options to address hospital price growth, including antitrust enforcement, administered pricing, the use of reference pricing, and incentivizing referring physicians to make more cost-efficient referrals.

From the Discussion

Our findings suggest that there may be significant differences in the bargaining leverage of hospitals and physicians. More work needs to be done to quantify the differences between the two groups’ bargaining leverages and the extent to which there are differences in the price elasticities facing the two types of providers.

Our results also have direct implications for strategies to address growth in health spending for the privately insured. For example, a bill recently introduced in the California legislature would allow state officials to regulate hospital and physician prices. Broad-brush efforts that do not discriminate by setting could miss the mark. Our work suggests that instead of focusing on growth of physician prices (which have grown roughly at the pace of inflation), in the short run policy makers should devote more of their efforts to addressing growth of hospital prices.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

Under our current fragmented system of financing health care, it is no surprise that hospital prices have been growing faster than physician prices for both inpatient and outpatient services. Merger and acquisition activities, including hospital acquisition of medical groups have long been suspected as contributors to health care inflation. So what do we do about it?

It is well established that markets do not work well in setting prices for health care, whereas publicly financed and publicly administered programs are more effective in determining appropriate value. A well designed single payer Medicare for All program would go a long way toward improving pricing in health care.

Central planning and budgeting of capital improvements does a better job in controlling capacity of the system, thus ensuring the right number of beds. Operations of the facility should be funded through global budgets, just as the fire department is. That would both slow excessive growth in prices while ensuring adequate funding to fulfill the community’s needs.

Physicians would be reimbursed at negotiated rates whether through fee-for-service or capitation, depending on the practice model. Our government Medicare program has been more effective than private insurers at keeping price increases at sustainable rates.

At any rate, according to this study, “efforts to reduce health care spending should be primarily focused on addressing growth in hospital rather than physician prices.”

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

An Open Letter to Rep. Pramila Jayapal Regarding Medicare for All

We applaud your efforts to improve the legislation from previous versions by including guaranteed access to vital services such as reproductive health and long-term care, but have two serious questions about the future of private insurers and exactly who might be left out of an otherwise universal system.

By Isabel Ostrer, Chris Cai, and Ana Malinow, M.D.
Common Dreams, Feb. 6, 2019

Dear Congresswoman Jayapal,

Thank you for your hard work and leadership as the new lead sponsor of the forthcoming Medicare for All Act of 2019. As health care providers and health justice advocates, we look forward to working with you to grow support for the bill and ensure its future passage.

We applaud your efforts to improve the legislation from previous versions by including guaranteed access to vital services such as reproductive health and long-term care. However, we have identified two key policy provisions that must be addressed in the final bill: 1) the explicit prohibition and buyout of investor-owned, for-profit health facilities, and 2) the explicit inclusion of coverage for every resident of the U.S., regardless of immigration or citizenship status.

1. As part of a transition to a Medicare-for-all system, for-profit health facilities should be converted to nonprofit governance and their owners compensated for past investments.

There is no place for profit in a humane and efficient national health program. For-profit providers (including hospitals, dialysis centers, nursing homes, home care agencies, and hospices) have been shown to provide inferior care at inflated prices and are more likely to bend care to profitability. For-profit hospitals spend less on nurses and other clinical aspects of care, but more on administration and financial management, compared to nonprofits. For-profit nursing homes are cited for quality deficiencies 28 percent more often than nonprofits, and for deficiencies that place residents in immediate jeopardy 53 percent more frequently. Investor-owned home care agencies cost Medicare $752 more per patient than nonprofit agencies, while providing worse care. In addition, investor-owned chains have often been cited for questionable business practices and have been repeatedly  implicated in large-scale fraud.

To achieve a fully nonprofit health system, Medicare for all legislation should include plans for the government to “buy out” investors in for-profit institutions. Researchers estimate the fair market value of investor-owned facilities covered by a buyout to be $150 billion at most. Using Treasury Bill financing over 15 years at the current interest rate of 3 percent would cost the government about $12.75 billion annually, equivalent to about 1 percent of annual hospital costs. Even in the short term, these costs would be offset by eliminating what we currently waste on investor profits. For example, total profits of just three investor-owned firms (HCA, DaVita and Fresenius) totaled more than $6 billion in 2017. For the sake of both patient health and cost savings, we cannot afford to let investor-owned facilities participate in a Medicare for all system.

2. A future Medicare for all program must include everyone living in the U.S., regardless of immigration or citizenship status. 

Aside from humanitarian concerns, excluding anyone in the U.S. from a national health plan only adds waste and unnecessary administrative costs. Immigrants are often used as a scapegoat for skyrocketing health costs, but studies show that instead of draining our health care dollars, immigrants subsidize and maintain our health care system.

Between 2002 and 2009, immigrants contributed $115 billion more to the Medicare Trust Fund than they used in health care. Because of their lower utilization costs, immigrants also heavily subsidize private insurance for U.S.-born residents. A single-payer bill must explicitly include both documented and undocumented immigrants, and not leave eligibility up to administrative whims.

As medical students and physicians, we strongly believe that a single-payer program is the only solution to our country’s failing health care system. However, to ensure the long-term success of Medicare for All, we must get the policy details right, including a ban on for-profit health facilities with a planned buyout of investors, and the inclusion of every U.S. resident, regardless of immigration status.

Sincerely,

Christopher Cai, Medical Student
Isabel Ostrer, Medical Student
Ana Malinow, M.D.

Isabel Ostrer is a medical student at the University of California San Francisco (UCSF) and a member of Students for a National Health Program (SNaHP).

Chris Cai is a medical student at the University of California San Francisco (UCSF) and a member of Students for a National Health Program (SNaHP).

Dr. Ana Malinow has  spent her career taking care of undocumented, refugee, and poor children in Cleveland, Houston and Pittsburgh before moving to San Francisco, where she is currently practicing as a general pediatrician. She is past President of Physicians for a National Health Program (PNHP), an organization of 20,000 health care providers that support single payer national health care.

https://www.commondreams.org…

Racial bias influences health care — and it starts in the exam room

By Monica Maalouf, M.D.
Chicago Tribune, February 6, 2019

“No doctor has ever reminded me that I am black before,” the patient said, laughing and nodding his head to let me know he appreciated my advice.

Just as he was startled by my open recognition of his race, so too was I startled by his reaction.

As his physician, I felt the issue I’d raised wasn’t worth ignoring; if anything, I viewed it as the “elephant in the exam room,” desperately begging to be called out: Black patients continue to suffer higher morbidity and mortality from colon cancer, compared to any other racial group, according to a 2016 study published in the Journal of Clinical and Translational Gastroenterology, and that is a fact that warrants discussion in the doctor’s office.

In 2002 the Institute of Medicine, a national consortium of experts, published a 700-page report on racial and ethnic disparities in health care. The group examined more than 100 individual studies and concluded, overwhelmingly, that health disparities exist. While the report emphasized that the reasons behind health status disparities “are complex and poorly understood,” evidence suggests that both socieconomic differences and “direct and indirect consequences of discrimination” are at play.

We are now nearly two decades out from the original publication of many of the studies examined by the IOM, yet we are still grappling with stark disparities in both disease outcomes and treatment. And, although “the incidence and mortality rates of colorectal cancer in the United States has steadily declined” over the years, according to the 2016 study, “reductions have been strikingly much slower among African-Americans.”

This fact shouldn’t shock anyone, given the reality that health systems, and health training environments, are poorly equipped to tackle the crisis of disparate treatment and disparate outcomes.

In 2016, the Accreditation Council for Graduate Medical Education conducted a study of physician training programs nationwide and concluded that few programs “appeared to have a formal strategy for addressing health care disparities or a systematic approach to identifying variability in the care provided to … known vulnerable patient populations.”

Furthermore, there is growing evidence published in recent years, highlighting the fact that practitioners’ implicit biases often shape treatment decisions and health outcomes.

Being a young black child with appendicitis, for instance, means you are less likely than a white child to get pain medication in an emergency room. Being a black patient in an intensive care unit means you might not get as much time with your physician as a white patient. And when it comes to colon cancer, physicians are much less likely to even bring up screening modalities with black patients compared to whites.

The data have led me to believe that we, as a scientific community, have done an amazing job highlighting a problem. Truthfully, the problem of health disparities has not only been highlighted, it’s been written in bold font and ALL CAPS.

What we have yet to do, however, is come up with systematic approaches for tackling this issue and supporting our most marginalized patients.

For the patient I brought up earlier, who was sitting in my exam room asking me if he should get a colonoscopy, I knew we had to discuss it.

As a black man, the numbers are not in his favor. By acknowledging race with him, I hoped that whatever implicit bias I might have as a practitioner would become explicit. By bringing race to the forefront, I hoped it would no longer fall to the side.

We have to chisel away at this disparity, and as a primary care physician, I can do so by starting the conversation, one patient at a time.

Dr. Monica Maalouf is a physician and assistant professor of medicine at Loyola Stritch School of Medicine.

https://www.chicagotribune.com…

Immigration for a healthier nation

California’s secret to health is immigration

By Joe Mathews
San Francisco Chronicle, February 3, 2019

What makes California the very picture of health? It’s neither sunshine nor silicone.

Our health secret is immigration.

While the president blames immigrants for being sources of disease, Californians have long known that immigrants make us healthier.

Those health benefits go beyond the “immigrant health advantage,” the fact that new arrivals to this country are healthier than the native-born. Throughout California history, immigrants have adapted cultural practices and introduced new ideas that have expanded our definition of health.

Today, it is impossible to separate the issues of health and immigration in California. For one thing, our rapidly aging state relies heavily on immigrants to deliver our health care. In many communities, more than half of doctors are foreign-born, and statewide, one-third of the health care workers are immigrants.

You can see the impact of immigration on health across all stages of life. In our homes, multigenerational living, long associated with immigrants, has gone mainstream; sharing a house both saves money on rent and helps older people live longer, while reducing stress for kids.

California’s concepts of healthy eating also have immigrant roots. Catherine Nimmo, a doctor from the Netherlands, founded America’s first vegan society in our state in 1948.

What is more California than a yoga workout? The state has seen waves of immigrant yogis make and remake yoga practice.

Or if you’re really hurting, you might slip into a whirlpool bath, with jets first invented as a rheumatoid arthritis cure by an Italian immigrant to California named Candido Jacuzzi.

It is no exaggeration to say that Californians have chosen to be ruled by immigrant visions of health. After all, it was two brothers from Canada, Joe and Ben Weider, who popularized bodybuilding and working out with weights, sparking the gym industry, which is an inescapable feature of the state landscape.

https://www.sfchronicle.com…

Comment:

By Don McCanne, M.D.

This article might be reaching a little bit to suggest that perhaps health here is dependent on immigration, but it is accurate to state that immigrants by and large are healthier than the average U.S. citizen, and that they do contribute significantly to the health care workforce. They also contribute to the economy, and not just in harvesting our food, but in all sectors of our economy.

Tonight we are expected to hear from President Trump in his State of the Union address some words about immigration, but we should keep in perspective the reality as opposed to our president’s inclination to be creative in his rhetoric.

Immigrants do not burden our health care system. In fact, they contribute more to our economy than they use in public services. A Single Payer Medicare for All program would benefit by adding in to the risk pool our comparatively healthy immigrant population. Those who contend that including immigrants in a national health program would create a burden on the system are flat out wrong. They would help pay for our health care (and even help pay for the Wall if Trump were to get his way).

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

Top Nancy Pelosi Aide Privately Tells Insurance Executives Not to Worry About Democrats Pushing “Medicare for All”

By Ryan Grim
The Intercept, Feb. 5, 2019

Less than a month after Democrats — many of them running on “Medicare for All” — won back control of the House of Representatives in November, the top health policy aide to then-prospective House Speaker Nancy Pelosi met with Blue Cross Blue Shield executives and assured them that party leadership had strong reservations about single-payer health care and was more focused on lowering drug prices, according to sources familiar with the meeting.

Pelosi adviser Wendell Primus detailed five objections to Medicare for All and said that Democrats would be allies to the insurance industry in the fight against single-payer health care. Primus pitched the insurers on supporting Democrats on efforts to shrink drug prices, specifically by backing a number of measures that the pharmaceutical lobby is opposing.

Primus, in a slide presentation obtained by The Intercept, criticized single payer on the basis of cost (“Monies are needed for other priorities”), opposition (“Stakeholders are against; Creates winners and losers”), and “implementation challenges.” We have recreated the slides for source protection purposes.

Democrats, Primus said, are united around the concept of universal coverage, but see strengthening the Affordable Care Act as the means to that end. He made his presentation to the Blue Cross executives on December 4. “We don’t discuss private meetings, if there was such a meeting,” said a BCBS spokesperson. Primus said that he did not discuss any kind of deal with the insurers. Henry Connelly, a spokesperson for Pelosi, said that the assessment of single payer was not related to any dealmaking with the industry. “We’re not going to barter lower prescription drug costs for inaction in the rest of the health care industry. The presentation was a broad look at the health care environment and some of House Democrats’ legislative priorities over the next two years in a period of GOP control of the Senate and White House,” Connelly said.

The debate over Medicare for All is playing out on a number of different levels, with no clear consensus over how the government-run, single-payer health plan ought to take shape. Presidential candidates are arguing over whose plan is stronger and gets to full Medicare for All faster, with a debate raging over whether private insurance should be banned outright or operate in addition to universal Medicare coverage.

In the House, even as the idea has picked up momentum with voters and members of the Democratic caucus, Democratic leadership has remained deeply skeptical. Pelosi’s consistent messaging, instead, has been around protecting the Affordable Care Act and lowering prescription drug prices.

“Speaker Pelosi has ensured that Medicare for All will have hearings in the House and tapped Congressman Brian Higgins to take the lead on Medicare buy-in legislation. For the first time, House committees will be seriously examining and tackling some of the questions and possible solutions raised by Medicare for All legislation,” said Connelly.

“The biggest obstacles facing Medicare for All right now are Mitch McConnell and Donald Trump,” he added. “But in the near term, there is a window for Democrats to press Trump to help pass aggressive legislation to negotiate down the skyrocketing price of prescription drugs.”

Primus concluded his presentation with a bullet point that summarized Pelosi’s mission on health care: “Lower your health care costs and prescription drug prices.”

The “your” refers to insurers, who bear costs for medical expenses covered under their plans. That puts insurers and Pelosi, at least in one sense, in alignment, as both have an interest in lower costs. Indeed, insurers regularly negotiate to lower their health care costs, but in practice their efforts have had little effect on the general trend in costs. Drug company patents give pharmaceutical giants outsized power to set prices, and hospital consolidation has also given providers more power in those negotiations. Even where insurers have been able to negotiate lower prices for their own customers, that has done little to shrink the list price of drugs for the public.

At the briefing, Primus mentioned three avenues that Pelosi, a California Democrat, sees toward lower drug prices, sources said. The first, the CREATES Act, is bipartisan legislation, strongly opposed by Big Pharma, that would make it easier for generic drug companies to get access to a sufficient quantity of medications needed to produce generics.

The second measure addresses what’s known as “pay for delay,” in which a drug company pays a generic manufacturer to not produce a generic version of an expensive drug. Democratic leadership wants to ban that practice. The third revolves around the issue of “evergreening,” which is a pharmaceutical industry practice of extending patent protection for a particular drug through a variety of practices. Democrats want to restrict evergreening to encourage cheaper generics make it to the market faster.

Primus’s approach has a strong political logic to it, as taking on every health care stakeholder at once is arguably more difficult than singling out one industry and hammering away, even if the effort is out of step with where progressive energy is at the moment.

Primus is known in Congress as one of the staunchest foes of Big Pharma, while Pelosi’s posture toward Medicare for All is more complicated. Publicly, she has long said that she supports it aspirationally. “I was carrying around single-payer signs probably before you were born, so I, you know, I understand that aspiration,” she said in 2017 during an interview with TV host Joy Reid.

“This is an idea that if we had a tabula rasa, if we were just starting clean, would be the most cost-effective way to go forward. We don’t have that,” she said. “Over 120 or 150 million people in our country have employer-based access to their health coverage and insurance.”

At the time, her objection to Medicare for All was that it distracted from the fight to defend the ACA, which Republicans were trying to gut. “So right now, I’m going to be crude. Now we’re in my living room, so I can be crude. It isn’t helpful to tinkle all over the ACA right now,” Pelosi said. “Right now, we need to support the Affordable Care Act and defeat what the Republicans are doing.”

At other moments, she has said that single payer isn’t popular, arguing, also in 2017, that “the comfort level with a broader base of the American people is not there yet.”

The Democratic Congressional Campaign Committee, which operates under Pelosi, in 2017 presented House Democrats with survey data, claiming that it showed that single-payer was a political loser, and that Democrats should focus their messaging on lowering drug prices and protecting the ACA.

Yet a significant number of Democrats who flipped Republican districts blue in 2018 were publicly supportive of Medicare for All, suggesting that it isn’t necessarily the albatross Pelosi and the DCCC believe it to be. A poll from October found that more than half of Republicans support the concept.

Pelosi’s agreement to hold House hearings on Medicare for All came after pressure from the Congressional Progressive Caucus. Yet the hearings will be held by the Budget Committee, which, unlike the powerful Ways and Means and Energy and Commerce committees, would not have final jurisdiction over Medicare for All in the event of a genuine attempt to pass it.

Primus, like Pelosi, is well-known to be a deficit hawk, and both subscribe to the argument put forward by the late Pete Peterson that the debt and deficit are among the gravest threats facing the country. When Peterson, a billionaire who spent hundreds of millions of dollars to push Washington policymakers toward austerity, died in 2018, Pelosi delivered a floor speech that praised him and his vision effusively, speaking of the man as if he’d dedicated his life to eradicating child malnutrition or curing cancer, rather than as a Wall Street tycoon who spent millions pushing for major cuts to Social Security and Medicare. “Pete was a clarion voice for fiscal responsibility, and a strong moral conscience in Washington,” Pelosi said in her House floor eulogy of Peterson, who, by 2012, had already spent half a billion dollars targeting Social Security, Medicare, and other spending programs.

“Pete’s prophetic voice on the importance of fiscal sustainability brought together generations of policymakers, no matter their political background,” Pelosi said. “His legacy will endure in many ways, but especially through the work of the Peterson Foundation, which continues to focus on solutions to America’s fiscal and economic challenges.”

Two of Primus’s five objections to single payer before the Blue Cross audience related to such alleged fiscal challenges. That argument, though, runs headlong into a surge of new interest among Democrats in Modern Monetary Theory, the idea that policymakers are still constrained by a mindset that was justifiable when the U.S. was on the gold standard, but is no longer defensible. Now that the U.S. issues a currency independent of its gold reserves, the obstacle to government spending is inflation, not the debt or deficit, proponents of MMT say. “This zero-sum mentality has no place in a post-Bretton Woods world,” said economist Stephanie Kelton in reaction to Primus’s argument that spending on Medicare for All would foreclose other priorities. (Post-Bretton refers to the global agreement that the dollar will be the global economy’s reserve currency, ultimately decoupled from gold.)

“The U.S. dollar is no longer tethered to gold, which means the federal government is not constrained in its spending by the need to raise revenue. The federal government cannot run out of dollars. This should be painfully obvious, but the gold-standard mentality continues to grip many lawmakers,” Kelton said.

As long as inflation remains low, the government can continue to authorize additional spending. That’s not so much an argument as it is simply an observation of the post-gold-standard reality that austerity advocates like Peterson have spent billions to distort. “The government can afford any new program it chooses to fund. The limits are in the real economy — if producers can’t keep up with the additional demand, inflation will result,” said Kelton, a former adviser to the Senate Budget Committee when it was chaired by Sen. Bernie Sanders. “The federal government — as the issuer of the U.S. dollar — can create all the money that is needed to guarantee health care for all of its people. It’s the rest of us — who merely use the dollar — who have to worry about costs and where to come up with the money to pay a huge medical bill when our private insurer refuses to cover the cost of care.”

This reality has been recognized by former Federal Reserve Chairs Alan Greenspan and Ben Bernanke, as well. “The United States can pay any debt it has because we can always print money to do that. So, there is zero probability of default,” Greenspan once said.

https://theintercept.com…