By Chad Terhune
Kaiser Health News, January 3, 2019

Marcela Villa isn’t a big name in health care — but she played a crucial role in the lives of thousands of Medicaid patients in California. Her official title: denial nurse.

Each week, dozens of requests for treatment landed on her desk after preliminary rejections. Her job, with the assistance of a part-time medical director, was to conclusively determine whether the care — from doctor visits to cancer treatment — should be covered under the nation’s health insurance program for low-income Americans.

She was drowning in requests, she said, and felt pressed to uphold most of the denials she saw. “If it was a high-dollar case, they tried to deny it,” Villa said. “I told them you can’t deny it just because it’s going to cost $20,000.”

Villa, 32, did not work for the government. She did not even work for an insurer under contract with the government. She worked for a company now called Agilon Health. Owned by a private equity firm, it’s among the legion of private subcontractors looking to profit from Medicaid patients.

California’s Medicaid program, known as Medi-Cal, has determined that the Long Beach company, which was paid to coordinate care for about 400,000 patients, improperly denied or delayed care for at least 1,400 of them, state officials confirmed. The state Department of Managed Health Care is investigating further.

The state findings, along with internal company documents and a whistleblower complaint obtained by Kaiser Health News, shine a light on the potential dangers of outsourcing care for poor people. Government oversight, not rigorous to begin with, fades as taxpayer money filters down through layers of companies eager to seize on Medicaid’s substantial growth under the Affordable Care Act. Medicaid officials say they have authority only over the health plans, not their subcontractors.

Skimping On Services?

Nearly three-quarters of the 73 million low-income Americans on Medicaid are now in managed care, in which states pay health insurers fixed monthly amounts for each enrollee to cover the range of services they need.

Under this system, keeping patients as healthy as possible is one way to make money. Another is to deny or skimp on services.

Increasingly, Medicaid plans outsource the work of managing patients’ health and medical treatment to subcontractors like Agilon — passing along a share of the government money coupled with the financial risk posed by a fixed budget.

These firms can be powerful gatekeepers. They run physician groups, bear responsibility for forming doctor networks and judge whether a request for care is necessary.

Agilon is a big player in California — doing business with insurers such as Molina Healthcare and Blue Shield of California.

Agilon’s June report depicts an operation that was often stretched thin: Nurses were handling 120 to 200 requests for care per day, on average, with no full-time medical director to review the findings.

From 2014 until May, the company relied on a family physician who was working 10 to 12 hours a day running his own medical practice, according to the report.

Ultimately, Agilon’s internal investigation found that patient care may have been denied 439 times since 2014 without a physician’s review of the medical records — a potential violation of state law. Under California law, only a licensed physician or health care professional who is “competent to evaluate the specific clinical issues involved” can determine medical necessity.

“These private entities get very little oversight,” said Linda Nguy, a policy advocate at the Western Center on Law & Poverty in Sacramento, “and there’s real harm being done to patients.”

https://khn.org…

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Comment:

By Don McCanne, M.D.

Private Medicaid managed care companies using private subcontractors to appropriate to themselves our public funds by denying health care – need we say more?

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

By Doug Henwood
Jacobin, December 26, 2018

How much will universal health coverage cost? The Mercatus Institute, a Koch-funded free-market think tank at George Mason University, recently put it at $32 trillion over the next decade. That sounds like a lot, but is it?

Well, the study also estimated that the cost was $2 trillion less than it would cost to do just the same thing as we are now — which is surprising considering the source, but much less interesting to mainstream reporters.

But the Political Economy Research Institute at the University of Massachusetts has its own estimates. Its long and rigorous study shows we could cover everyone in the United States with no copays and cut overall health spending by almost a fifth. Lead author Robert Pollin, professor of economics at the University of Massachusetts and co-director of PERI, recently spoke with Doug Henwood for his Jacobin podcast Behind the News.

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Doug Henwood: You’re projecting over the long-term that US health care expenditure would stabilize around 15 percent or 16 percent of GDP. Which is still well above what we see in Canada and Britain, and quite above also Germany and France, who spend more than Canada and Britain.

We’re talking about a difference of a trillion or more dollars, which is enough to save the climate and have enough left over for dessert. Why can’t we get down to those levels?

Robert Pollin: Very good question. We really wanted this study to be really heavily peer reviewed. One reviewer was Jeffrey Sachs, who was extremely active and very helpful, and was quite critical in some points. This was his main question. “If we’re going to do all of this, we end up with a system that is going to cost 16 percent of GDP. Why can’t we do better, if Canada and the others are 11 percent, 10 percent, 9 percent?”

Some of the other reviewers I have were pushing on the other side, saying, “You can’t make these cuts. It’s unrealistic to think you’re going to get this level of savings.” On balance, this is where I think is realistically we can get to.

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Henwood: We have this coalition now developing in Congress of Democrats opposed to any idea of single-payer, so not obvious at this point.

Pollin: Well, not obvious. But 70 percent of the population says they’re for it.

The argument was for a long time, “Yeah, you may be for it, but you don’t know what the hell it is and you can’t pay for it.” I hope that my study and other people’s studies have demonstrated that that simply isn’t true. It was obvious all along that it wasn’t true — other countries are paying a lot less, and they have some equivalent to Medicare for All.

But in the US case, now we have these various studies, including ours, that make it blindingly clear that this is completely practical, and the financing works. It works way better for almost everybody in society. It relieves people of all the anxieties they have about how they cover themselves when they have health problems. It’s a much better way to run a health care system.

On the other side, you have people making tons of money off of a bad health care system. That’s what we are going to struggle over.

https://www.jacobinmag.com…

U MASS PERI Analysis:
https://www.peri.umass.edu…

Reviewer Assessments, including that of PNHP’s Woolhandler, Himmelstein, and Gaffney:
https://www.peri.umass.edu…

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Comment:

By Don McCanne, M.D.

Those passionate about single payer have been energized by the expanding public support for Medicare for All and by recent policy studies such as that by U MASS-Amherst Professor Robert Pollin and his colleagues, and also particularly by the fact that legislative models are in development on both the state and federal levels. But there are disputes about both policy and process.

Once you exclude those who oppose a government role in ensuring health care for all, the primary disagreement on policy is whether we want to build on our current dysfunctional model of financing health care or if we want to move forward with Single Payer Medicare for All. There is really no contest since the single payer model wins out based on effectiveness, efficiency, accessibility in a system that is both affordable and equitable. Building on the current system by measures such as adding a public option or Medicare buy-in doesn’t come close; lack of insurance, underinsurance, impaired access, and financial hardship would be perpetuated. There are still some differences of opinion regarding details of the single payer model, but this can be worked out cooperatively. What is clear is that expanding the current system is not adequate.

What about process? Above all we need to work with legislators and their staffs and others in the policy community who will be providing input into the legislative process. But in our passion it is essential that we not forget about the importance of civility.

Before Pollin’s team released their analysis, they had it reviewed by several other noted individuals from the policy community (link above). Although not all differences were resolved, the various opinions were advanced for consideration by the community at large. This process includes the crucial ingredient of civility. Without it, the process breaks down, as our highly polarized members of Congress demonstrate repeatedly.

When the legislation needs to be protected against flawed or harmful policies, working together with our colleagues to educate the legislative staffs will get us much further than bombarding them with what appears to them to be the product of uncooperative dissidents. Again, when we are clearly in the right, civility will pave the way.

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

By Robert Pear
The New York Times, December 29, 2018

More and more Democrats, fed up with private health insurance companies, are endorsing the goal of a government-run, single-payer system like Medicare for all Americans. But they have discovered a problem. More than one-third of Medicare beneficiaries are in Medicare Advantage plans, run not by the government but by private insurers.

Whether to allow younger Americans to enroll in such private Medicare plans has become a hotly debated political question as Democrats look to 2020.

When liberal Democrats started advocating “Medicare for all” more than 25 years ago, Medicare was the original fee-for-service program run by the government. Since then, it has changed in big ways. More than 20 million of the 60 million beneficiaries are in comprehensive Medicare Advantage plans sold by private insurers like UnitedHealth, Humana, Kaiser Permanente and Blue Cross and Blue Shield.

“Medicare for all” has become a rallying cry for progressive Democrats, though it means different things to different people. Supporters generally agree that it is a way to achieve universal coverage with a system of national health insurance in which a single public program would pay most of the bills, but care would still be delivered by private doctors and hospitals.

Billy Wynne, a health care lobbyist who used to work for Senate Democrats, said: “The literal meaning of ‘Medicare for all’ would include Medicare Advantage. But that is not what most supporters of Medicare for all have in mind.”

The champions of Medicare for all generally see insurance companies as part of the problem, not the solution.

“There are a lot of insurance companies and medical companies that are advocating for their own best interests, and those best interests are usually money, and not people’s health,” Representative-elect Deb Haaland, Democrat of New Mexico and a supporter of Medicare for all, said in an interview.

President Trump and other Republicans have mocked the idea of Medicare for all, saying it could ruin the program for older Americans and generate huge costs for the federal government. It would “come at a staggering cost to taxpayers,” said Alex M. Azar II, the secretary of health and human services.

Asked if his vision of Medicare for all included private Medicare Advantage plans, Adam Green, a founder of the Progressive Change Campaign Committee, an advocacy group, said: “No, absolutely not. Why would it? Medicare for all, in the end, means fundamental systemic change. People would no longer be at the mercy of for-profit insurers that make money by denying people care.”

Mr. Sanders and Representative Pramila Jayapal, Democrat of Washington and a chairwoman of the Medicare for All Caucus in Congress, see no need for private Medicare Advantage plans.

Vedant Patel, a spokesman for Ms. Jayapal, said her vision of Medicare for all was the traditional Medicare program, not private plans. “The purpose of Medicare for all is defeated if there are other plans people can buy into,” he said.

Josh Miller Lewis, a spokesman for Mr. Sanders, said: “We would get rid of duplicative health insurance. Our version of Medicare would cover most procedures. There would be no need for a Medicare Advantage program.”

Other lawmakers support expanding Medicare, but do not want to disrupt coverage for consumers who like the insurance they have.

Josh Miller Lewis, a spokesman for Mr. Sanders, said: “We would get rid of duplicative health insurance. Our version of Medicare would cover most procedures. There would be no need for a Medicare Advantage program.”

Other lawmakers support expanding Medicare, but do not want to disrupt coverage for consumers who like the insurance they have.

“Millions of Americans who rely on employer-sponsored insurance and Medicare Advantage are satisfied with their coverage,” said Representative Rosa DeLauro, Democrat of Connecticut.

Some health policy experts have suggested building a national health insurance program on Medicare Advantage rather than on the traditional fee-for-service Medicare program.

“Medicare Advantage for all — that would be a much more politically feasible and a uniquely American spin on single payer,” said John K. Gorman, a former Medicare official who is a consultant to many insurers. “It would be Medicare paying all the bills, but it would be privately administered by heavily regulated plans that would effectively serve as utilities.”

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

As we move into the next year, we should be celebrating the fact that “Medicare for All” has gained traction and now has widespread support throughout the United States. But can we? Any celebration has to be tempered by the fact that a multitude of very powerful forces are hijacking the “Medicare for All” label and using it to advance their own agendas based on ideology and especially greed.

What has crept into the national dialogue more recently is an emphasis that Medicare is not just the traditional public program but it also includes the private Medicare Advantage plans. The latter are being promoted by those in the insurance industry camp as the ideal model for expanding the Medicare program, whether by reducing the eligibility age, or by offering Medicare Advantage as a ready-to-go “public option” (that is actually private), or by opening up the ACA exchanges to include private Medicare Advantage plans (as a devious route to premium support – using ACA subsidies to support privatized Medicare).

Whatever, it is clear that the private insurance industry is going to continue to do all it can to capture the present and future versions of the Medicare program, and they are doing it with the help not only of the conservatives but also the neoliberals who have infiltrated the progressive camp. We will likely be hearing much more about Medicare Advantage for All.

It is going to be a rough year.

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

By Theodore R. Marmor
Journal of Health Politics, Policy and Law, December 2018

Abstract

Social insurance, like commercial insurance, is about protection against financial risk. In the United States, Medicare and the Social Security Administration’s programs for retirement, disability, worker’s compensation, and worker’s life insurance have become dominant features of American public policy, amounting to more than 41 percent of the federal budget. Yet their fiscal centrality does not rest on anything like an understanding of what makes social insurance social—or why that is so important to American political life. This essay seeks to clarify the crucial differences between social and commercial insurance and elaborates on the conceptual justifications and distinctive operational features of America’s social insurance programs.

What Is Social about Social Insurance?

Social insurance, like commercial insurance, is about protection against financial risk. It is “insurance” in the sense that people contribute to a fund to protect themselves against unpredictable financial risks. These include outliving one’s savings in old age, the early death of a breadwinner, the onset of disability that makes work difficult if not impossible, the high costs of illness, involuntary unemployment, and work-related injury. Contributions are not prices in a market and so, unlike commercial insurance, are not higher or lower depending on the customer’s risk profile. Instead of a commercial insurance contract between enrollee and insurer, social insurance is for shared protection among participants in which they agree that each should pay for that protection according to their work income. The “insurer”—a government agency or, originally in Europe, a corporate body with a joint labor/management board—is the agent of the contributing enrollees. The social insurance contract, once created, cannot be voluntary and survive long. By law contributions are required, because otherwise adverse selection would be financially disabling.

Social insurance, then, spreads the costs of coverage according to a different logic than that of commercial insurers. In commercial insurance, price must reflect risk. Social insurance, by contrast, operates on the premise that contributions are calculated according to one’s income and benefits are related to one’s needs. But the central political feature of social insurance is that the contributors are also beneficiaries. This is not the case with social assistance programs with means-tested eligibility standards. As important as such programs are for those who experience poverty, taxpayers do not in general identify with welfare beneficiaries. And, finally, private insurers, unlike governments, cannot tax citizens to make up for losses. But private insurers do routinely try to select customers with an eye to signing up those least likely to experience the risk the insurance policy is to mitigate. That’s why fire insurance is more expensive in poorer neighborhoods, not because insurance firms are racist.

Medicaid, Medicare, and Social Insurance

Medicaid’s very structure is ill designed for broad expansion. Its means-tested mode of eligibility creates a fiscal cliff. That is the term for when an additional dollar of a beneficiary’s income means the loss of a program’s benefit.5 No wealthy democracy has found a way to set the cliff at a point where some other arrangement and a means-tested program can combine to create universal health care. The design problems are particularly evident in the supposedly more middle-class part of the program, long-term care. The means testing and asset testing create cliffs and incentives for fraud. Quality problems can be severe, and yet many people go without needed services

There is little to say about Medicare in the context of conflict over the ACA. Democrats did not rely on expanding Medicare, save for a brief dalliance with voluntary coverage for Americans fifty-five to sixty-five years of age. The “public option” relied on Medicare’s ability to limit prices but not on explicit social insurance principles.6 Indeed, there was no serious discussion of how social insurance ideas were relevant, even though they were important in fact. The regulatory innovations of Obamacare represent earnest efforts to regulate commercial health insurance to become more like social insurance. Requiring insurers to guarantee issue at a fixed price regardless of preexisting conditions would reduce risk selection that social insurance eliminates directly. Requiring commercial insurers to offer a basic benefit plan also moves toward the common coverage that social health insurance offers automatically. The partial measures in the ACA appealed to the values underlying social insurance, but almost no connection was made between these measures and a principled vision of social insurance.

https://read.dukeupress.edu…

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Our Lost Vocabulary of Social Insurance

By Theodore R. Marmor
Niskanen Center, December 10, 2018

Social Insurance, Our Neglected Heritage

There are at least two plausible criticisms of this essay’s argument about the importance of relearning the appeal of social insurance principles. One is that the world has changed dramatically since the birth of social insurance in the late 19th century, let alone since the 1934-35 Committee on Economic Security provided a blueprint for expanding social insurance in American public life. The other is that changes in long-standing European social insurance programs show that major adjustments in the American programs are required as well.

The claim that the world has changed does not necessarily mean that the economic risks against which social insurance programs offer protection have been fundamentally altered. Consider every one of the risks noted in this essay — outliving one’s savings, involuntary unemployment, medical costs, and disability. Not one has disappeared, and social insurance programs for each have been implemented in wealthy democracies. I doubt, in other words, whether social insurance is in any conceptual trouble.

But that does not mean social insurance programs don’t need to adapt to contemporary circumstances. The spread of contract employment has been particularly challenging for European countries where social insurance is a function of trade unions and other sector-level organizations. It is equally obvious in the US that employer-provided health insurance puts a damper on labor market flexibility. Reduced employment in regular jobs with health coverage will demand the search for other sources of provision. These and other realities of our changing economy will only bring to the fore the central claim of this essay: Social insurance programs dominate American social policy but what that means for our politics is too little understood or explained. And that criticism extends not only to harried reporters but to a significant amount of the public policy community, as well.

https://niskanencenter.org…

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Comment:

By Don McCanne, M.D.

From Repeal and Replace to Medicare for All, with heavy doses of health care financing policy such as accountable care organizations, other alternative payment models, and the public option, we are being inundated with messages intended to ignite much needed improvements in our health care financing system. What seems to have slid out of these discussions is the crucial importance of policy design based on a solid foundation of social insurance.

Ted Marmor has provided us with an excellent account of the principles and paradoxes of social insurance as it has played out, or rather failed to play out fully, in the United States. Rather than reading comments here that I might make, it would be more important to download his article from the Journal of Health Politics, Policy and Law. The publisher has kindly removed the paywall, allowing free access to this article, available at the link above. A modified version has also been published by the Niskanen Center. Reading both versions can clarify any points that might not be clear on your first reading.

I believe that this is one of those landmark articles that should be in your health policy library file, whether you are an academic, activist, or simply someone who really cares about our health care system and the people who receive its services. Whatever we do, it is imperative that our future system be imbued with the principles of social insurance. Actually the principles are already there in our model of a universal single-payer improved-Medicare-for-all national health program. But people have to feel it.

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

By Ralph Nader
Common Dreams, December 26, 2018

Costly complexity is baked into Obamacare. No health insurance system is without problems but Canadian-style single-payer— full Medicare for all— is simple, affordable, comprehensive and universal.

Below please find 25 ways the Canadian health care system is better than the chaotic U.S. system.

Replace it with the much more efficient Medicare-for-all: everybody in, nobody out, free choice of doctor and hospital. It will produce far less anxiety, dread, and fear.

Number 25:

• In Canada, everyone is covered automatically at birth – everybody in, nobody out.
• In the United States, under Obamacare, 28 million Americans (9 percent) are still uninsured and 85 million Americans (26 percent) are underinsured.

Number 24:

• In Canada, the health system is designed to put people, not profits, first.
• In the United States, Obamacare has done little to curb insurance industry profits and in fact has increased the concentrated insurance industry’s massive profits.

Number 23:

• In Canada, coverage is not tied to a job or dependent on your income – rich and poor are in the same system, the best guaranty of quality.
• In the United States, under Obamacare, much still depends on your job or income. Lose your job or lose your income, and you might lose your existing health insurance or have to settle for lesser coverage.

Number 22:

• In Canada, health care coverage stays with you for your entire life.
• In the United States, under Obamacare, for tens of millions of Americans, health care coverage stays with you for as long as you can afford your insurance.

Number 21:

• In Canada, you can freely choose your doctors and hospitals and keep them. There are no lists of “in-network” vendors and no extra hidden charges for going “out of network.”
• In the United States, under Obamacare, the in-network list of places where you can get treated is shrinking – thus restricting freedom of choice – and if you want to go out of network, you pay dearly for it.

Number 20:

• In Canada, the health care system is funded by income, sales and corporate taxes that, combined, are much lower than what Americans pay in insurance premiums directly and indirectly per employer.
• In the United States, under Obamacare, for thousands of Americans, it’s pay or die – if you can’t pay, you die. That’s why many thousands will still die every year under Obamacare from lack of health insurance to get diagnosed and treated in time.

Number 19:

• In Canada, there are no complex hospital or doctor bills. In fact, usually you don’t even see a bill.
• In the United States, under Obamacare, hospital and doctor bills are terribly complex, making it very difficult to discover the many costly overcharges or massive billing fraud.

Number 18:

• In Canada, costs are controlled. Canada pays 10 percent of its GDP for its health care system, covering everyone.
• In the United States, under Obamacare, costs continue to skyrocket. The U.S. currently pays 17.9 percent of its GDP and still doesn’t cover tens of millions of people.

Number 17:

• In Canada, it is unheard of for anyone to go bankrupt due to health care costs.
• In the United States, health-care-driven bankruptcy will continue to plague Americans.

Number 16:

• In Canada, simplicity leads to major savings in administrative costs and overhead.
• In the United States, under Obamacare, often staggering complexity leads to ratcheting up huge administrative costs and overhead.

Number 15:

• In Canada, when you go to a doctor or hospital the first thing they ask you is: “What’s wrong?”
• In the United States, the first thing they ask you is: “What kind of insurance do you have?”

Number 14:

• In Canada, the government negotiates drug prices so they are more affordable.
• In the United States, under Obamacare, Congress made it specifically illegal for the government to negotiate drug prices for volume purchases, so they remain unaffordable and skyrocketing.

Number 13:

• In Canada, the government health care funds are not profitably diverted to the top one percent.
• In the United States, under Obamacare, health care funds will continue to flow to the top. In 2017, the CEO of Aetna alone made a whopping $59 million.

Number 12:

• In Canada, there are no required co-pays or deductibles in inscrutable contracts.
• In the United States, under Obamacare, the deductibles and co-pays will continue to be unaffordable for many millions of Americans.

Number 11:

• In Canada, the health care system contributes to social solidarity and national pride.
• In the United States, Obamacare is divisive, with rich and poor in different systems and tens of millions left out or with sorely limited benefits.

Number 10:

• In Canada, delays in health care are not due to the cost of insurance.
• In the United States, under Obamacare, patients without health insurance or who are underinsured will continue to delay or forgo care and put their lives at risk.

Number 9:

• In Canada, nobody dies due to lack of health insurance.
• In the United States, tens of thousands of Americans will continue to die every year due to lack of health insurance and much higher prices for drugs, medical devices, and health care itself.

Number 8:

• In Canada, health care on average costs half as much, per person, as in the United States. And in Canada, everyone is covered.
• In the United States, a majority support Medicare-for-all.

Number 7:

• In Canada, the tax payments to fund the health care system are modestly progressive – the lowest 20 percent pays 6 percent of income into the system while the highest 20 percent pays 8 percent.
• In the United States, under Obamacare, the poor pay a larger share of their income for health care than the affluent.

Number 6:

• In Canada, people use GoFundMe to start new businesses.
• In the United States, fully one in three GoFundMe fundraisers are now to raise money to pay medical bills. Recently, one American was rejected for a heart transplant because she couldn’t afford the follow-up care. Her insurance company suggested she raise the money through GoFundMe.

Number 5:

• In Canada, people avoid prison at all costs.
• In the United States, some Americans commit minor crimes so that they can get to prison and get free health care.

Number 4:

• In Canada, people look forward to the benefits of early retirement.
• In the United States, people delay retirement to 65 to avoid being uninsured.

Number 3:

• In Canada, Nobel Prize winners hold on to their medal and pass it down to their children and grandchildren.
• In the United States, Nobel Prize winners sell their medals to pay for their medical bills. Leon Lederman won a Nobel Prize in 1988 for his pioneering physics research. But in 2015, the physicist, who passed away in November 2018, sold his Nobel Prize medal for $765,000 to pay his mounting medical bills. According to a report in Vox, the University of Chicago professor began to suffer from memory loss in 2011, and died in an Idaho nursing home.

Number 2:

• In Canada, the system is simple. You get a health care card when you are born. And you swipe it when you go to a doctor or hospital. End of story.
• In the United States, Obamacare’s 2,500 pages plus regulations (the Canadian Medicare Bill was 13 pages) is so complex that then Speaker of the House Nancy Pelosi said before passage “we have to pass the bill so that you can find out what is in it, away from the fog of the controversy.”

Number 1:

• In Canada, the majority of citizens love their health care system.
• In the United States, a growing majority of citizens, physicians, and nurses prefer the Canadian type system – Medicare-for-all, free choice of doctor and hospital , everybody in, nobody out and far less expensive.

https://www.commondreams.org…

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Comment:

By Don McCanne, M.D.

As if we needed a reminder.

Would it be that Number 11 would gain traction in the United States: “In Canada, the health care system contributes to social solidarity and national pride.”

We should share at least that much with our Canadian brethren.

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

By Austin Frakt
The New York Times, December 24, 2018

One of the original justifications for Medicare — which kicks in at age 65 — is that older people have much higher health care needs and expenses.

But there are a few common misunderstandings about health costs when people are older, including the idea that money can easily be saved by reducing wasteful end-of-life spending.

Total health care spending for Americans 65 and older is about $15,000 per year, on average, nearly three times that of working-age Americans.

A widely held view is that much spending is wasted on “heroic” measures taken at the end of life. Are all the resources devoted to Medicare and Medicaid really necessary?

First, let’s get one misunderstanding out of the way. The proportion of health spending at the end of life in the United States is lower than in many other wealthy countries.

Still, it’s a tempting area to look for savings. Only 5 percent of Medicare beneficiaries die each year, but 25 percent of all Medicare spending is on individuals within one year of death. However, the big challenge in reducing end-of-life spending, highlighted by a recent study in Science, is that it is hard to know which patients are in their final year.

The study used all the data available from Medicare records to make predictions: For each beneficiary, it assigned a probability of death within a year. Of those with the very highest probability of dying — the top 1 percent — fewer than half actually died.

“This shows that it’s just very hard to know in advance who will die soon with much certainty,” said Amy Finkelstein, an M.I.T. economist and an author of the study. “That makes it infeasible to make a big dent in health care spending by cutting spending on patients who are almost certain to die soon.”

“There absolutely is waste in the system,” said Ashish Jha, director of the Harvard Global Health Institute. But, he argues, waste is present throughout the life span, not just at the end of life: “We have confused that spending as end-of-life spending is somehow wasteful. But that’s not right because we are terrible at predicting who is going to die.”

Of course, beyond any statistical analysis, there are actual people involved, and wrenching individual decisions that need to be made.

“We should do all we can to push waste out of the system,” Dr. Jha said. “But spending more money on people who are suffering from an illness is appropriate, even if they die.”

Austin Frakt is director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health. He blogs at The Incidental Economist.

https://www.nytimes.com…

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NYT Reader Comment:

By Don McCanne, M.D.

I am a retired physician who writes a daily commentary on health policy (PNHP, Quote of the Day), believing that everyone should have affordable access to beneficial health care services when needed (i.e., I support Single Payer Medicare for All). I am also an octogenarian undergoing an evaluation for a medical problem that may well have a guarded prognosis. Believe me, I am very tuned in to this article on late-life care written by one of my favorite health policy analysts, Austin Frakt.

Should an old man like me have a workup for a condition for which there may be no beneficial intervention (though that is uncertain because of the lack of a definitive diagnosis at this point)? Can society afford to fund such care? Well, there is extensive literature that indicates that we can, in fact, afford to fund essentially all truly beneficial health care services for everyone as long as those services are priced reasonably. The line we should not cross is when diagnostic and therapeutic health care interventions become futile, but then that is precisely why we have palliative/hospice care.

The goals of health care should be to prevent premature death when possible, and to maintain quality of life as best we can while we are here. Studies have confirmed that such care would be affordable for society with a well designed, improved version of Medicare that covered everyone – a system that’s efficient, effective and equitable – a system that places the patient first.

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

By Kathryn Elena Woolhandler Himmelstein, M.D., M.S.Ed. and Atheendar S. Venkataramani, M.D., Ph.D.
American Journal of Public Health, December 20, 2018 (published online ahead of print)

Abstract

Objectives: To investigate racial/ethnic and gender inequities in the compensation and benefits of US health care workers and assess the potential impact of a $15-per-hour minimum wage on their economic well-being.

Methods: Using the 2017 Annual Social and Economic Supplement to the Current Population Survey, we compared earnings, insurance coverage, public benefits usage, and occupational distribution of male and female health care workers of different races/ethnicities. We modeled the impact of raising the minimum wage to $15 per hour with different scenarios for labor demand.

Results: Of female health care workers, 34.9% earned less than $15 per hour. Nearly half of Black and Latina female health care workers earned less than $15 per hour, and more than 10% lacked health insurance. A total of 1.7 million female health care workers and their children lived in poverty. Raising the minimum wage to $15 per hour would reduce poverty rates among female health care workers by 27.1% to 50.3%.

Conclusions: Many US female health care workers, particularly women of color, suffer economic privation and lack health insurance. Achieving economic, gender, and racial/ethnic justice will require significant changes to the compensation structure of health care.

(Am J Public Health. Published online ahead of print December 20, 2018: e1–e8. doi:10.2105/AJPH.2018.304801)

https://ajph.aphapublications.org…

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Comment:

By Don McCanne, M.D.

On Christmas Eve, regardless of your religious affiliations, it seems appropriate to consider what Jesus might have had to say about the economic vulnerability of US female health care workers. The lead author of this study, heir and namesake of the co-founders of PNHP, has helped us by providing objective data and an analysis of the plight of female health care workers.

At a time that our political leadership has decided to furlough workers just in time for Christmas, it seems that we should give more thought as to what is wrong and how we can find the moral pathway forward.

Really.

Peace.

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