AMSA (American Medical Student Association), April 12, 2019

The American Medical Student Association (AMSA) stands in strong support of Rep. Pramila Jayapal’s Medicare for All Act of 2019, H.R. 1384, and of Sen. Bernie Sanders Medicare for All Act, S. 1129. As an organization of future physicians, AMSA seeks to improve the health and enhance healthcare access for everyone in America, true healthcare for all; and the federal single-payer system proposed in the Medicare for All Act would be a momentous step toward that vision.

The current system creates a huge administrative burden that takes physicians away from patient care, allows pharmaceutical companies to drive up costs of medicines, and makes essential healthcare services unaffordable for many. As AMSA National President Perry Tsai, M.D., Ph.D., remarked at the introduction of Sen. Sanders’ bill, “For each thing we learn on our way to becoming physicians who care for patients, we find one more thing that will prevent us from caring for our patients…Our dream [of caring for patients] is turning into a nightmare, and we will not stand for it.” Comprehensive health coverage through Medicare for All would result in lower administrative costs, increased healthcare access for everyone regardless of employment, and reduced burdens on physicians such that they can spend more energy on patient care.

“As medical trainees, we have witnessed on multiple occasions how the current healthcare system fails to provide affordable, high quality, comprehensive care to all patients and their families,” Avanthi Jayaweera, AMSA’s Education and Advocacy Fellow, said. “We are inheriting a system that puts profits over our patients’ lives. The next generation of physicians want Medicare for All to allow for a future where we can put our patients first just as we are taught in our clinical training.”

AMSA is proud to support these bills to establish Medicare for All and is organizing a Health Care for All Week of Action, April 15-19, in order to educate and engage medical trainees to ask their members of Congress to support Medicare for All. Hanan Rakine, co-chair of AMSA’s Health Care for All Campaign, stresses, “It is our role as future health care professionals to advocate for our patients’ well-being and right to health care.”

Through our Health Care for All Campaign, AMSA has over 50 years of experience fighting for equitable, efficient and quality universal health care coverage. Unburdened by conflicts-of-interest, medical students are fighting for the healthcare system that our nation and our communities need, not the system pharmaceutical and insurance companies have created. As the largest body of future doctors in the U.S., AMSA is fighting for a future that puts patients ahead of special interests. AMSA believes that no person should go without needed emergent or preventive health care services. AMSA believes that these proposals released by Rep. Jayapal and Sen. Sanders will address the current inequities of the U.S. healthcare system by ensuring every individual living in the U.S. has access to comprehensive health care benefits.

About the American Medical Student Association:

AMSA is the oldest and largest independent association of physicians-in-training in the United States. Founded in 1950, AMSA is a student-governed, non-profit organization committed to representing physicians-in-training, advocating for quality and affordable health care for all, and building the next generation of physician leaders.

https://www.amsa.org…

---

Comment:

By Don McCanne, M.D.

With AMSA’s endorsement of both Rep. Pramila Jayapal’s and Sen. Bernie Sanders’ Medicare for All Acts of 2019, we know that the future of health care is in very good hands.

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

By Paul O’Rourke-Babb
Enterprise-Record, April 7, 2019

New Medicare-for-All legislation (The Medicare for All Act of 2019, HR 1384) was just introduced in the U.S. House of Representatives by Rep. Pramila Jayapal (D-Wash) with 103 cosponsors. I’m for it. Our nation has another, better, chance to fix our broken health insurance system.

As a retired Nurse Practitioner and a long-time Butte County resident, I strongly believe Medicare for All will give our communities the health care security that we desperately need. Here’s why.

Whether you’re a patient, a health care provider or a hospital, I don’t need to tell you the health care challenges we were facing before the fire just got a whole lot worse. You already know.

Fifty thousand people have been displaced. Adventist Hospital, doctors’ and therapists’ offices, and clinics have been damaged or destroyed by fire. If you owned your business and lost it, you also lost your ability to pay for private insurance. If your employer was burned out, you lost your job and if your employer was sponsoring your health insurance, you lost that too.

Getting health care was a problem before the fire, but it’s even worse now. No matter whether you get insurance through work, Covered California or Medicare, the scarcity of primary care doctors was already a problem. If you’re on Medi-Cal, almost no physician would accept you as a patient. At the same time that the number of people who qualify for Medi-Cal will likely rise, the ability of doctors to hire staff and see those people will worsen.

That’s because many patients and their doctors lost their homes and businesses and had to move away to find shelter. The Butte County vacancy rate was already critical at around 2%. Then the fire took out an estimated 6.5% of the county’s housing units.

On top of that, our communities have been traumatized. Month-long waits or long drives to access mental health care were common before the fire. Today it’s worse.

Affording health care remains another big problem. Over 21% of Butte County households were living in poverty before the fire. But even at higher incomes, the costs of health insurance prevented 4 in 10 of us from seeking the care we need.

Now it’s worse. Insurance premiums, deductibles and co-pays don’t magically disappear during disasters. But the money to pay them has to compete with the need to rebuild our lives from scratch.

Area hospitals, greatly impacted by the fire, are also disproportionately burdened by having to deal with multiple insurance companies and this adds a layer of completely unnecessary expense to our health care.

Medicare for All would make health care more affordable. Here’s how:

It would reduce the cost of billing.

Medicare for All would dramatically reduce the average $99,581 that physicians spend each year on billing and insurance-related work just to get paid. It would save hospitals millions of dollars on redundant and often competing billing administration, up to 25% to 30% of their budgets.

Reduced billing costs means savings for you and for a public insurance system.

It would finance health care in a completely different way.

A public Medicare-for-All system will eliminate upfront costs like premiums, deductibles and co-pays. A combination of taxes, based on one’s ability to pay, would ensure that everybody would pay their fair share for the same comprehensive policy. And universal coverage would ensure that the system would remain solvent and financially stable.

It would cost you less.

The savings from a more efficient health care system means that we would pay less in taxes than we are now paying in premiums and out-of-pocket costs.

We would all have the same comprehensive, high-quality health insurance no matter what circumstances change in our lives.

You could see the doctor of your choice, even if your doctor had to set up a new practice in another area or gave up private practice and took a job at a hospital.

When I moved to Butte County many years ago for work, the active arts community and beautiful environment attracted me. Life here should be peaceful and uncomplicated. When it comes to our health care, it’s anything but. It doesn’t have to be this way. Contact your congressional representatives and voice support for Jayapal’s new bill. At the same time, let your state legislators know that you also support California Medicare for All. We need it now, more than ever.

Paul O’Rourke-Babb is a retired Nurse Practitioner and longtime member of Physicians for a National Health Program. He lives in Chico.

https://www.chicoer.com…

---

Comment:

By Don McCanne, M.D.

The Butte County fire in which the beautiful town of Paradise was destroyed was a heart-wrenching experience for my wife and me, especially wistful since we had visited our dear friends there frequently in years past. Our friend and health care reform colleague, Paul O’Rourke-Babb, describes in his article what this meant to so many residents of Butte County. It was a terribly tragic event that only those who were there to experience it can truly comprehend.

So why does this belong in a blog on single payer Medicare for All? Paul tells us. Although they lost their hospitals and clinics, the surrounding communities were there to help. But they were restricted by the deficiencies in our highly dysfunctional health care financing system. Imagine if, instead, everyone was covered by a single payer Medicare for All program. All attention would be directed to providing the care needed, with no concerns about insurance coverage, cost sharing, provider networks, prior authorization requirements, or any of the other cruel, parsimonious features of our current system.

When the fire and forest services were battling the blazes destroying the homes, they did not first check to see if the homes were registered to qualify for fire services nor did they have to obtain prior authorization to extinguish the blazes. We have often said that health care should always be there for you just as the fire department is when you need it. We would have that with a well designed, single payer Medicare for All.

Maybe it would not have made much difference during the urgent moments of the fire, but it can make a very big difference now for those who lost their work and the health insurance that went with it and are now facing medical bills that compound the financial hardships that they are facing. We can do only so much to try to console those facing grief, but at least we can take worries about paying for health out of any future tragedy like this – by enacting and implementing single payer Medicare for All.

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

Bureau of Labor Statistics, March 15, 2019

Separations

Total separations includes quits, layoffs and discharges, and other separations. Total separations is referred to as turnover. Quits are generally voluntary separations initiated by the employee. Therefore, the quits rate can serve as a measure of workers’ willingness or ability to leave jobs. Layoffs and discharges are involuntary separations initiated by the employer. Other separations includes separations due to retirement, death, disability, and transfers to other locations of the same firm.

Annual Levels and Rates

In 2018, there were 68.9 million hires, an increase of 3.3 million from 2017. Total separations (the sum of quits, layoffs and discharges, and other separations) rose by 2.6 million in 2018 to 66.1 million. Quits rose for the ninth consecutive year reaching 40.1 million in 2018, up by 2.4 million. Quits comprised 61 percent of total separations. Layoffs and discharges edged up by 307,000 in 2018 to 21.9 million and comprised 33 percent of total separations. Other separations edged down by 44,000 in 2018 to 4.1 million and comprised 6 percent of total separations.

The annual hires for 2018 was 46.3 percent of the annual average CES (Current Employment Statistics) employment level. This rate has been trending upwards since 2009. The annual total separations rate for 2018 was 44.3 percent. The annual rates for the components of total separations were 26.9 percent for quits, 14.7 percent for layoffs and discharges, and 2.8 percent for other separations.

https://www.bls.gov…

---

Comment:

By Don McCanne, M.D.

We are being told repeatedly that we should not enact a single payer Medicare for All program because people like their insurance they get at work, and they should be able to keep it if they want. Yet in 2018, 66 million individuals left their employment – a turnover rate of 44 percent!

For those 66 million separations from work, employer-sponsored plans did not prove to be the stable coverage that most of us want. Sure, many of these individuals were not even offered coverage at work, but that is more evidence that the employer-sponsored plans that the Affordable Care Act was designed to protect often do not provide reliable, stable coverage.

Of course there are other problems with employer-sponsored plans. They frequently have excessive cost sharing requirements, especially high deductibles, that can create financial hardship and impair access to care. Provider networks frequently prevent access to the patients’ choices of health care professionals and facilities, and often even fail to include much choice for highly specialized problems (though some larger employers may have special programs for centers of excellence). With change of employment, provider networks, benefits covered, and cost sharing requirements may change dramatically, potentially creating instability in the individual’s health care.

So who are these individuals who are so pleased with the health insurance that they get at work? Well, the workforce is a relatively healthy population that on average does not require much health care. Many feel secure with the financial protection that they believe their plan is providing even though they may have little experience with the system because of their good health. Some do have more significant medical problems and many of them do find professionals with whom they are pleased, and so the system works fairly well for them. But what about those who can’t go to their established care sources, or who cannot afford the out-of-pocket cost sharing, or who cannot afford the medications on which they have been maintained, or are one of the 44 percent with employment turnover and find that their new employer does not provide coverage, yet they earn too much for ACA subsidies? How can you say that employer-sponsored plans work well for them?

Another thing, employers insure predominantly the healthy workforce and their young healthy families. Those with more significant and costly medical problems tend to receive their care from government programs – Medicaid, Medicare, the VA system, safety-net institutions, and cost shifting by the uninsured (disproportionate share payments, etc.) – financed by us, the taxpayers. Pooling risk is one of the most fundamental functions of health insurance, so why are we granting employers favorable selection in their risk pools while passing adverse selection onto the taxpayers? Obviously it would be much more equitable to have one universal risk pool under single payer Medicare for All. Insurance premiums paid by employees along with forgone wage increases to cover the employer’s contribution are a form of regressive financing of health care – the opposite of the more equitable progressive financing of a tax-funded single payer system.

Next time you are told that we have to reject single payer Medicare for All because it would not allow individuals to have the choice of remaining enrolled in a health plan at work, point out that last year the 66 million people experiencing work separations did not have that choice, even if they previously had been offered insurance at work.

---

Addendum: About that 66 million job turnover

Quote of the Day, Addendum for April 11, 2019

About that 66 million job turnover each year, Dr. Ed Weisbart makes a very important point:

“I’ve been using numbers like this for a while but to make a different point — that the ~1.3M job displacements from single payer are a single bump in the road, with mitigation strategies, compared to the unending sea that is our current culture. 60M every year, for decades before and decades to come, vs 1M in a single planned way.”

---

Comment:

By Don McCanne, M.D.

Thus not only can we use this number of a 66 million job turnover each year as as an argument against “you can keep your insurance,” but also as an indication that the job displacement caused by eliminating private insurance does not create a formidable employment nightmare for the one million or so that might be displaced. We can do it.

---

Another addendum: About that 66 million job turnover

Quote of the Day, Second addendum for April 11, 2019

About that 66 million job turnover each year, UMass economics professor Gerald Friedman makes another very important point:

“Excellent note! To these 66 million need to be added all those whose employers change their insurance plan. And this is a growing problem because of narrow insurance plans where people need to change their primary care provider.”

---

Comment:

By Don McCanne, M.D.

None needed. This thing has a life of its own.

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

Physicians for a National Health Program (PNHP), April 10, 2019

Dear colleague,

Today is another important day in the movement towards improved Medicare for All. This morning, Sen. Bernie Sanders introduced the Medicare for All Act of 2019 in the Senate, along with 14 co-sponsors. Sen. Sanders has long been a strong voice for health care justice in the U.S., and we welcome his continued advocacy and leadership for single-payer reform.

What’s in the bill?

The Medicare for All Act of 2019 mostly follows the Senator’s 2017 bill, with one notable addition. Here’s a summary of what’s in the bill:

• Eligibility: Covers everyone residing in the U.S.
• Benefits: Covers medically-necessary services including primary and preventive care, mental health care, reproductive care (bans the Hyde Amendment), vision and dental care, and prescription drugs. This bill also provides home- and community-based long-term services and supports, which were not covered in the 2017 Medicare for All Act.
• Patient Choice: Provides full choice of any participating doctor or hospital. Providers may not dual-practice within and outside the Medicare system.
• Patient Costs: Provides first-dollar coverage without premiums, deductibles or copays for medical services, and prohibits balance billing. Copays for some brand-name prescription drugs.
• Cost Controls: Prohibits duplicative coverage. Drug prices negotiated with manufacturers.
• Timeline: Provides for a four-year transition. In year one, improves Medicare by adding dental, vision and hearing benefits and lowering out-of-pocket costs for Parts A & B; also lowers eligibility age to 55 and allows anyone to buy into the Medicare program. In year two, lowers eligibility to 45, and to 35 in year three.

How can the bill be improved?

Similar to the 2017 bill, the launch of this bill is a major step forward in the fight for Medicare for All. At the same time, PNHP again recommends ways that this bill can be improved:

Fund hospitals through global budgets, with separate funding for capital projects: A “global budget” is a lump sum paid to hospitals and similar institutions to cover operating expenses, eliminating wasteful per-patient billing. Global budgets could not be used for capital projects like expansion or modernization (which would be funded separately), advertising, profit, or bonuses. Global budgeting minimizes hospitals’ incentives to avoid (or seek out) particular patients or services, inflate volumes, or upcode. Funding capital projects separately, in turn, allows us to ensure that new hospitals and facilities are built where they are needed, not simply where profits are highest. They also allow us to control long term cost growth.

End “value-based” payment systems and other pay-for-performance schemes: This bill continues current flawed Medicare payment methods, including alternative payment models (including Accountable Care Organizations) established under the ACA, and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Studies show these payment programs fail to improve quality or reduce costs, while penalizing hospitals and doctors that care for the poorest and sickest patients.

Establish a national long-term care program: This bill includes home- and community-based long-term services and supports, a laudable improvement from the 2017 bill. However, institutional long-term care coverage for seniors and people with disabilities will continue to be covered under state-based Medicaid plans, complete with a maintenance of effort provision. PNHP recommends that Sen. Sanders include institutional long-term care in the national Medicare program, as it is in Rep. Pramila Jayapal?s single-payer bill, H.R. 1384.

Ban investor-owned health facilities: For-profit health care facilities and agencies provide lower-quality care at higher costs than nonprofits, resulting in worse outcomes and higher costs compared to not-for-profit providers. Medicare for All should provide a path for the orderly conversion of investor-owned, for-profit health-care providers to not-for-profit status.

Fully cover all medications, without copayment: Sen. Sanders’ bill excludes cost-sharing for health care services. However, it does require small patient copays (up to $200 annually) on certain non-preventive prescription drugs. Research shows that copays of any kind discourage patients from seeking needed medical care, increasing sickness and long-term costs. Experience in other nations prove that they are not needed for cost control.

What’s next?

Single-payer opponents, including deep-pocketed lobbying groups like the Partnership for America’s Health Care Future that represent corporate health care interests, will certainly attack this bill and its co-sponsors. At the same time, a slew of alternative proposals that fall short of what is needed, like a public option, could confuse the public.

Let’s remind our members of Congress that a majority of Americans (including a growing majority of physicians) support real single-payer reform. So please consider calling both of your U.S. Senators at (202) 224-3121 and request that they co-sponsor the Medicare for All Act of 2019. If they are already a co-sponsor, thank them and ask them to work towards improving this bill, educating their colleagues, and amplifying the work of grassroots organizers.

The fight for a just health care system for all is moving forward. Together, it’s a fight we can win.

Sincerely,

Adam Gaffney, M.D., M.P.H
President

---

Comment:

By Don McCanne, M.D.

Single payer Medicare for All bills have now been introduced in both the House and the Senate. They are both named Medicare for All Act of 2019, although there are significant differences in the bills. What do we do with them?

In this session of Congress, neither bill can clear the Senate, and they would certainly face a veto by President Trump. But that is true of other reform measures, especially those that offer a Medicare-like public option. So our goal during this session of Congress is to use the two single payer Medicare for All bills to educate, not only the public at large, but also present and potential future members of Congress and potential presidential candidates. But remember, the politicians need to hear it from their constituents. The public leads, politicians follow, unless corrupted.

The most important message is why the single payer model of Medicare for All is the only model that will achieve the goal of truly affordable and equitable health care for absolutely everyone. There is a surge in popularity for reform that protects private employer-sponsored plans and the private Medicare Advantage plans, reflecting the fact that the public and many politicians do not realize the profound differences in the efficiency, affordability, and equity of the two models of reform: single payer Medicare for All versus public option Medicare for some. Tweaks to the Affordable Care Act do not even qualify as a game changer.

For those who do understand the single payer model, it is important to educate them on the policy details that are important, such as those concerns listed in the PNHP message above. Time is short. Potential presidential candidates are already refining their policy positions, as are members and candidates for Congress. Their positions should be clear before the election, and the policy details of the legislation should be carefully defined before the next session of Congress begins. This work has to be done now. Relying on a drawn-out, legislative sausage-making process could be disastrous. Human lives depend on getting it right.

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

I’ve spent decades studying US health care. Time to get real: Medicare for All is the only reasonable path to controlling costs and covering everyone.

By Gerald Friedman
USA TODAY, April 8, 2019

There is an instinct among political pundits to confuse caution for practicality — an assumption that those who advocate for incremental change are being reasonable, while those pushing for bold reforms aren’t. This is seen most starkly in the debate around health care reform, despite the fact that the “practical” pushers of limited reform fail to address the real problems in our health care system.

We all recognize that the status quo isn’t working. We spend more per person than any other country on health care, but we aren’t getting any bang for our buck. We have lower life expectancy, higher infant mortality rates and more preventable deaths, and too many personal bankruptcies are due at least in part to medical bills.

Where we disagree is the solution. The favorite new “reasonable” plan is “Medicare for America,” a bill from Reps. Jan Schakowsky and Rosa DeLauro that has won the support of big names like Texas presidential hopeful Beto O’Rourke and the Center for American Progress, the left-of-center think tank where the plan originated as “Medicare Extra for All.” It has been extolled in opinion pieces for some of America’s largest newspapers as a “realistic” plan to fix what’s broken in our health care system.

On the other side, if punditry is to be believed, there are the Medicare for All “hard-liners” who believe in expanding a significantly improved Medicare system to every American, with coverage that includes dental, vision and long-term care. This is portrayed as radical or even unreasonable.

Time to get real. As an economist who has spent decades studying our health care system, I can tell you that Medicare for All advocates are the only ones who are being reasonable, because theirs is the only plan that will control health care costs while finally achieving universal coverage.

Insurance companies are middle men

The problem with incremental plans, whether they are public options, buy-ins to Medicare or Medicaid, or pumping more money into subsidies in the Affordable Care Act’s individual marketplace, is that they preserve the private health insurance system weighing down our health care.

This may be why pundits and centrist politicians view those plans as “reasonable,” but it means that they are leaving the main reason for our system’s dysfunction in place: the multipayer, for-profit financing model.

Commercial insurance companies are nothing more than middle men. They add no value to our system, but they do drive up costs with their bloated claims departments, marketing and advertising budgets and executive salaries. We pay for all of these things before a single dollar is spent on the delivery of care.
They also create extra costs for providers who need large administrative staffs to deal with billing systems, accounting for as much as $100,000 per physician.

Any plans short of Medicare for All leaves these costs in place. In other words, they leave hundreds of billions of dollars a year in savings on the table.

Medicare for All attacks costs

The waste goes beyond administrative savings. While pharmaceutical companies and hospital groups are consolidating and forming regional monopolies, our fragmented, multipayer system leaves no one insurance plan with a large enough share of the market to negotiate effectively. That allows these companies to essentially set their own inflated prices and bilk the public for hundreds of billions of dollars.

Is it any wonder that they oppose Medicare for All?

If we’re talking about which health care reform plans are serious about attacking cost, providing universal coverage and making sure everyone has access to health care, Medicare for All is the only reasonable answer. No other plan does this effectively, which is why I suspect that the Center for American Progress has not come out with spending estimates. Basic economic tenets tell us that their plan will not reduce health care spending as effectively.

Is Medicare for All bold? Absolutely. Is it reasonable? You bet. It is time to accept that Medicare for All is the practical alternative.

Gerald Friedman, a health care and labor economist, is an economics professor at University of Massachusetts Amherst and the director of the Hopbrook Institute. Follow him on Twitter: @gfriedma.

https://www.usatoday.com…

---

Comment:

By Don McCanne, M.D.

The incrementalists who advocate for tweaks to the Affordable Care Act, perhaps with the addition of a Medicare-like public option, claim to be taking a reasonable pathway to reform. But is it really reasonable to advocate for a system that wastes tremendous resources while leaving tens of millions without adequate coverage and impaired health outcomes, not to mention financial hardship? Well it is unreasonable to make such a claim when fundamental structural reform of our financing system through single payer Medicare for All would establish an equitable and affordable system that ensures health care for everyone. Claiming that displacing the dysfunctional private insurance system is unreasonable is, well, unreasonable.

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