By Merrill Goozner
Modern Healthcare, March 16, 2018

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Comment posted at Modern Healthcare:

By Don McCanne, M.D.

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

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

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

https://www.modernhealthcare.com…

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Comment:

By Don McCanne, M.D.

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

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

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

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

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

Abstract

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

From the Introduction

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

From the Discussion

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

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

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

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

Conclusions

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

Significance for Public Health

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

https://www.jphres.org…

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Comment:

By Don McCanne, M.D.

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

Solution? Single Payer Improved Medicare for All – Now!

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

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

Key Findings

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

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

Conclusions

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

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

https://fah.org…

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Comment:

By Don McCanne, M.D.

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

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

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

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By Diane Archer
The Hill, March 11, 2019

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

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

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

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

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

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

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

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

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

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

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

https://thehill.com…

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Comment:

By Don McCanne, M.D.

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

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