PNHP

I just want my blood pressure pills, dammit! (and why it should matter to others)

I just want my blood pressure pills, dammit! (and why it should matter to others)

By Don McCanne, M.D.
September 17, 2018

In the big picture of health care in America, the following anecdote is quite trivial, but, as I’ll explain, the implications are of great consequence.

Through the years my wife and I have had great care coordinated by our highly competent primary care physician. He retired recently and his practice was taken over by another physician. I needed a refill on my two blood pressure medications, but rather than interacting with the physician, I was now interacting with OptumCare Medical Group, a subsidiary of UnitedHealth. (You’ve no doubt read about insurers consolidating with physician groups – it’s very real.) Although we have avoided the private Medicare Advantage plans, I found by perusing OptumCare’s website that, without my knowledge, I was assigned to their Medicare Pioneer ACO.

The trivial complaint of mine is that I had to have numerous contacts through an always-busy telephone system and a non-responsive contact point on their website which resulted in many days of effort just trying to get my two basic blood pressure medications refilled. Several errors were made and, in fact, they never were correct even after repeated attempts. The prescriptions had the names of two different nurse practitioners on them, and finally one had the name of my new primary care physician after I was finally able to see him. Part of these glitches were due to the fact that they were transitioning to a computer system.

Not only were my prescriptions under the control of OptumCare, I was also covered by a Part D Medicare drug plan through Anthem Blue Cross. All I wanted was a 90 day supply of each pill with 3 refills, just as I had had under our previous physician. Well, somewhere between OptumCare and the Anthem drug plan, our independent pharmacist of many years was authorized to fill only a 30 day supply, but for only one of them since it was too early to fill the other one. This meant that I would have to come back every 15 days indefinitely to pick up only one prescription at a time. I checked the Anthem website and found that not only was my pharmacy not on the preferred list, it was no longer listed in the Anthem network at all (with a statement that pharmacies could be changed at any time without notice).

I discovered that I could receive 90 day supplies by mail through Anthem’s pharmacy benefit manager, but it seemed unfair to me that they should take over the bread and butter trade of easy long term prescriptions while leaving the local pharmacist with the need to carry a huge stock of a great variety of prescription items that are filled usually only once, creating an overhead headache without a volume offset.

I finally gave up. Since I still have my medical license, I ordered stock jars of 1000 pills each through a medical supplier so I wouldn’t be bothered with the hassle any more (a strategy not available to most people). Of course, that’s not covered by the Part D plan, but I had had enough. (I should mention that though it is unethical for a physician to prescribe for himself, these two medications were actually prescribed by my primary care physician and by my cardiologist.)

Yes, this is very trivial compared to some of the horrendous problems that others face in our health care system. But it is what this annoyance represents that is so objectionable. The system should work so that I can get my very common, tier one generic medications every three months with an effortless system of refilling them. Instead, my physician has been hijacked by one of the largest insurers in the nation, and my pharmacist has had barriers erected by another of the largest insurers, together making it much more difficult for me to obtain my straightforward maintenance medication. What value are these giant insurers adding that we should have to tolerate their inanity?

The reason that everyone should be concerned is that this takeover of health care is expanding rapidly, with no relief in sight. If it doesn’t work well for minor routine matters, how could it work well for the big stuff? A well designed, single payer improved Medicare for all program as is advocated by Physicians for a National Health Program would solve most of the problems with our highly dysfunctional health care financing system. Although there is widespread public support for such a model of reform, look very carefully at what is actually happening in the political arena.

Congress and the administration are continuing to expand the private Medicare Advantage and private Medicaid managed care models. They are continuing to push alternative payment models including accountable care organizations and other so called value-based proposals that involve intrusions by insurers and other managers. While using the Medicare for all rhetoric, they are quietly suppressing the bona fide single payer model while giving the business intermediaries an even greater role in (mis)managing our health care system.

HR 676, the Expanded and Improved Medicare for All Act contains many of the principles of a well designed single payer system. People are enthused to see the formation of a Medicare for All caucus in the House. There has also been considerable enthusiasm over the introduction in the Senate of Bernie Sanders’ bill, S 1804, as supposedly being a single payer Medicare for All bill in the Senate. However, to gain cosponsors, many compromises were made. Exemplifying them is the inclusion of the following:

“Sec. 611 (b) Application Of Current And Planned Payment Reforms.—Any payment reform activities or demonstrations planned or implemented with respect to such title XVIII as of the date of the enactment of this Act shall apply to benefits under this Act, including any reform activities or demonstrations planned or implemented under the provisions of, or amendments made by, the Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 114–10) and the Patient Protection and Affordable Care Act (Public Law 111–148).”

This means that the payment models of ACA and MACRA with MIPS and APMs including ACOs would be perpetuated under S 1804. What is especially alarming is that members of the House Medicare for All caucus, instead of protecting and supporting the single payer features of HR 676 and encouraging the Senate to endorse the same, they want to change HR 676 to include the highly flawed features of S 1804. It appears that the intent of Congress is to perpetuate the entities that are creating many of the very problems that we are trying to solve with PNHP’s version of an improved Medicare for all. Leaving our dysfunctional system in place while merely adding a Medicare Advantage-style public option is no solution at all.

My wife and I have transferred our care to another excellent physician. We left OptumCare but are continuing with the traditional Medicare program with a Medigap supplement to protect us in the event of catastrophic events. We also are continuing with our Part D drug plan to protect us against the potential of those $100,000 drugs that are becoming so commonplace. But wouldn’t it be nice to have the Medigap benefits and the drug benefits rolled into the traditional Medicare program along with the other improvements that would be ideal in an improved Medicare for all? We’re not going to have that unless we start communicating more effectively with our members of Congress, even if it means using our boot.

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Universal healthcare was unthinkable in America, but not any more

A single-payer healthcare system appears closer than ever but to make it a reality we must avoid the pitfalls of the past

By Adam Gaffney, M.D.
The Guardian, September 16, 2018

Barack Obama dropped a bombshell into the healthcare debate roiling the Democratic party last Friday. “Democrats aren’t just running on good old ideas like a higher minimum wage,” he said, “they’re running on good new ideas, like Medicare for All…” His endorsement made headlines, and for a good reason: until recently, real universal healthcare had long resided on the margins of the American political discourse. Obama’s announcement, then, was yet one more indication that this idea – also called single-payer healthcare – had migrated to the mainstream. The shift is an encouraging development for proponents, to be sure, but there is also cause for caution: as history shows, formidable political obstacles and pitfalls lie ahead.

It is difficult to overstate how far single-payer has recently moved. Consider, for a moment, where things stood after Democrats took the presidency and both houses of Congress in 2008. “The White House and Democratic leaders have made clear,” the Washington Post reported the following year, “there is no chance that Congress will adopt a single-payer approach…because it is too radical a change.” Single-payer supporters didn’t even have a seat at the table (and some were arrested when they showed up anyway).

Following the passage of the Affordable Care Act, however, several developments pushed single-payer to the fore. First, although Obamacare expanded coverage to some 20 million people – achieving much good – it raised hopes that universal healthcare would be achieved while failing to deliver it: some 29 million remain uninsured today, while many more face onerous deductibles, restrictive insurance networks, surprise bills, unaffordable medications, medical bankruptcies and disruptions in care with every change in insurance plan.

Next, there was the 2016 election of Donald Trump, which made it obvious that Republicans lacked even a semi-serious alternative. Congressman Paul Ryan’s long-awaited ACA repeal bill was mostly a mechanism to transfer healthcare dollars from the poor into the savings accounts of the rich, and it seemed to satisfy no one except for wealthy donors.

Finally, there was a marked progressive shift within the Democratic party, beginning with the 2015-16 presidential primary campaign. Former secretary of state Hillary Clinton opposed single-payer, saying it would “never, ever” happen, but it was central to the platform of Vermont senator Bernie Sanders. Sanders lost the primary, of course, but he advocated better ideas.

Obama’s endorsement of single-payer on Friday (despite having previously said something similar) is therefore tantamount to a major shift in the Overton window, reflecting years of activism by single-payer supporters as well as a historic intra-party shift.

Today, in primary contests across the country, progressive Medicare-for-All proponents are ousting more centrist and establishment candidates – Alexandria Ocasio-Cortez’s surprise primary win in New York’s 14th congressional district being the most popular example. At the same time, public support has soared: a recent Reuters poll found that 70.1% want Medicare for All, including 84.5% of Democrats. One might even argue that for people who want a job as a Democratic politician, in other words, supporting single-payer is nearly becoming a prerequisite.

None of this is to say, however, that enacting it legislatively – even with a new government in power – will be easy. We have, after all, been down this road before.

A concept older than Medicare

As some have noted, Obama wasn’t quite right to call Medicare for All a “new” idea: on the contrary, Medicare for All is a concept older than Medicare itself. Medicare came about after the defeat of single-payer – then called “national health insurance”– during the Truman administration. The campaign against it was led by the American Medical Association (AMA), which famously did it in with the help of a cutting-edge public relations firm that waged an unremitting campaign of cutthroat red baiting (drug firms also lent support).

But something similar is brewing today. As the Hill reported last month, a new anti-single-payer group has recently formed – drawing together the lobbying muscle of both insurance companies and big pharma – and it’s spoiling for a fight. Single-payer poses an existential threat to insurers, after all, and the industry’s coming PR blitz could make the famed “Harry and Louise” TV ad campaign of the 1990s – credited with helping sink Bill Clinton’s healthcare reform –look like an undergraduate’s mediocre final project for a marketing course.

This is a major obstacle, but a surmountable one: all great reforms in history, including Medicare itself, had to overcome powerful opponents. Yet a second potential pitfall lies ahead: despite all that has happened, politicians could still walk away from single-payer – probably by watering “improved Medicare for All” down into something unrecognizable. And again, something similar has happened before.

After the AMA’s defeat of national health insurance, its architects narrowed their proposal to cover just seniors; this became known as “Medicare.” However, the idea was that the Medicare approach could later be used to cover everyone. A push was made to realize this universal vision within a few years of the implementation of the program, and indeed, had things happened somewhat differently, some sort of national health insurance legislation could have been achieved in the 1970s.

Ultimately, however, the movement disintegrated – in large part the consequence of a historic rightward political turn that culminated in the election of Ronald Reagan. Fatefully, this was also the moment when the Democratic party abandoned national health insurance, instead embracing a private-insurance based alternative built on Richard Nixon’s reform proposal, which the ethically compromised Republican president had offered as a counter to single-payer.

Brick-by-brick, the campaign for national health insurance was rebuilt. In the late 1980s, for instance, the organization I serve – Physicians for a National Health Program – was formed, and its proposal for what was newly called “single-payer” became the blueprint for HR 676, the Improved and Expanded Medicare for All Act that was first introduced in Congress in 2003. That year, it had only 38 co-sponsors, but today HR 676 is supported by an unprecedented 123 lawmakers, or some two-thirds of the Democratic caucus. Meanwhile, Bernie Sanders’ companion bill in the Senate, the Medicare for All Act of 2017, has achieved 16 co-sponsors (his previous bills had zero).

The future of single-payer

The danger, however, is that even with the prospects of these bills on the rise, Democrats could turn away from the essence of the vision. Already, some are aiming to mutate Medicare for All into something vastly inferior – for instance, into an expansive “public option”-type program that would retain a major role for private insurers (e.g. the Center for American Progress’s confusingly labelled “Medicare Extra-for-All”). But to achieve real universal healthcare, Democrats can’t afford to repeat the mistakes of the past and flee to a private-insurance based reform a second time around. Medicare for All must remain what it is today – how it is detailed in a bill like HR 676 – if it is to mean anything at all: fully public national health insurance providing comprehensive, universal coverage to the entire nation.

Wilbur Cohen, a chief architect of both Truman-era national health insurance and Medicare, recognized this when he asserted that private insurance companies should have no role in a Medicare for All system, although it was not yet called that. “[O]nce the Federal Government decides that everybody is going to be insured,” he put it in 1977, “there is no need for a private insurance company to go out and sell coverage…using private insurance agencies to achieve the public responsibility seems to me to be wasteful and unnecessary, imposing an additional cost…without any essential advantage.”

His point is even more salient today: private insurance companies add only fragmentation and cost, something we can’t afford as we work to provide everyone in the nation with comprehensive first-dollar coverage.

For the first time in a generation, the realization of a right to healthcare – through implementation of a single-payer system – is on the horizon. But achieving it requires not repeating the mistakes of history. It means somehow countering a staggeringly rich corporate opposition while at the same time preserving the essence and the details of the vision – one which, by necessity, leaves no room for the waste and avarice of the private insurance industry. It is a formidable task, but one that has never seemed so winnable.

Dr. Adam Gaffney is an instructor in medicine at Harvard Medical School. He is secretary of the advocacy organization Physicians for a National Health Program.

https://www.theguardian.com…

A cost-effective alternative for U.S. health care

By Ken Lefkowitz
Courier Post (Cherry Hill, N.J.), September 15, 2018

If someone paid $1,000 for a service they could purchase elsewhere for $512, you’d think they were quite foolish. Yet, that’s the situation facing healthcare in America today.

Our current system for financing healthcare has been ineffective in controlling costs or providing the highest-level quality care. In 2016, the U.S. spent 17.2% of its GDP on a system that still leaves tens of millions of Americans uninsured or underinsured. In contrast, Canada spent 10.6% of GDP for universal coverage while the United Kingdom spent 9.7%. The nations of the European Union spent an average 8.8% of their GDP on healthcare1 (i.e. $512 for every $1,000 spent here). Despite the high cost, the U.S. ranked only 5th of 11 wealthy nations in quality.

American healthcare is financed through a free market. But free markets require transparency, so that buyers can compare the price and quality of competing products. Healthcare simply doesn’t lend itself to these comparisons. The dizzying complexity of both medical care and insurance plan design precludes the consumer from making informed choices. The average person cannot be expected to have knowledge of illness or treatment options, and primary care physicians strongly influence or dictate choice.

For example, you might select an insurance plan as an individual, or one offered by your employer, because it has a low price and includes your doctor in its network. This feels like an informed choice. However, when you become ill and require surgery, your doctor (probably not you) selects the hospital you go to. Much to your surprise, the anesthesiologist and radiologist are not “in-network” and, as a result, you incur huge bills. Transparency did not exist beyond choosing your plan and primary doctor. This is but one example of many in our complex system.

While the Affordable Care Act introduced many needed reforms, it too relies on market forces to control costs.

There is an alternative worth considering. A single-payer system can deliver both cost-effective and high-quality care.

One model of a single-payer system, H.R. 676, the Expanded and Improved Medicare for All Act, if enacted, would fund all necessary care including dental, vision and prescriptions, with no co-pays or deductibles. Patients are free to choose any doctor or hospital since the delivery of care continues to remain in private hands. A study by Professor Gerald Friedman of the University of Massachusetts estimates H.R. 676 could cover everyone in the U.S. while yielding $592 billion in gross savings annually. These savings are mostly achieved by eliminating the duplicative administrative and marketing costs of our profit-based insurance industry, and allowing for the negotiation of medical services and pharmaceuticals on a national level.

Single-payer systems can provide additional savings by emphasizing evidence-based medicine, preventive care and improved health outcomes, vs. our current method of fee-for service. Additionally, single-payer will reduce the high cost of care for those uninsured citizens using hospital emergency rooms for their healthcare. Focus on quality of care, and early disease intervention resulting from eliminating co-pays and deductibles, can lower costs even further.

Research I have spearheaded demonstrates that a single-payer system would be a boon to businesses by reducing absenteeism and increasing labor productivity gained through a healthier workforce, all while lifting employers’ burden of providing healthcare, allowing them to be more competitive in today’s global economy.

According to the Pew Research Center, 60% of Americans currently believe the government should be responsible for ensuring health coverage. And the government is already heavily involved in financing healthcare. In fact, a 2016 study found taxpayers fund 63% of U.S. healthcare through Medicare, Medicaid, Veterans Affairs, government employee benefits, and tax subsidies for employer plans.

Our current system has failed us. Americans need to understand the evidence for more cost-effective financing of healthcare and further support a single-payer program like Medicare for all.

Ken Lefkowitz is a former senior director of benefits and compensation for several major corporations. He is a member of the Physicians for a National Health Program and the New Jersey Universal Healthcare Coalition.

https://www.courierpostonline.com…

The support for Medicare for all is solid

The Nation’s Pulse: Year Four

Texas Medical Center Health Policy Institute
Survey completed June-July 2018 (4,020 national participants)

Support for Medicare for All U.S. Adults

Q: Are you in favor of the federal government providing Medicare insurance coverage for all U.S. adults?

59% – All
71% – Democrats
46% – Republicans
55% – Independent

http://www.tmc.edu…

***

Comment:

By Don McCanne, M.D.

Although this question asks about providing Medicare insurance coverage for all U.S. adults without mentioning children, nevertheless it still shows strong support for Medicare for all, including close to one-half of Republicans.

Efforts are being made to discredit these surveys by tacking on questions such as “even if it means the government raising your taxes,” or “even if it means losing your choice of health plans,” or “even if it means they take away your insurance through your work.” Inevitably these questions slightly reduce polling support for Medicare for all.

Polls that we don’t see are those that would tack on questions that would increase the credibility of the Medicare for all model. Instead of threatening an increase in taxes, suppose they were asked, “even if it meant that all but the very wealthiest would end up paying on average less overall for health care.” Instead of threatening loss of choice of health plans, suppose they were asked “even if it meant that you would no longer be limited to a list of physicians and hospitals dictated by the insurer but rather you had complete free choice of your health care professionals and institutions.” Instead of threatening loss of your health plan through work, suppose they were asked, “even if it meant that you would never have to worry about health insurance again because you would automatically have full comprehensive coverage for life.”

Obviously we could go further. “Even if Medicare for all meant that we would save hundreds of billions of dollars in administrative waste.” “Even if Medicare for all meant that nobody would ever have to go without care because they couldn’t afford it.” “Even if it meant that wherever you are in the country, you would never have to worry whether your insurance is good.” “Even if it meant that you would never have to busy yourself with insurance paperwork because coverage and billing is automatic.” “Even if it meant that you would not have to worry about whether you could afford the care you are about to receive since out-of-pocket costs would be eliminated for all essential health care services.”

Well, the good news is that people are gaining a better understanding of the benefits of the Medicare for all single payer model. Republican voters are realizing that the Republican promise of a better replacement for Obamacare proved to be false, and yet they understand that we need more than what the Affordable Care Act brought us. Democratic voters largely understand the benefits of single payer, but they are just beginning to realize that some Democratic politicians are using the Medicare for all rhetoric deceptively to maintain the status quo that caters to the insurers and pharmaceutical firms. It is no wonder that we are seeing an increase in independent voters who are wary of both major parties but who also seem to understand that Medicare for all seems to be a much better option than our current dysfunctional system.

We need to keep on with what we’re doing, except do a whole lot more of it. Maybe those of us who are octogenarians will no longer have to say, “but not in my lifetime.”

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The coverage of the uninsured has plateaued

Health Insurance Coverage in the United States: 2017

By Edward R. Berchick, Emily Hood, and Jessica C. Barnett
United States Census Bureau, Current Population Survey Annual Social and Economic Supplement (CPS ASEC), September 2018

In 2017, 8.8 percent of people, or 28.5 million, did not have health insurance at any point during the year. The uninsured rate and number of uninsured in 2017 were not statistically different from 2016 (8.8 percent or 28.1 million).

https://www.census.gov…

***

Comment:

By Don McCanne, M.D.

This definitive report on the health insurance status of U.S. residents provides an extensive breakdown of the statistics on insurance coverage, but the one highlight above pretty well summarizes the status. There was no statistically significant change in the numbers of uninsured between 2016 and 2017.

Although the reported change from 28.1 million to 28.5 million uninsured may not be statistically significant, there are likely 400,000 people out there who personally believe it is significant for themselves even if the statistical analysis is dismissive of it. At any rate, there are still over 28 million people who can’t be pleased with their lack of insurance coverage.

The major lesson in this report is that the gain from the Affordable Care Act has appeared to plateau, although the numbers may not have fully stabilized yet, largely because of the policies being adopted by the Trump administration and the various state governments. But it is safe to say that complete elimination of uninsurance is not imminent and cannot possibly occur without a major policy change.

One of the least promising policy changes would be a Medicare public option, or Medicare buy-in, which some have mislabeled as Medicare for All. It would provide only one more option in the market of plans that already exists and thus would have very little impact on overall coverage or affordability since the other options are already available.

Of course, the most promising policy change under consideration that would be fully effective would be a single payer national health program – a bona fide Improved Medicare for All.

It has now been a decade since we started down the path of Obamacare. Regarding the goals of universality, equity, affordability, administrative efficiency, and guaranteed lifetime coverage, it is clear that the Affordable Care Act has been a failure. Rather than merely adding a Medicare Advantage-like public option to our expensive but mediocre system, we should finally provide the fix our system truly needs – an Improved Medicare for All. Just make sure it’s the real thing.

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

Where do we stand now with health care?

By George Bohmfalk, M.D.
The Aspen (Colo.) Times, September 13, 2018
(Part 2 of 6. Read parts 1, 3, 4, 5 and 6.)

In this series of weekly articles, I will describe the current status of health care in America and how we might improve it. Inasmuch as most people younger than 65 have no great need to understand what Medicare is, and as Medicare may be a good model on which to build a universal system, I’ll briefly explain a bit about it.

Medicare began over 50 years ago, in response to poor medical care and high poverty rates among our seniors. It has succeeded in alleviating both of these crises and continues to be a very popular and efficient health insurance program. Medicare is a universal, single-payer system, meaning that it covers everyone in the designated group, and that payments for medical care are all made via a single source — the federal government. Funding comes from both taxes and premiums. In striking contrast to some European-style socialized systems, medical care under Medicare is privately delivered, at private hospitals by doctors in private practice. Every Traditional Medicare enrollee has free choice of doctors and hospitals.

Notwithstanding its many successes, Medicare is not a perfect system. Its most glaring deficiency is that it pays only 80 percent of charges, leaving the enrollee to pay the remainder, either out-of-pocket or through Medigap plans sold by for-profit private insurers. While seemingly small, this 20 percent difference, along with deductibles and copayments, can become an insurmountable financial burden in complex cases. Seniors are filing bankruptcy because of medical debt.

Another major deficiency when Medicare began was that it did not cover prescription drugs. As medicines became unaffordable to many seniors, Congress attempted to remedy this in 2003 by adding Medicare Part D, the prescription drug program, available for an added premium. Unfortunately, the pharmaceutical lobby arranged for a provision to be included in the law that forbids Medicare from negotiating drug prices. As a result, we in the world’s largest pharmaceutical market pay the world’s highest prescription drug prices. Productive young people are dying because they can’t afford insulin, once one of the least expensive and most life-saving prescription drugs.

Traditional Medicare still does not cover dental, hearing or vision care, aspects which can have large impacts on our overall health. I once operated on a man whose tooth infection spread to his brain. Dental problems contribute to arterial disease, and poor hearing and eyesight lead to higher injury rates and accelerated mental deterioration. These and other deficiencies can be readily corrected in a national Improved Medicare for All program.

Where do we stand now overall? Unfortunately, we don’t have the best health care system in the world. We do have many great doctors and hospitals, but we pay about twice per person what most other industrialized countries pay for their excellent health care. Yet nearly 30 million of us remain uninsured and 40 million underinsured. You may know someone, or find yourself, among the underinsured. These are folks who believe they have good insurance, often through their employer, but when a health issue arises, the high deductibles and copayments are daunting. If you’re underinsured, you may be forced to choose among wiping out your life savings to pay for care, filing for bankruptcy when the bills come in, or delaying or declining needed care, if that’s possible.

Even people with good insurance are often surprised by its deficiencies and disruptions. In order to maximize their profits, insurers seek discounts from doctors and hospitals and form provider networks of those low-bid participants. These narrow networks become very inconvenient when you are covered only at a remote hospital or forced to change doctors. There are dozens of stories of people being stuck with $25,000 to $60,000 bills from air ambulance companies that were not in their insurance networks. How were they to know that beforehand? Health insurance isn’t what it used to be, and it’s getting worse.

You might think that paying such high prices gets us good results, but it doesn’t. Reports by the OECD (Organisation for Economic Co-operation and Development) show that we rank below most industrialized nations in many health outcomes, including life expectancy. Our maternal and infant mortality rates are among the highest. We pay the most, and get the least for it.

In subsequent articles, we’ll see where all our money is going and how it might be redirected to improve our nation’s health. The short answer is by expanding Medicare to cover everyone, and improving it to remove the deficiencies described above.

Spoiler alert: In the end, we’ll spend less overall. It’s a mind-boggling thing.

Dr. George Bohmfalk practiced neurosurgery in Texas before retiring to spend half of each year in the Roaring Fork Valley. He is active in Physicians for a National Health Program, a physician-driven group advocating for a single-payer health care system.

https://www.aspentimes.com…

How can we afford not to adopt single payer?

By Thomas Gates, M.D.
Lancaster News (Penn.), September 13, 2018

The Sept. 10 letter “How can we afford ‘Medicare for all’?” asks the wrong question. The real question is, “How can we continue to afford our current fragmented and wasteful health care system?”

U.S. health care expenditures in 2016 were $3.3 trillion — $10,348 per capita — or 17.9 percent of gross domestic product, a far higher percentage of our income than any other country. A former administrator of the Centers for Medicare and Medicaid Services estimated that up to 30 percent of U.S. health expenditures are waste, largely driven by high administrative costs of for-profit insurance companies. Total overhead for private insurance is 16.8 percent, more than four times that of Medicare and Medicaid. Our current system leaves 12.9 percent of Americans uninsured, while the insured are stuck with ever-increasing premiums, co-pays and deductibles.

The letter cites a study that puts the “Medicare for all” cost at $2.5 trillion, versus our current cost of $3.3 trillion (over half of which is already government funded). That’s $800 billion in savings: How can we afford not to adopt single payer? Yes, it would mean new taxes, but by eliminating insurance premiums, deductibles, co-pays and most out-of-pocket expenses, 95 percent of Americans would end up saving money.

Our expensive health care system makes individuals and society poorer. Single payer would be far more equitable and far less expensive. What are we waiting for?

Dr. Thomas Gates resides in Manheim Township.

https://lancasteronline.com…

Without pharmaceutical price regulation, gouging is to be expected

Pharma chief defends 400% drug price rise as a ‘moral requirement’

By David Crow
Financial Times, September 11, 2018

A pharma executive has defended his decision to raise the price of an antibiotic mixture to more than $2,000 a bottle, arguing there was a “moral requirement to sell the product at the highest price.”

Last month, Nostrum Laboratories, a small Missouri-based drugmaker, more than quadrupled the price of a bottle of nitrofurantoin from $474.75 to $2,392, according to Elsevier’s Gold Standard drug database.

Nitrofurantoin is an antibiotic used to treat bladder infections that was first marketed in 1953, which appears on the World Health Organization’s list of essential medicines.

In an interview, Nirmal Mulye, Nostrum chief executive, said he had priced the product according to market dynamics, adding: “I think it is a moral requirement to make money when you can…to sell the product for the highest price.”

Mr. Mulye said Nostrum was responding to a price rise from Casper Pharma, which makes a branded version of the product known as Furadantin. Casper increased the price of its product by 182 per cent between the end of 2015 and March 2018, taking a bottle to $2,800, according to the Elsevier database.

He also defended the actions of Martin Shkreli, who became infamous in 2015 for his decision to raise the price of an Aids and cancer drug from $13.50 to $750 per tablet. Shkreli was jailed earlier this year on unrelated fraud charges.

“I agree with Martin Shkreli that when he raised the price of his drug he was within his rights because he had to reward his shareholders,” said Mr. Mulye.

Mr. Mulye pointed out that Shkreli was able to increase the price of Daraprim so dramatically because his company was the only one making it.

“If he’s the only one selling it then he can make as much money as he can,” said Mr. Mulye. “This is a capitalist economy and if you can’t make money you can’t stay in business.”

In a tweet responding to Mr. Mulye’s comments, Scott Gottlieb, FDA commissioner, said, “There’s no moral imperative to price gouge and take advantage of patients. FDA will continue to promote competition so speculators and those with no regard to public health consequences can’t take advantage of patients who need medicine.”

https://www.ft.com…

***

Comment:

By Don McCanne, M.D.

Appalling drug price gouging will continue until our government fulfills its responsibility to protect the consumer, that is, the patient. FDA Commissioner Scott Gottlieb represents the view of current and previous administrations when he says that we need to promote competition, as if the market will take care of it.

But that’s not the way markets really work. The 400 percent price increase of this generic nitrofurantoin was to bring the price closer to the competition – the branded version, Furadantin. Nostrum chief executive Nirmal Mulye explains to us the way markets really work, “I think it is a moral requirement to make money when you can…to sell the product for the highest price.” A moral requirement, he says.

Maybe we should begin discussions of nationalizing the pharmaceutical industry. That might make them nervous enough that they would finally agree to regulation of prices as is done in other civilized nations. Whether they agree or not, we need to do it.

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

Inequities of social spending

The Government-Citizen Disconnect

By Suzanne Mettler
Russell Sage Foundation

From Chapter 1 – A Time of Contradiction

Over the past four decades, Americans’ relationship to the federal government has evolved in a deeply paradoxical manner. As a society, we appear to regard government with ever greater disdain, as evidenced by popular discourse, numerous polls, and election results. Yet people depend on the federal government more than ever to help them attain economic security, health care and educational opportunity.

Yet over these very same decades, Americans have increasingly counted on the federal government’s assistance in their personal lives. Nationwide, the share of the average citizen’s income that flows from federal social “transfers” – including Social Security, food stamps, the Earned Income Tax Credit (EITC), and more than forty other programs – increased from 7 percent in 1969 to 17 percent in 2014. On a per capita basis, the rate grew fairly steadily over time, escalated more quickly with the onset of the 2008 financial downturn, and then declined somewhat more recently. The amount received by the average person increased from $1,853 in 1969 to $7,729 in 2014, in 2014 dollars.

These figures do not include the most generous social benefits, which are either channeled through the tax code, such as home mortgage interest deduction, or provided in tandem with private organizations, such as tax-subsidized, employer-provided health and retirement benefits. These policies serve the same function as social benefits delivered as direct payments or services – such as helping families to afford health care, housing, or education – but in permitting beneficiaries simply to pay less in taxes, they differ in design. If we consider only public social spending or government transfers, the U.S. welfare state is smaller as a percentage of GDP than that of other affluent nations, ranking twenty-fourth worldwide, but if we account also for the social expenditures channeled through the tax code and tax-subsidized payments from employers, the United States has the second largest welfare state in the world after France.

From Chapter 3 – We Are All Beneficiaries

Sheila Turner, who was born in 1973, is a self-described “stay-at-home-mom” who lives in Dallas, Texas, in a middle-income household. She considers herself to be extremely conservative on politics and identifies with the Republican Party. When asked what she thinks of when she hears the term “government social programs,” she says, “Giving money to those who don’t want to work.” Her views of such programs are “mostly negative,” she reports, because they provide support for “people who don’t prioritize their budgets and pay for their (own) bills.” She believes that “government does a poor job of managing things,” and that “people should provide for themselves.”

Yet Turner readily acknowledges that her family has used several specific policies. Her daughter used financial aid to attend college, both Pell Grants and student loans. Her husband used Unemployment Insurance for several months while unemployed, about which she comments, “Every little bit helps when you have no income.” She and her family have also utilized several features of the tax code, including the EITC, the home mortgage interest deduction, and the tax-free status of employer-provided health and retirement benefits. She does not view these tax expenditures as government social benefits, but rather as incentives for making certain decisions, explaining, “They give people a reward for using their money the right way”

American rhetoric about government benefits implies that we are a deeply divided nation of “us” and “them,” the deserving and the undeserving. Yet the evidence tells a different story. When we consider individual Americans across different incomes, parties, and ages, nearly all have used social benefits, and although usage patterns vary, particularly with respect to policy types, the commonalities loom larger than the differences. Similarly, when we consider Americans with respect to the communities across the country where they live, whether rich or poor, they are far more likely to use more such benefits today than Americans did thirty-five years ago. We nearly all benefit from the federal government’s social policies, and we nearly all contribute to those policies. whether through payroll taxes, income taxes, or both.

Percentage of Americans Who Report Having Ever Used Specific Social Policies:

55.3 – Employer-provided retirement (current only)
49.9 – Employer-provided health care (current only)
45.6 – Home mortgage interest deduction
38.5 – Unemployment insurance
34.4 – Earned Income Tax Credit
27.4 – Student loans
25.7 – Child and Dependent Care Tax Credit
25.4 – Food stamps
22.2 – Medicare
17.5 – Medicaid
16.0 – Pell Grants
15.8 – Social Security – retirement and survivors’
13.9 – Welfare/public assistance
10.0 – Hope or Lifetime Learning Tax Credit
9.7 – Social Security Disability Insurance
8.7 – Government-subsidized housing
8.1 – Supplemental Security Income
8.0 – Head Start
5.9 – GI Bill
5.1 – 529 plan or Coverdell Education Savings Account
4.6 – Veterans’ benefits (other than GI Bill)

From Chapter 4 – Different Lenses

In sum, when Americans think about government, only in some instances does their memory of the social policies they have benefited from hover at the top of their minds. As a result, the strong antigovernment attitudes that prevail in the United States today can be found even among many people who themselves have benefited a great deal from social policies. These views may attract Americans to candidates and organizations that articulate such views, even if they hold positions that threaten the very policies from which individuals have benefited.

From Chapter 5 – Unequal Voice

How is it that the nation has shifted to electing more officials who want to undermine social policies at the very same time as citizens depend on them more than before? The answer is in part for reasons we saw in chapter 4, that many Americans use benefits that make government’s role less than apparent, and that when they evaluate government, other considerations and affiliations loom more heavily in their minds than their social policy experiences. But it is also a matter of who shows up to participate in political activity. Those who have benefited from more visible government programs are both more aware of the role that government has played in their lives and more supportive of social spending. Yet they tend to participate less than other Americans, for reasons related to their socioeconomic status and also because candidates, parties, and groups do less to mobilize them and involve them. As a result, their voices are less likely to be heard in the political process, which meanwhile overrepresents those who are less aware that government has made a difference for them. The American polity is skewed by a participatory tilt that exaggerates the views of those who remain incognizant of government’s role in their lives and drowns out those of others. But it does not have to be this way.

From Chapter 6 – Reconnecting Citizens and Government

Although the United States has nevertheless increased the extent to which it provides economic security and educational opportunity to citizens, many Americans who are beneficiaries of these policies do not perceive government to be responsive to them. This conundrum amounts to a government-citizen disconnect.

Policy designs do not speak for themselves in communicating the value of government. Even if appealing internet tools and other procedures help citizens make sense of how government has helped them and their families over time, the impact on assessments of government may still be minimal. In our highly polarized polity, where organizational linkages that connect citizens and government have frayed and some groups beat the antigovernment drum, more is needed. Organizations that seek to strengthen democracy must step up to play these roles, making connections for citizens and drawing them into politics when the fate of policies is at stake. They can do so effectively by developing activists, including individuals from communities that are usually excluded from civic engagement. In the process, they can help people see how government matters in their lives – through social policies like those examined here as well as through others – and spur their involvement in the political process.

As Americans face the future, far more unites us than divides us. We are not a nation of moochers and takers. Rather, we are a political community, one built on respect for the ideas that all are created equal and that “we the people’ can govern ourselves. We can advance by honoring our reciprocal obligations to each other through the bonds of citizenship. By reaffirming that quest, we can carry on together, as citizens of a democracy.

Suzanne Mettler is Clinton Rossiter Professor of American Institutions in the Government Department at Cornell University.

http://www.russellsage.org…

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Comment:

By Don McCanne, M.D.

Because much of our social spending is not transparent, most people do not realize just how much they benefit from these government social policies. Those who benefit the most, especially though tax expenditures (tax deductibility of retirement plans, health plans, home mortgage interest, etc.), frequently do not consider the government’s largess accruing to their benefit as a government social program, yet they are resentful when others of lesser means receive more visible support to meet basic needs such as food stamps, unemployment benefits, public assistance, or Medicaid.

Yet the opaque social benefits the wealthy receive to help pay for their large mortgages, generous retirement plans or executive health benefit programs are frequently much more than the person with the food stamps at the super market checkout stand is receiving. Further, there is a prevailing attitude that somehow the person working at a job with poverty-level wages is not deserving of a government handout, whereas the very wealthy individual has somehow earned, as a reward, much greater benefits through tax expenditures, which is still a government handout, but for the rich.

It seems that we could inject a much greater dose of fairness into our social spending programs, and this is where health care financing enters the scene. Everyone should have health care, and they could if we used progressive tax policies to fund an equitable universal system such as an improved Medicare that covered everyone. If the system already existed, the rich would not be resentful of poor people getting the health care that they need. At least the rich don’t seem to be so in other nations that have equitable, universal systems.

We really could have the same here, but we’re going to have to acknowledge that we must change our attitude that low-income workers are not deserving of support for basic needs while the rich are entitled to tax expenditures to support their more extravagant lifestyles.

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Medicare for All and the Myth of the 40% Physician Pay Cut

A single payer system works by cutting administrative waste, not doctors' income

By Carol Paris, M.D.
Common Dreams, September 11, 2018

The surge in support for improved Medicare for All—now up to 70% in recent polling—has single-payer opponents ramping up their scare tactics. The Koch-funded Mercatus Center recently claimed that Medicare for all could only work with painful sacrifices from doctors, specifically by paying us Medicare’s current reimbursement rates, which are about 40% lower than private insurance.

If single payer would cost doctors so much, why do a majority of us now prefer it? I invite supporters of the status quo to spend a week at a typical doctor’s office to understand the out-of-control costs of practicing medicine in our current system.

Let’s look at how doctors actually get paid. Most of us accept a mix of Medicare, Medicaid, and private insurance, which pay mostly on a fee-for-service basis: a certain amount for each exam, scan, or procedure. While rates differ from state to state, private insurance usually pays the most, Medicaid usually pays the least, and Medicare is somewhere in between (and for those patients with no insurance, it’s anybody’s guess).

But don’t assume physicians prefer dealing with private insurers just because they pay more. Private insurers make their money by paying out less in claims than they collect in premiums, and make us jump through bureaucratic hoops to secure payment. Basic tests and treatments must be cleared in advance with insurers or they won’t be covered. Claims are routinely denied. If you’ve ever spent hours on the phone haggling with your insurance company, then you’ve had a small taste of what it’s like to practice medicine today.

Since for-profit insurers ultimately decide what will be covered, it’s like having a third party in the exam room second-guessing our medical decisions. This process disrupts the doctor-patient relationship that we work so hard to build. And copays and coinsurance (what patients pay out-of-pocket) mean that even smaller practices must employ several full-time staff just to handle payments, billing, and collections.

Smaller practices spend an average of $83,000 per year on claims, coverage and billing. Doctors personally spend nine hours each week on billing and admin; that’s time we’re not seeing patients. It’s no surprise that doctors today report unprecedented levels of exhaustion and burnout.

Then there’s the issue of malpractice insurance, which takes a big bite out of doctors’ income. Future medical costs are a large part of malpractice settlements, but are removed from the settlement equation under Medicare for All. Lower potential settlements means lower premiums for doctors.

Dealing with one single payer—Medicare—would mean drastically fewer hours of uncompensated administrative time, fewer office staff, and lower overhead. It’s a tremendous amount of time and money that Mercatus fails to include in their analysis.

In reality, relatively few doctors work in private practice anymore. Due to rampant industry consolidation, most providers actually work on salary for larger health systems or hospitals. Under our current multi-payer system, billing and administration account for one-quarter of U.S. hospital expenditures, twice the level in single-payer nations. Medicare for All would simplify hospital payments by funding them through global budgets (similar to the way fire departments are paid), rather than the current patient-by-patient payments, saving billions more in administrative costs.

At the national level, single payer would cut about $504 billion annually in administrative costs. In other words, single payer works by cutting administrative waste and corporate profits, not doctor incomes.

Overall, we estimate that average physician incomes would remain unchanged under Medicare for All. Some doctors, such as family physicians and pediatricians, might see a pay increase while others, such as highly-paid specialists, might see a slight pay cut. But “painful sacrifices” would not be required.

Single-payer opponents will try to pit doctors against patients by claiming that universal coverage only works by cutting doctor incomes. That’s a false choice. The only winners in the current system are the insurance companies who profit by keeping more of our nation’s health care dollars for themselves. By moving to a single-payer program, doctors can finally get back to our calling: caring for patients.

Dr. Carol Paris is a psychiatrist and president of Physicians for a National Health Program.

https://www.commondreams.org…

Ask Medicaid-eligible individuals what a work requirement would do

Medicaid Recipients’ Early Experience With the Arkansas Medicaid Work Requirement

By Jessica Greene
Health Affairs Blog, September 5, 2018

In June, Arkansas became the first state to implement a work requirement in its Medicaid program.

Little is known to date about how those impacted by the new Medicaid work requirement feel about the policy. To explore Medicaid recipients’ attitudes about Arkansas’ work requirement and their early experiences with the policy, in mid-August I conducted in-depth interviews with 18 adult Medicaid recipients in northeast Arkansas.

While this group is far too small to provide generalizable results, the interviews do illustrate how the state’s policy is interacting with the day-to-day lives of Medicaid recipients to produce serious potential consequences that have little to do with policy’s stated objectives.

Lack Of Awareness

Two thirds of the Medicaid recipients (12/18) I interviewed had not heard anything about the new work requirement. “First time I’ve ever heard anything [about it],” a 31-year old man, who had started a vocational training program the day we spoke, said. “You’d think it’d be on the news or something. I ain’t seen it on the news, and I watch Channel 8 news every night.”

At Risk Of Losing Coverage

Of the nine people who, based on their age, should have received a DHS letter letting them know they were subject to the work requirement, four said they had received a letter. Two said the letters indicated they were exempt because they already met the SNAP work requirement.

The other two were at risk for losing Medicaid coverage. One, a 47-year old woman, said she had received her letter about three months earlier; she believed, incorrectly, that she had three months to report her hours. When I asked her if reporting her hours was an obstacle, she said she was struggling with very stressful life issues, including a mentally ill sister, and as a result the work requirement had not received much of her attention. The other person, a 40-year-old woman, described being overwhelmed by receiving the letter: “Basically… I’m like, okay, I’ve got this letter. I file it and I don’t know what to do with it…”

The other five who should have received a work requirement letter were either not sure if the letter arrived or thought it had not. When asked about receiving a DHS letter, a 42-year-old woman said, “I don’t know, I’m going to have to check and make sure [I didn’t receive the letter], because I need my Medicaid card for my sugar pill and my blood pressure pills.” A 46-year-old man, who had recently completed an inpatient drug treatment program, kicking a multi-decade drug addiction, wasn’t sure either. “I may have [received the letter]…I’m horrible about opening mail….I probably throw’d it away.” While the three others did not believe they received the letter, they were all exempt by either working and/or having children in the home, but likely needed to report their hours and exemptions in the portal to maintain Medicaid coverage.

Policy Not Sparking Work-Related Changes

Of the nine participants who were likely subject to the policy, only two were not meeting the 80 hour work-related activity requirement and did not seem to qualify for an exemption. Both told me that they were actively seeking work, and that the work requirement had not at all impacted their job seeking. In addition, those I interviewed between the ages of 19-29, who will be subject to the policy in 2019, either worked, went to school, and/or had children under 18 years old in the home. No one I spoke with reported that the policy had or would spark them to change their work-related activities.

Online Portal Challenging For Many

Participants described a very wide range of computer and online skills and access. Approximately a third said that reporting hours on the online portal would not be possible for them: “I can’t do that. I don’t have a phone. I don’t have a computer.”

Several, who were confident of their own skills, mentioned family members who would struggle. “Half my family probably doesn’t have a smart phone….A lot of people here don’t have internet still,” a 19-year old woman explained.

Mixed Attitudes About Linking Medicaid And Work-Related Activities

Almost all the participants believed that people who could work should be working. “I believe if you are able to work and you want the extra help that Medicaid gives, then you should work,” said a 28-year old woman who was currently working and has young children. But several expressed concern about those who had mental or physical conditions that would prevent them from meeting the requirement. One man raised questions about people who were “borderline” who were not officially considered disabled but still had serious health conditions. A 42-year-old woman, who works with people with disabilities said, “I think it’ll do more harm than good…. What they supposed to do, just get cut off Medicaid because they can’t meet those requirements?”

Others raised concerns about transportation needed to get to work and volunteering. “Some people don’t have vehicles, and sometimes it’s not necessarily their fault. Sometimes something happens and they lose their money… It’s not fair,” said a 21-year old recipient who is a college student. When I asked a woman who was looking for work whether she had tried to get help from the Department of Workforce Services, she said that she couldn’t get there because it was 30 miles away and there is no public transportation.

Not Going To Lift People Out Of Poverty

Participants were very skeptical about the Governor’s claim that the work requirement policy would help them out of poverty, as many were already working and still struggling financially.

One participant argued that the policy was not about getting people to work at all, but about reducing the number of Medicaid recipients: “It seems like a ploy for the state to save money. That’s all it is. It’s nothing about trying to get people back to work…”

Summing Up

Of the people I interviewed who were at risk of losing Medicaid coverage as a result of the work requirement, most were at risk because they lacked awareness of the policy or were overwhelmed by it, rather than because they were not meeting the 80 hours a month of work-related activities or the terms of an exemption. If this is true more broadly, the state will be ending people’s health coverage for the wrong reasons, adding credence to those who argue this policy is about reducing the rolls, rather than supporting people to get employment.

A 38-year-old woman who recently had to quit her job to get her niece, who she mothers, a birth certificate and other paperwork to start school argued that the policy does not take into account the complex lives of low-income people. “You are saying this should be possible, but you don’t know my circumstances. You haven’t been here,” she explained.

Dr. Jessica Greene is a Professor and the Luciano Chair of Health Care Policy at Baruch College, City University of New York.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Sometimes you simply do not need extensive health policy research to understand what impact various policy proposals would have. As an example, to understand what a work requirement to qualify for Medicaid would mean for the low-income, target population, just ask them.

This brief series of interviews of Medicaid beneficiaries done by Professor Jessica Green provides enough anecdotes that are fully predictable. This relatively unsophisticated, low-income population is already struggling with just trying to make ends meet. Throwing in an employment reporting requirement just further complicates their personal agendas. Besides, none of them believe that the program will cause them to change their work-related activities.

The purpose of Medicaid is to provide access to medical care for individuals who cannot afford it. Does requiring work as a condition of Medicaid enrollment advance that goal? No, just the opposite. Under this requirement many will lose their Medicaid coverage and thus lose access to medical care.

Look. We’re trying to get people the health care that they need. We already understand the policy decisions that would do that. A well designed, single payer, improved Medicare for all would take care of it. We do not need the injection of screwball ideas based on sterile ideology rather than benevolent compassion.

As one interviewee said, “you don’t know my circumstances; you haven’t been here.” But we do know how to get her and everyone else the health care program that they need. That’s what we need to be working on.

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Additional Comment:

By Stephen Tarzynski, M.D.

Republican opposition to government-regulated medical care is partially based on the view that government governs best which governs least. Conservatives associate liberty with markets.

They may not realize it but they have more than a little in common, ideologically, with the early 17th century British statesmen who crafted the Elizabethan Poor Laws. These laws gave local governments the power to raise taxes to maintain almshouses and provide relief for the “worthy” poor, including the elderly. But they also mandated that the “able-bodied poor” be set to work in a House of Industry and sent the “idle poor” to Houses of Correction. In their twisted logic, poor people were only desperate because they were lazy or morally inferior to the wealthy.

GOP legislators echo these obsolete ideas when they talk about indigent “able-bodied adults” needing to work to deserve health insurance.

From my decades of experience as a doctor, it seems to me that no market-driven healthcare system can simultaneously limit costs, guarantee universal coverage and deliver desired outcomes. Overwhelming evidence demonstrates that the best way to reduce costs and guarantee healthcare to everyone is to have the largest risk pool — that is, the entire nation. These facts compel the United States to move to a single-payer system guided by comparisons with other countries’ experiences and by our own American successes, such as Medicare and Medicaid.

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Thanks, Obama?

Barack Obama thinks Medicare for All is a good idea. His support is welcome — but this time, we won’t accept any compromises on a universal, free public health program.

By Tim Higginbotham
Jacobin, September 10, 2018

For the first time in over a decade, Barack Obama is a Medicare for All supporter.

On September 7 in Illinois, Obama promoted the idea while campaigning for Democrats ahead of the 2018 midterm elections. “Democrats aren’t just running on good old ideas like a higher minimum wage,” he said, “they’re running on good new ideas like Medicare for All.” His is the biggest endorsement from the political center for the idea, and a sign that Democrats are beginning to yield to this overwhelmingly popular demand — a recent Reuters/Ipsos poll showed that 70 percent of Americans support the plan.

But Medicare for All supporters should be skeptical of Obama’s support. Centrists are engaged in an ongoing effort to reinterpret what M4A means, which could lead to a watered-down proposal that throws the possibility of achieving single-payer health care into jeopardy.

Back in 2003, Obama spoke glowingly of single-payer, arguing that the only reason it might not happen “immediately” was that first, the Democrats would have to take back the White House and Congress. By 2009, Obama’s stated prerequisite for single-payer had come true. He himself occupied the White House, while Democrats held majorities in both the House and Senate. But by that point, of course, Obama had long abandoned single payer.

In fact, his administration worked to deliberately marginalize the idea and instead rallied support for the Affordable Care Act’s market-centered approach. They even dropped the planned inclusion of a public option when Senator Joe Lieberman threatened to filibuster the ACA in protest.

Ultimately, the powerful Democratic majority passed only a weak, fragmented plan with high costs and uneven benefits. While the ACA helped many people by expanding Medicaid and adding protections for people with preexisting conditions, it failed to combat the true source of the United States’ health-care crisis: the privatized multi-payer system that allows giant for-profit health companies to profit from Americans’ illnesses. Unsurprisingly, after voters replaced Obama with Trump, the key accomplishments of the ACA came under immediate threat.

In the wake of the ACA’s failure to lower costs and achieve universal coverage, single-payer has become a popular, viable demand. It was the lead plank of Bernie Sanders’s 2016 presidential platform and a regular applause line at his mass rallies. Sanders has kept Medicare for All in the spotlight, hosting viral town halls and releasing dozens of social media videos highlighting the plan’s benefits.

Sanders’s message is clearly resonating. Polling shows that Medicare for All now maintains majority support. Progressive candidates have successfully used the demand as a key campaign plank. And grassroots activists have found success taking the message to the streets, with groups like National Nurses United and Democratic Socialists of America running nationwide canvassing campaigns to build on the plan’s popularity.

Yet despite Medicare for All’s overwhelming popular support, many Democratic politicians have been reluctant to sign on. Sanders has earned sixteen cosponsors for his Senate bill, while its companion legislation in the House has 123. That amounts to only 34 percent and 64 percent of Democrats in the Senate and House, respectively — far lower than the 85 percent of Democratic voters who support the plan nationwide, according to the Reuters/Ipsos poll.

But that level of mass demand can’t be ignored forever. It has now become a litmus test for candidates.

Democratic socialists Alexandria Ocasio-Cortez and Rashida Tlaib campaigned heavily on Medicare for All while making waves this summer with upset primary wins in their bids for House seats. Andrew Gillum supported it on his way to winning the Democratic primary in Florida’s gubernatorial race. And nearly all prospective 2020 Democratic presidential candidates have expressed support for the plan, including Kirsten Gillibrand, Cory Booker, Kamala Harris, and Elizabeth Warren. Democrats are finally recognizing that they need Medicare for All — not rhetoric about “fixing the ACA” — in order to win.

Obama’s 180-degree turn on Medicare for All could cement the Democratic establishment’s shift into the M4A camp. It’s now likely that the congressional bills will have strong legislative support should Congress change hands. At the same time, centrist Democrats have a history of grinding down progressive policies into complex, unpopular, market-friendly schemes.

In order for Sanders’s vision of single-payer health care to succeed, the public must remain uncompromising in its demand for a truly ambitious Medicare for All — one that guarantees comprehensive care to every American resident as a single, public program and ensures a just transition that provides severance and jobs training to all workers whose jobs are impacted. Liberal think tanks and pundits are attempting to capitalize on Medicare for All’s popularity by watering it down, arguing that its meaning is ambiguous and could refer to something as meager as a Medicare buy-in — essentially a “public option” plan that would preserve the multi-payer system while allowing people to purchase Medicare coverage.

Given his record, it’s reasonable to expect that Obama will join this effort to co-opt Medicare for All and kowtow to the private insurance industry, the pharmaceutical lobby, and the American Medical Association, which have spent the last century using their power and influence to squash every effort to win a national insurance system. Democrats haven’t confronted this power in the past and, as shown in 2009, can’t be expected to do so even if they manage to take back Congress.

It’s going to take an unshakeable mass movement to win a system that actually provides health care as a right. That means no financial barriers to care — no copays, no deductibles, and no premiums. It means abolishing the private insurance industry once and for all. It means universal care with equal treatment for everyone — not means-tested coverage with a higher standard of care for the rich. It means a single, simple, and bold public program — not a public option that will leave millions underinsured and keep insurance profiteers intact.

Obama’s endorsement is a sign that the demand for Medicare for All is overwhelming. It will hopefully bring much-needed legislative support to the congressional single-payer bills. But Americans cannot allow the people who bungled the Affordable Care Act to undermine this fight, too. Medicare for All means nothing less than a universal, single-payer program that provides comprehensive care, free at the point of delivery. Obama’s support is welcome. But this time, we won’t accept any compromises.

Tim Higginbotham is an organizer with the Democratic Socialists of America’s Medicare for All campaign.

https://www.jacobinmag.com…