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Analysis of Work Requirement Exemptions and Medicaid Spending

Analysis of Work Requirement Exemptions and Medicaid Spending

By Anna L. Goldman, M.D., M.P.H.1,2; Steffie Woolhandler, M.D., M.P.H.3,4; David U. Himmelstein, M.D.3,4; David H. Bor, M.D.1,3; Danny McCormick, M.D., M.P.H.1,3
JAMA Internal Medicine, Research Letter, September 10, 2018

To date, 4 states (Arkansas, Indiana, Kentucky, and New Hampshire) have federal waivers to impose work requirements as a condition of eligibility for Medicaid (although a judge recently stayed Kentucky’s waiver1), and 7 other states (Arizona, Kansas, Maine, Mississippi, Ohio, Utah, and Wisconsin) have submitted waiver applications. The governor of Kentucky2 claimed that excluding “able-bodied” adults will reduce Medicaid enrollment by 16%, ensuring the program’s “fiscal sustainability.” However, such claims may be overstated because many Medicaid enrollees already work, and waivers have specified that many others (eg, people with disabilities and caregivers of young children) will be exempted. To our knowledge, no studies have quantified the potential influence of work requirements on Medicaid spending. We estimated the number of Medicaid enrollees at risk of losing coverage if work requirements are implemented with the exemptions specified in approved waiver applications, and we calculated current Medicaid spending for those enrollees at the national level and among states with approved or pending waivers.

Methods

The Institutional Review Board at Cambridge Health Alliance deemed this study exempt from review and waived the need for informed consent of participants. We identified characteristics of Medicaid enrollees and Medicaid spending on their behalf using the 2015 Medical Expenditure Panel Survey.3 We calculated Medicaid enrollment and expenditures for categories of persons already fulfilling or exempt from work requirements specified in approved waiver applications (Kentucky, Indiana, Arkansas, and New Hampshire) including persons with the following characteristics: older than 64 years or younger than 19 years, employed or actively seeking work, receiving Supplemental Security Income for disability, disabled but not receiving Supplemental Security Income, and serving as caregivers for disabled household members or children younger than 6 years, as well as those who are pregnant, students, or medically frail. These exemptions are common to all approved waivers.

Using total Medicaid enrollment and total Medicaid spending from the Medicaid Budget and Expenditure System, we then calculated the proportion of total Medicaid enrollment and total Medicaid spending accounted for by the residual group of nonworking, nonexempt adults (“work-eligible adults”). We estimated enrollment figures and spending for the work-eligible adults nationally and for states requesting waivers.4,5 We repeated our national analysis using varying age limits, including 50 years and older (Arkansas waiver) and 60 years and older (Indiana waiver). All analyses account for the complex survey design of the MEPS.

Results

Most Medicaid enrollees were already working or exempt (Table 1). If work requirements were applied nationally with all of the exemptions applied, 2.1 million persons could be at risk for disenrollment, representing 2.8% of current Medicaid enrollees, who account for 0.7% (95% CI, 0.4%-1.1%) of Medicaid spending (Table 2). Among those at risk for disenrollment, the mean annual income is $3820, 42.0% are of black or Hispanic race/ethnicity, 18.6% have children younger than 18 years, 26.6% have hypertension, 33.7% have depression/anxiety, and 31.0% report an activity limitation.

In the 6 states (Arizona, Arkansas, Indiana, Kentucky, New Hampshire, and Ohio) that have applied for waivers and have expanded Medicaid through the Patient Protection and Affordable Care Act, the affected group represents 3.4% (95% CI, 1.6%-5.2%) of the current total Medicaid enrollment and 1.1% (95% CI, 0.3%-1.9%) of total Medicaid spending (Table 2). In nonexpansion states that have applied for waivers (Kansas, Maine, Mississippi, Utah, and Wisconsin), work requirements would affect 0.8% (95% CI, 0.0%-1.6%) of current total Medicaid enrollment and 0.04% (95% CI, 0.0% to 0.3%) of total Medicaid spending.

Discussion

After applying exemptions and removing working adults, 2.8% of current Medicaid enrollees would be subject to new work requirements nationally; they account for less than 1% of Medicaid spending. In states that applied for waivers but did not expand Medicaid, potential savings represent less than 0.1% of Medicaid spending.

Our study was limited by several factors. The analysis likely overestimates the population size and Medicaid spending of the work-eligible group because accurate data on several exemption or work categories were unavailable, including addiction or behavioral health treatment, homelessness, volunteer work, and history of foster care. In addition, exemptions specified in waivers vary among states, and we opted to only include exemptions that were present consistently in all states with approved waivers. Exemptions present in only a subset of waivers, such as receipt of unemployment benefits, were not included, which may also have resulted in overestimation of the population size and Medicaid spending by individuals affected by work requirements. Conversely, we may have underestimated the population size and Medicaid spending by the work-eligible group because we did not have information on the number of hours worked per week by employed individuals (adults must work 20 hours per week or 80 hours per month to meet the work requirement); therefore, we classified all individuals reporting employment as fulfilling work requirements. We also classified individuals with an exempt status lasting less than a full year, such as pregnancy, as exempt for the full year. We did so because data on Medicaid expenditures are only available as annual totals, making it impossible to calculate expenditures for less than a full year. Furthermore, there is wide variability in the frequency of redetermination of exemption: in Kentucky, redetermination is required only on an annual basis, while redetermination is monthly in Arkansas. Finally, data in the MEPS are self-reported and thus subject to inaccuracy and may not correspond with data obtained through Medicaid documentation.

Conclusions

Results of our analysis indicate that savings to Medicaid would be minimal if exemptions were precisely applied. However, savings might be much larger (as Kentucky’s governor2 suggested) if work requirements caused a “spillover effect” (ie, loss of coverage by exempt Medicaid enrollees unable to comply with documentation requirements).6 If spillover loss of coverage is the primary mechanism by which work requirements decrease Medicaid enrollment and spending, these savings would likely come at substantial cost in terms of human health.

https://jamanetwork.com…

References

1. Ronnie Maurice Stewart, et al, Plaintiffs v Alex M Azar, II, et al, Defendants. US District Court for the District of Columbia. Filed June 29, 2018. Accessed August 3, 2018.

2. Yetter D. Bevin revises Medicaid plan, seeks to reduce Kentucky’s rolls by another 9,000 people. Louisville Courier Journal. July 7, 2017. Accessed August 3, 2018.

3. Medical Expenditure Panel Survey, Agency for Healthcare Research and Quality. MEPS HC-181: 2015 Full Year Consolidated Data File. HC-174 replaced by HC-181. Released August 2017. Accessed April 23, 2018.

4. Centers for Medicare & Medicaid Services. Source of state enrollment totals: Medicaid December 2015 enrollment files. Accessed August 6, 2018.

5. Medicaid and CHIP Payment and Access Commission. Source of state Medicaid spending totals: MACPAC’s MACStats: Medicaid and CHIP Data Book, Figure 16, December 2016. Accessed June 28, 2018.

6. Garfield R, Rudowitz R, Musumeci M, Henry J. Kaiser Family Foundation. Implications of a Medicaid work requirement: national estimates of potential coverage losses. Published June 27, 2018. Accessed June 28, 2018.

Author Affiliations

1. Cambridge Health Alliance, Cambridge, Massachusetts

2. Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts

3. Department of Medicine, Harvard Medical School, Boston, Massachusetts

4. Department of Medicine, City University of New York at Hunter College, New York

Stan Brock

Stan Brock, 82, Intrepid Provider of Health Care in Remote Areas, Dies

By Sam Roberts
The New York Times, September 6, 2018

Stan Brock died on Aug. 29 at RAM’s offices in Rockford, Tenn., where he had lived ascetically since he founded the nonprofit outfit in 1985. He was 82.

(The Remote Area Medical clinic service, or RAM) began operating initially in British Guiana and then expanded to the United States in 1992, starting out with a single pickup truck that hauled a single dentist’s chair. It opened its first American clinic in Sneedville, Tenn., in 1992 and still runs an airborne ambulance operation in what is now the independent nation of Guyana.

The organization estimates that it has provided medical, vision and dental care to more than 700,000 patients since its founding, in areas ranging from Appalachia to New York City, and in Puerto Rico in the aftermath of Hurricane Maria.

Last year, about 1,400 health professionals volunteered to treat 2,300 people who showed up at one of RAM’s outdoor clinics at the fairgrounds in the western Virginia town of Wise. Some had camped out for three days to make sure they would be treated.

“The health fair reminded me of scenes I’ve witnessed in refugee camps in South Sudan,” Nicholas Kristof wrote in his Op-Ed column in The New York Times. “But here in America?”

“I’m just the voice of the homeless and the underserved,” he said. “But unless they fix these basic things, we’re going to be doing this long after my lifetime.”

Asked in an interview about his legacy, Mr. Brock said, “I hope that a hundred years from now, nobody will remember me at all because this will be a thing of the past.”

“But,” he added, “there seems to be no end in sight.”

https://www.nytimes.com…

***

Comment:

By Don McCanne, M.D.

For those who want to see that all of us receive the health care that we should have, each of us approaches the deficiencies in our own way. Stan Brock’s high-profile efforts were quite unique. Besides serving people in need, he continued to provide us with an unambiguous visual image of how great the unmet need is.

When he recognized that the need was not only in poor countries but also right here in the United States, he began holding these Remote Area Medical (RAM) clinics in this country. At the time he began, the nation was ready for comprehensive health care reform which many thought that we would have under the Clinton administration. When that effort failed, people were still ready. Eventually the Affordable Care Act was enacted, but it was not the comprehensive reform that we needed. A quarter of a century after Brock began, people are still camping out at the RAM clinics in hopes of receiving just a modicum of care, here in America!

When asked about his legacy, Mr. Brock said, “I hope that a hundred years from now, nobody will remember me at all because this will be a thing of the past. But there seems to be no end in sight.”

No end in sight… here in America? We have to change that ASAP.

And thanks, Mr. Brock, for pointing that out.

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A physician/policy wonk faces our health care financing system

As consumers' out-of-pocket costs grow, will the patient bill-of-rights movement rise again?

By Harris Meyer
Modern Healthcare, September 1, 2018

Emergency physician Dr. Matthew Wetschler was body surfing off Ocean Beach in San Francisco last November when a wave slammed him head-first onto the ocean floor, breaking his neck and paralyzing him. Another surfer pulled him out of the water just before he drowned.

He was taken to Zuckerberg San Francisco General Hospital, the closest hospital that was well-equipped to treat him, where neurosurgeons performed surgery to fuse five vertebrae and maintain blood flow to his spinal cord. After months of physical therapy at Santa Clara Medical Center and Valley Medical Center, he’s walking, but still has no feeling in his hands.

During his grueling recovery, Wetschler received frequent calls from bill collectors seeking payment of nearly $500,000 in medical bills from the hospitals and physicians, plus a $13,000 bill from the air ambulance company that flew him 40 miles to Santa Clara for rehab care. Those providers were not in network for his insurer, Oscar Health.

Wetschler’s experience with a large out-of-network bills and opaque healthcare bureaucracies is common. Nearly 18% of hospital stays for members of large-employer health plans resulted in patients facing out-of-network balance bills, the Kaiser Family Foundation recently found. That rose to 27% when patients passed through the emergency department.

Healthcare consumers also face other common problems with cost, coverage and access, which may increase as the federal government allows the expansion of skimpier, less-regulated health plans. These problems include:

* Coverage denials for emergency department visits that insurers later deem unnecessary.

* Lack of access to specialty providers in health plan networks.

* Difficulty in getting coverage for mental health and substance abuse treatment from health plans.

* Delays in receiving care due to plans’ preauthorization requirements on providers.

* Patients’ inability to find out from providers ahead of time how much they will owe for particular services.

* Large out-of-pocket costs for prescription drugs, particularly specialty medicines.

“There’s plenty to do in the area of consumer protection, with high deductibles and out-of-network bills,” said Dr. David Blumenthal, president of the Commonwealth Fund. “But there is an anti-regulatory fervor we’re seeing in Congress and conservative circles that will be an obstacle to moving a consumer-protection agenda.”

Wetschler, the doctor injured in the surfing accident, has finally gotten the hospitals, physicians and his health plan, Oscar Health, to waive most of out-of-network bills. But he still gets calls from collectors on about $27,000 of that total, including $13,000 for air ambulance services from ProTransport-1.

In his view, there should be consumer protections in place so patients don’t find themselves in this type of terrible situation, which can destroy their finances.

“I’m a doctor with a master’s degree in health policy, yet I feel so overwhelmed that it’s almost paralyzing,” Wetschler said. “I’m stuck in no man’s land. For a person with no medical training, what hope is there?”

http://www.modernhealthcare.com…

***

Oscar

Oscar’s story begins, fittingly, in a hospital room. In 2012, Oscar CEO Mario Schlosser and his wife were going through their first pregnancy in New York. Confronted with a maze of insurance jargon and no practical way to identify the best obstetrician, their first meaningful experience with the health care system put them at a loss as to how to navigate care or hold anyone accountable.

Mario’s friend Josh Kushner had recently had his own frustrating encounter following what should’ve been a routine treatment for an injury. Mario and Josh knew that their experiences were reflective of a larger problem in health care: consumers were powerless. That spring, they founded Oscar Health.

Oscar has been focused on one mission – to be a health insurance company centered around the patient.

https://www.hioscar.com/about

***

Comment:

By Don McCanne, M.D.

A young emergency physician with a master’s degree in health policy should understand better than anyone how to interact with our health care financing system. Dr. Wetschler was insured by Oscar, a relatively new health insurance company cofounded by Josh Kushner, the brother of Jared Kushner of White House fame – a company that professes to be centered around the patient. Yet if the system is not working well in this situation, it could hardly be expected to work better for the rest of us.

Imagine having an improved version of Medicare wherein you receive the medical care you need, when you need it, and wherever you need it, and payment is taken care of automatically through a public system of health care financing. Instead we have a system in which even the most innovative insurers, like Oscar, restrict your choices and burden you with further debt. How can Oscar claim to be “a health insurance company centered around the patient” when they create additional problems for the patient that would be unnecessary in a well designed, publicly-financed and publicly-administered system?

It appears that President Trump and his son-in-law and advisor Jared Kushner are not going to help resolve these problems even though there is already more than enough money in the health care system, and they both profess to know a lot about how to manage money. Maybe instead of having a political leadership of money managers dedicated to business interests, we should replace them with political leaders who are dedicated to serving the people. It would really be nice to be rid of these unnecessary barriers to health care, and it wouldn’t cost us any more than we are already spending collectively.

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Physicians for a National Health Program Advocate for Single-Payer System

Interview with Dr. George Bohmfalk
KDNK Community Radio (Carbondale, Colo.), September 6, 2018

On Thursday, September 6, Physicians for a National Health Program screens Fix It: Healthcare at The Tipping Point at Carbondale’s Third Street Center. KDNK’s Raleigh Burleigh spoke with retired neurosurgeon George Bohmfalk about why he advocates for a single-payer healthcare system.

full audio:
http://www.kdnk.org…

Is there a moral basis for universal health care?

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

Is health care is a right or a privilege? Discussions about health care commonly break down over this moral disagreement.

In a series of articles over the next six weeks in The Aspen Times, I will explore many aspects of the U.S. health care system and how it might be improved. I will not express an opinion on the right-versus-privilege dilemma, because it is a false argument. We each have our own moral systems, and mine may conflict with yours. Just like religions, I can’t claim that my moral pillars are any more valid than yours.

As social psychologist Jonathan Haidt described in his book, “The Righteous Mind,” conservatives and liberals feel differently about several moral values, and those values affect almost every decision we make. Liberals feel very strongly about fairness and caring, as seen in their traditional support for civil rights for the poor and the disenfranchised. They certainly also value loyalty, liberty, sanctity and authority, but fairness and caring take precedence. Conservatives hold all of these values in about equal regard, such that questions of fairness and caring may at times take a back seat if an issue of authority or liberty arises. Most conservatives are comfortable that a few innocent prisoners may have been held in Guantanamo, as they regard national security as being morally more important than fairness to certain individuals. Given our differing moral systems, it’s no wonder that we often find it difficult to discuss politics and religion.

Many conservatives feel that it’s unfair to ask them to pay for anything that will benefit someone else. They believe everyone who is capable should be self-sufficient and not depend on the government. I don’t know any liberals who are opposed to self-sufficiency, but liberals tend to be more empathetic to those who, for any number of reasons, need help. Let’s look at one industry that everyone supports: fire departments.

Until the mid-1800s, most fire departments were formed and run by property insurance companies. Insured buildings were marked by plaques, just as we erect signage of our home security companies. An insurer’s fire brigade would only extinguish fires in buildings carrying their sign. This system was very profitable for the companies.

As you might imagine, terrible things happened, as unattended fires from uninsured buildings spread to insured ones. Public demand prompted cities to form their own fire departments as a community service. Insurance company fire brigades disappeared, many merging into municipal fire departments. Fire departments were fully socialized, with governments owning and operating all aspects. We all pay for them in taxes and hope never to have to use them. As a nation, we decided that for-profit fire departments were not a good idea, and that universal protection, for everyone, simply made more practical sense.

What moral values led to that decision? Perhaps the main one is group loyalty — we’re all better off putting out fires as a community than as individuals. Another is authority — putting someone in charge of the overall situation, rather than responsibility being spread around a myriad of companies. Sanctity and liberty also play roles — we protect our sacred homes and enjoy some freedom from worry and loss. Municipal fire departments are fair — everyone gets the same protection, regardless of ability to pay. Fire departments care for their communities. Accordingly, fire departments enjoy broad bipartisan support. But in the end, tax-supported municipal fire departments are just a good, common sense solution, immune from any contentious moral debate.

Similarly, providing health care to everyone is a good, common-sense community service. It also would satisfy both conservative and liberal moral values. Insurance companies should not be motivated to withhold care in order to make profits, like the old fire brigade companies. Health care protects individuals and families and strengthens the entire nation. Universal health care brings everyone together, under clear public, not-for-profit leadership. In helping all Americans, and providing liberty from financial ruin, universal health care would be patriotic and fair.

So, is health care a right or a privilege? It doesn’t matter. As I hope to demonstrate in this series, providing health care to everyone is simply the common-sense, correct thing to do, regardless of your moral pillars.

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…

Beyond The ACA: Paths To Universal Coverage In California

By Andrew B. Bindman, Marian R. Mulkey, and Richard Kronick
Health Affairs, September 2018

Abstract

California has long sought to achieve universal health insurance coverage for its residents. The state’s uninsured population was dramatically reduced as a result of the Affordable Care Act (ACA). However, faced with federal threats to the ACA, California is exploring how it might take greater control over the financing of health care. In 2017 the state Senate passed the Healthy California Act, SB-562, calling for California to adopt a single-payer health care system. The state Assembly did not vote on the bill but held hearings on a range of options to expand coverage. These hearings highlighted the many benefits of unified public financing, whether a single- or multipayer system (which would retain health plans as intermediaries). The hearings also identified significant challenges to pooling financial resources, including the need for federal cooperation and for new state taxes to replace employer and employee payments. For now, California’s single-payer legislation is stalled, but the state will establish a task force to pursue unified public financing to achieve universal health insurance. California’s 2018 gubernatorial and legislative elections will provide a forum for further health policy debate and, depending on election outcomes, may establish momentum for more sweeping change.

Barriers to Unified Public Financing

California would need to overcome daunting technical and political challenges if it were to transition to a system of unified public financing, whether single- or multipayer. It would be doubly challenging to accomplish this transition at the state level, in part because political agreement would be needed from two levels of government—state and federal. Concerns about providers fleeing the state or sick people being drawn to the state complicate the technical challenges of establishing a unified publicly financed health care system at the state level. These concerns would be minimized if unified public financing were enacted at the federal level.

Accomplishing such a sweeping transition would require substantial and unprecedented changes in federal and state law as well as decisions regarding many design parameters. To implement such a system, Congress would need to pass legislation to redirect payments away from individual Medicare beneficiaries and providers to whatever state agency was operating California’s unified public financing program.

Current federal law might allow federal waivers to redirect federal funds for Medi-Cal and subsidies for individuals in Covered California into a unified state pool, but such waiver requests would be unprecedented. In addition to establishing an initial set of assurances about payments, determining the rate at which the federal payment to California would grow over time would require political agreement. It is hard to imagine that the current Congress or administration would approve such requests. Even with a hypothetical Democratic Congress and president, such approvals would be far from certain.

At the state level, a move to unified public financing of health care would also face significant political challenges. Very large new state taxes would be required to generate program revenue to replace employer-sponsored insurance funding, support those who are currently uninsured, and cover the administrative costs of operating the program. Given anticipated savings from reduced billing and insurance-related costs and potentially (at least eventually) some reduction in low-value care and in the rate of growth of prices, it seems likely that total spending would be less over time than under the status quo. But even if total health spending declined (or at least did not increase), transforming employer-sponsored funding into public funding would be a massive undertaking.

Other challenges include developing processes to match the rate of spending growth to the rate of revenue growth and to determine the “right” revenue growth rate. Physicians, other providers, and some patients would be concerned that a system of unified public financing would overly constrain spending growth, denying Californians the benefits of outcome-improving technology. On the other side, some would be concerned that as a result of regulatory capture, health spending would increase more quickly than justified by the rate of improvement in outcomes, leading to tax increases that did not produce commensurate increases in value or to squeezing out other government spending.

The Select Committee hearings convened to explore these and other issues did not delve into the details of how new taxes might be constructed to support unified public financing; however, the California Legislative Analyst’s Office provided broad tax alternatives with ballpark estimates. Assuming that the current amounts being spent by Medicare and Medicaid could be contributed to a unified public financing approach, new taxes would be needed mainly to substitute for the current employer and employee contributions. Because employer and most employee contributions are made with pretax dollars, purchasers of employer-sponsored coverage benefit today from a discount in the form of a federal tax subsidy. Other methods of financing might increase Californians’ federal income tax burden. Based on the Legislative Analyst’s Office estimates, a 3 percent gross receipts tax levied on all sales and services at all stages of production would generate approximately $120 billion—an amount similar to that spent in California for employer-sponsored insurance. Alternatively, a similar amount could be generated with a 9 percent payroll tax.

A payroll tax could be applied uniformly to all employers, or the state could consider a firm-specific payroll tax in which the tax rate for each firm approximated the percentage of the payroll that the firm pays for health benefits under the status quo—with a plan to narrow the gap between high- and low-rate firms over time. A firm-specific payroll tax would have the political advantage of creating fewer winners and losers, compared to most other financing approaches, and would also minimize any effect on federal income tax liabilities.

Amendments to the California constitution would be required to implement unified public financing in the state. Proposition 98 requires that a portion of any new taxes, regardless of the stated rationale for them, must be directed to K–14 education. The Gann limit, passed by voters via a 1979 statewide ballot initiative, sets appropriation limits on state budget categories supported by taxes. A new tax to support unified public financing would almost certainly exceed the limit. Therefore, adequate funding for unified public financing would require a majority vote of the state’s population to modify the limit.

Even if an amendment to the California constitution were not required by Proposition 98 and the Gann limit, support from California voters for a system of unified public financing would be important for at least two reasons. First, as we have seen with the Affordable Care Act, opponents of change will likely not concede after a legislative loss and will continue to litigate, both in court and in the court of public opinion. A statewide vote in support of change would not prevent that activity but would reduce its effectiveness. Second, and more important, obtaining the federal legislative changes and administrative approvals needed to implement unified public financing would be challenging, and a statewide expression of support could increase the chances of success.

https://www.healthaffairs.org…

***

Comment:

By Don McCanne, M.D.

The September, 2018 issue of Health Affairs is on “California: Leading The Way?” Of importance to not only California, but the entire nation, is California’s effort to enact a single payer program of health care financing. The article by Bindman, Mulkey, and Kronick describes the process that has been taking place. In the excerpt above they describe the barriers to unified public financing, whether single payer or multipayer. The policy community in other states and in the nation at large may find this information useful in their own work.

If California were an independent nation it would be the world’s fifth-largest economy. Yet, as described in another report by Zelman and Wulsin, California has had a very long history of attempting to achieve universal health insurance, but the goal has remained elusive. Even though the state has been very successful in implementing the Affordable Care Act, it still falls far short on most important goals of reform. There is even an article by Enthoven and Baker, still touting managed competition in spite of its obvious shortfalls. The state seems to be mired in health policy innovations that somehow seem to be adding to the muck that we’re trying to wade through.

The full article by Bindman, et al certainly acknowledges the benefits and virtues of a single payer system, but it is discouraging since it seems to default to the misguided direction in which we are headed in health care reform. The barriers, though clearly surmountable with the cooperation of state and federal legislators and their administrations, seem to be distracting the policy community as they redirect to approaches that perpetuate the fragmented, multipayer infrastructure we have, while adding yet more costly administrative complexity that leaves patients exposed to financial hardship and loss of choices in health care.

Bindman and his colleagues conclude, “Implementation of unified public financing in California is technically feasible, but leadership, vision, and persistent public and private commitment—both in California and in Washington, D.C.—are needed to make it happen. Recent deliberations within the California legislature demonstrated both the compelling logic of and the growing emotion associated with movement away from today’s unequal, complex, and fragmented health insurance arrangements. It remains to be seen whether the proponents of change can overcome status-quo interests, renegotiate state and federal responsibilities, and set a new course toward universal coverage.”

That will not happen unless the people lead.

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Medicare for all too costly? Not so fast.

By Louis Balizet, M.D.
The Pueblo (Colo.) Chieftain, September 4, 2018

Canadians live on average three years more than we do (82 versus 79 years). They pay, per capita, 50 percent less than we do for health care ($4,613 vs. $9,507). How do they do this? It’s fairly simple – their health care system (called ”Medicare”) covers everybody, is publicly funded by an assortment of taxes and delivers medical care largely by private providers. This arrangement produces efficiencies that allow all Canadians to access medical care without fear of financial ruin.

Driven by our persistent health care inequities and relentless cost increases, and faced with the embarrassing comparison with our neighbors to the north, more and more American politicians are backing bills that would convert our health care “system” to one that resembles the Canadian model. Two non-identical bills have been introduced into the current Congress to achieve “Medicare for all”: House Resolution 676, sponsored by Representative Keith Ellison of Minnesota (the stronger of the two, and which most closely duplicates the Canadian system), and Senate Bill 1804, proposed by Senator Bernie Sanders of Vermont.

It is the latter that has attracted ferocious attack by defenders of the status quo – by Ben Shapiro in The Pueblo Chieftain column of Aug. 5, and, more recently, in television ads that target Jared Polis (a co-sponsor of H.R. 676). Both assert that Medicare for all would be prohibitively expensive.

Both draw heavily on an analysis of Sanders’ bill by the Mercatus Center, a right-wing think tank founded by, funded by and run by the Koch brothers. This analysis, which contends that Medicare for all would increase federal spending by $32 trillion over 10 years, is influenced by the center’s anti-government, anti-tax agenda. (Previous Mercatus Center productions denounced restrictions on polluters, questioned climate change and opposed the Consumer Finance Protection Bureau.)

The center low-balls (by $3 trillion) the administrative savings that would accrue from replacing insurance companies’ 13-plus percent overhead with Canada Medicare’s 2 percent overhead. In ignores the estimated $5 trillion saved by providers (hospitals, doctors, pharmacies) no longer having to fund gargantuan billing, coding and collection systems. It miscalculates the savings that would result from the national government negotiating the price of drugs (as all single-payer countries do) rather than allowing drug companies to charge whatever the market will bear (as we do) – a $ 1.5 billion to $2 trillion error.

It assumes a massive surge in utilization under Medicare for all. But the “surge” when Medicare was introduced in 1966 was negligible, and it was minimal when Obamacare opened up in 2014. The Mercatus Center analysis does not recognize the savings by businesses and state and local governments that would no longer have to joust annually with insurance companies over health insurance for employees.

What the Mercatus Center study, and one with a similar conclusion from the Urban Institute, fail to recognize is that while federal taxes would certainly go up (just not by $3.2 trillion a year), money spent on insurance premiums would virtually disappear. The net result for most Americans would be that money would be directed to health care decreases. And for all Americans, getting sick would no longer mean courting financial disaster.

There will be dueling analyses of the cost of Medicare for all in the months and years to come. Relatively few of us are inclined to, or able to, sort through the numbers. But we can all recognize what is real – that citizens of 20-plus countries with national health insurance live longer than we do and pay far less for health care than we do. This is irrefutable and uncontested, even by the Mercatus Center. Why can’t we do the same as these countries? The answer: We can.

https://www.chieftain.com…

Alex Azar opposes setting drug prices by government fiat, while people die

Insulin's High Cost Leads To Lethal Rationing

By Bram Sable-Smith
NPR, September 1, 2018

Diabetic ketoacidosis is a terrible way to die. It’s what happens when you don’t have enough insulin. Your blood sugar gets so high that your blood becomes highly acidic, your cells dehydrate, and your body stops functioning.

Diabetic ketoacidosis is how Nicole Smith-Holt lost her son. Three days before his payday. Because he couldn’t afford his insulin.

“It shouldn’t have happened,” Smith-Holt says looking at her son’s death certificate on her dining room table in Richfield, Minn. “That cause of death of diabetic ketoacidosis should have never happened.”

The price of insulin in the U.S. has more than doubled since 2012. That has put the life-saving hormone out of reach for some people with diabetes, like Smith-Holt’s son Alec Raeshawn Smith. It has left others scrambling for solutions to afford the one thing they need to live. I’m one of those scrambling.

My first vial of insulin cost $24.56 in 2011, after insurance. Seven years later, I pay more than $80. That’s nothing compared with what Alec was up against when he turned 26 and aged off his mother’s insurance plan.

Smith-Holt says she and Alec started reviewing his options in February 2017, three months before his birthday on May 20. Alec’s pharmacist told him his diabetes supplies would cost $1,300 a month without insurance — most of that for insulin. His options with insurance weren’t much better.

Alec’s yearly salary as a restaurant manager was about $35,000. Too high to qualify for Medicaid and, Smith-Holt says, too high to qualify for subsidies in Minnesota’s health insurance marketplace. The plan they found had a $450 premium each month and an annual deductible of $7,600.

“At first, he didn’t realize what a deductible was,” Smith-Holt says. She says Alec figured he could pick up a part-time job to help cover the $450 per month.

Then Smith-Holt explained it.

“You have to pay the $7,600 out of pocket before your insurance is even going to kick in,” she remembers telling him. Alec decided going uninsured would be more manageable. Although there might have been cheaper alternatives for his insulin supply that Alec could have worked out with his doctor, he never made it that far.

He died less than one month after going off of his mother’s insurance. His family thinks he was rationing his insulin — using less than he needed — to try to make it last until he could afford to buy more. He died alone in his apartment three days before payday. The insulin pen he used to give himself shots was empty.

A miracle discovery

Insulin is an unlikely symbol of America’s problem with rising prescription costs.

Before the early 1920s, Type 1 diabetes was a death sentence for patients. Then, researchers at the University of Toronto — notably Frederick Banting, Charles Best and J.J.R. Macleod — discovered a method of extracting and purifying insulin that could be used to treat the condition. Banting and Macleod were awarded a Nobel Prize for the discovery in 1923.

For patients, it was nothing short of a miracle. The patent for the discovery was sold to the University of Toronto for only $1 so that live-saving insulin would be available to everyone who needed it.

Today, however, the list price for a single vial of insulin is more than $250. Most patients use two to four vials per month (I personally use two). Without insurance or other forms of medical assistance, those prices can get out of hand quickly, as they did for Alec.

Depending on whom you ask, you’ll get a different response for why insulin prices have risen so high. Some blame middlemen — such as pharmacy benefit managers, like Express Scripts and CVS Health — for negotiating lower prices with pharmaceutical companies without passing savings on to customers. Others say patents on incremental changes to insulin have kept cheaper generic versions out of the market.

For Nicole Holt-Smith, as well as a growing number of online activists who tweet under the hashtag #insulin4all, much of the blame should fall on the three main manufacturers of insulin today: Sanofi of France, Novo Nordisk of Denmark and Eli Lilly and Co. in the U.S.

https://www.npr.org…

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Remarks on Drug Pricing Blueprint

By HHS Secretary Alex M. Azar II
HHS.gov, May 14, 2018

You’ve probably heard before that Medicare could save tons of money by negotiating directly for drugs. This just isn’t true, and you don’t have to take my word for it.

The only way that direct negotiation saves money is by doing something this administration does not believe in: denying access to certain medicines for all Medicare beneficiaries, or setting prices for drugs by government fiat.

We don’t believe either of these proposals would put American patients first. They would move us toward the kind of socialized medicine systems that have such a notorious reputation for poor quality and access.

https://www.hhs.gov…

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Comment:

By Don McCanne, M.D.

There could not be a more glaring example of our policy failures in the design of our health care financing system. The tragic, premature death of 26 year old Alec Raeshawn Smith would have never happened with a well designed, single payer, improved Medicare for All. You can read through his story and pick out each of the policy defects that should be completely unacceptable in the most expensive health care financing system in the world.

There are now a plethora of reports about the outrageous pricing of our pharmaceutical products, including many tragic stories about the gouging of diabetic patients for their life-saving insulin. Yet we have as HHS Secretary, Alex Azar, the former president of the U.S. subsidiary of Eli Lilly – a major producer of insulin – under whose reign Lilly’s prices skyrocketed.

So what does Alex Azar have to say about the outrageous pricing of these products? He says, “this administration does not believe in… setting prices for drugs by government fiat.” He says, this “would move us toward the kind of socialized medicine systems that have such a notorious reputation for poor quality and access.”

With that kind of uncaring, cruel attitude, it seems that it is time to nationalize our health care financing system. We already have the tools to do that in a civil manner: replace our current politicians with ones that will enact an improved Medicare for All.

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Abraham Lincoln on labor

By President Abraham Lincoln
First Annual Message, December 3, 1861

It continues to develop that the insurrection is largely, if not exclusively, a war upon the first principle of popular government–the rights of the people. Conclusive evidence of this is found in the most grave and maturely considered public documents, as well as in the general tone of the insurgents. In those documents we find the abridgment of the existing right of suffrage and the denial to the people of all right to participate in the selection of public officers except the legislative boldly advocated, with labored arguments to prove that large control of the people in government is the source of all political evil. Monarchy itself is sometimes hinted at as a possible refuge from the power of the people.

In my present position I could scarcely be justified were I to omit raising a warning voice against this approach of returning despotism.

It is not needed nor fitting here that a general argument should be made in favor of popular institutions, but there is one point, with its connections, not so hackneyed as most others, to which I ask a brief attention. It is the effort to place capital on an equal footing with, if not above, labor in the structure of government. It is assumed that labor is available only in connection with capital; that nobody labors unless somebody else, owning capital, somehow by the use of it induces him to labor. This assumed, it is next considered whether it is best that capital shall hire laborers, and thus induce them to work by their own consent, or buy them and drive them to it without their consent. Having proceeded so far, it is naturally concluded that all laborers are either hired laborers or what we call slaves. And further, it is assumed that whoever is once a hired laborer is fixed in that condition for life.

Now there is no such relation between capital and labor as assumed, nor is there any such thing as a free man being fixed for life in the condition of a hired laborer. Both these assumptions are false, and all inferences from them are groundless.

Labor is prior to and independent of capital. Capital is only the fruit of labor, and could never have existed if labor had not first existed. Labor is the superior of capital, and deserves much the higher consideration. Capital has its rights, which are as worthy of protection as any other rights. Nor is it denied that there is, and probably always will be, a relation between labor and capital producing mutual benefits. The error is in assuming that the whole labor of community exists within that relation. A few men own capital, and that few avoid labor themselves, and with their capital hire or buy another few to labor for them. A large majority belong to neither class–neither work for others nor have others working for them. In most of the Southern States a majority of the whole people of all colors are neither slaves nor masters, while in the Northern a large majority are neither hirers nor hired. Men, with their families–wives, sons, and daughters–work for themselves on their farms, in their houses, and in their shops, taking the whole product to themselves, and asking no favors of capital on the one hand nor of hired laborers or slaves on the other. It is not forgotten that a considerable number of persons mingle their own labor with capital; that is, they labor with their own hands and also buy or hire others to labor for them; but this is only a mixed and not a distinct class. No principle stated is disturbed by the existence of this mixed class.

Again, as has already been said, there is not of necessity any such thing as the free hired laborer being fixed to that condition for life. Many independent men everywhere in these States a few years back in their lives were hired laborers. The prudent, penniless beginner in the world labors for wages awhile, saves a surplus with which to buy tools or land for himself, then labors on his own account another while, and at length hires another new beginner to help him. This is the just and generous and prosperous system which opens the way to all, gives hope to all, and consequent energy and progress and improvement of condition to all. No men living are more worthy to be trusted than those who toil up from poverty; none less inclined to take or touch aught which they have not honestly earned. Let them beware of surrendering a political power which they already possess, and which if surrendered will surely be used to close the door of advancement against such as they and to fix new disabilities and burdens upon them till all of liberty shall be lost.

http://www.presidency.ucsb.edu…

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Comment:

By Don McCanne, M.D.

There is a reason why we celebrate Labor Day rather than Capitalism Day. Although there was no Labor Day in 1861, President Lincoln’s astute and prescient words remind us why it is natural for our nation to celebrate labor.

And, yes, this message is very directly related to the issue of health care justice for all, even if unspoken.

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Off the Table. The Case for H.R. 676.

Hear U.S. and Canadian rank and file workers, leading officials from the U.S.W. and U.E., and doctors from Physicians for a National Health Program explain how Canadian-style Medicare could cover everyone in the U.S. without co-pays, deductibles, or premiums.

Featuring PNHP national coordinator Dr. Claudia Fegan and PNHP past president Dr. Andrew Coates. Produced by John Rice Films for Unions for Single Payer Health Care.

KFF: Public opinion on single payer, national health plan, and expanding Medicare

Public Opinion on Single-Payer, National Health Plans, and Expanding Access to Medicare Coverage

Kaiser Family Foundation

For many years, Kaiser Family Foundation has been tracking public opinion on the idea of national health plan. Since the 2016 presidential primary and Bernie Sanders’ rallying cry for “Medicare-for-all,” our polls have shown a modest increase in support for the idea of a national health plan (Figure 1), and broad support for proposals that expand Medicare (Figure 2). Overall, about six in ten adults favor a national health plan or Medicare-for-all plan (Figure 3). There is robust support among Democrats, and even somewhat among Republicans, for expansions of the Medicare program through a Medicare buy-in (Figure 6) or an “optional” Medicare-for-all proposal (Figure 7). Yet, it is unclear how much staying power this support has once people become aware of the details of any plan. Public support quickly erodes when people hear further explanation about potential tax increases or increased government control (Figure 8) and recent polling also shows many people falsely assume they would be able to keep their current health insurance under a single-payer plan (Figure 10), suggesting another potential area for decreased support.

While health care appears to be playing a role in the 2018 midterm campaigns (Figure 11) and single-payer has been a hot-button issue in some Democratic primaries, it is unclear that it will play a major role in the general election, with few voters saying a candidate’s position on a national health plan is an important factor in their vote (Figure 12). So while the general idea of a national health plan (whether accomplished through an expansion of Medicare or some other way) may enjoy fairly broad support in the abstract and it can be used as a rallying cry to motivate the liberal base of the Democratic party, it is unlikely to be a determining issue for most 2018 midterm voters.

12 Power Point slides which can be downloaded:
https://www.kff.org…

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Comment:

By Don McCanne, M.D.

Kaiser Family Foundation has summarized in twelve Power Point slides the public opinion on single payer, national health plans, and expanding access to Medicare coverage. Over the last two decades support for “a national health plan in which all Americans would get their insurance from a single government plan” has gradually grown from 40 percent to 53 percent.

Support increases when those initially opposed are told that such a plan would “reduce health insurance administrative costs,” “ensure that all Americans have health insurance as a basic right,” or “reduce the role of all private health insurance companies in health care.”

Support diminishes when those initially in support are told that such a plan would “give the government too much control over health care,” “require many Americans to pay more in taxes,” or “eliminate or replace the Affordable Care Act.”

However the polling suggests that there is considerable support for more incremental approaches. When asked, “Do you favor or oppose letting some people under the age of 65 buy insurance through the Medicare program?”, 63 percent are in favor and 33 percent are opposed. When asked if they would favor “A national Medicare-for-all plan open to anyone who wants it but people whom currently have other coverage could keep what they have,” support is 75 percent as opposed to 59 percent who favor “A national health plan, or Medicare-for-all, in which all Americans would get their insurance from a single government plan.”

Thus it seems that support for a multi-payer system that expands the role of Medicare is greater than support for a single payer version of Medicare for all. This, of course, plays into the hands of those who support expanding the use of private Medicare Advantage plans – a concept that currently is being sold under the false label of “Medicare for All.”

A Medicare Advantage option for all has almost nothing in common with a bona fide single payer improved Medicare for all. The former perpetuates all of the injustices, waste, and excess costs of our current fragmented, dysfunctional method of financing health care, whereas the latter finally brings to us an efficient, effective, equitable method of removing financial barriers to care for absolutely everyone with a system that each of us could afford.

It is going to be very difficult to get this crucial message across when “let those who want to buy into Medicare do it” becomes the reflex response. The polling suggests that it may already be a meme.

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A.M. Best: ‘U.S. Government-Related Health Insurance Business Continues to Grow’

Best’s Market Segment Report: U.S. Government-Related Health Insurance Business Continues to Grow Despite Risks

A.M. Best, August 13, 2018

The U.S. health insurance industry’s premium composition is increasingly shifting toward government-sponsored business, which exposes carriers to additional risks as the business is generally low-margin and results in a greater reliance on state and federal funding, according to a new A.M. Best report.

The Best’s Market Segment Report, “Government-Related Health Insurance Business Continues to Grow Despite Risks,” states that the health industry is generating an increasingly large share of premium from Medicare Advantage, Medicaid and individual commercial businesses. Medicaid reported the largest increase in net premiums written growth, to $224.0 billion in 2017 from $43.1 billion in 2007, owing to Medicaid expansion under the Affordable Care Act (ACA), and to more states turning to managed care to run traditional, pre-expansion Medicaid programs. Medicaid’s share of total industry NPW (Net Premiums Written) in that timeframe rose to 27.1% from 10.2%, although much of that growth occurred in 2014-2015. Medicare Advantage also has been a major source of premium growth for health insurers, with NPW increasing to $202.7 billion in 2017, representing 24.5% of overall industry premium, from $69.9 billion in 2007. Like Medicaid, growth in this business has flattened over the past few years.

According to the report, changes in the nature and financing of the individual market under the ACA have effectively turned this portion of the commercial market into government-sponsored business. At the same time, group commercial premium since 2014 has experienced lower growth because of relatively stable medical cost trends, the absence of material membership expansion and the transition to self-funded arrangements. As a result, many commercial carriers have a greater exposure to government-financed business without having increased their participation in Medicaid or Medicare Advantage lines. Increased exposure to the individual exchange business and its financial losses led to a decline in underwriting margins in the commercial segment from 2014 to 2016, but the market recovered in 2017, leading to historically high results for the overall commercial segment.

With health care remaining a controversial political issue, the regulatory regime is likely to remain volatile over the near to medium term, especially as it relates to the individual exchange segment.

As industry consolidation continues and as companies build massive operational infrastructures to service these programs, a quick exit, if need be, may be more difficult. However, the larger carriers, as well as some of the midsize ones, have been successful in adjusting to regulatory changes and revising business models to accommodate different population needs under the government programs.

https://news.ambest.com…

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Comment:

By Don McCanne, M.D.

This sterile report from A.M. Best suggests that there are uncertainties for the health insurance industry in its participation in government programs, but the important message is that their government-related health insurance business is growing as they prove capable of accommodating to regulatory volatility.

The clear trend is further privatization of the government health insurance programs. With the strong public support for Medicare for All, the insurance industry realizes that there is a great opportunity to expand their markets though the public option of a private Medicare Advantage for All. If you listen carefully to the political candidates supporting Medicare for All, many of them slip in “through a public option,” simply meaning a private insurance option with a Medicare label. That’s what Medicare Advantage is.

Listen up. As we attempt to insert ourselves into the process again (we failed during the Clinton and the Obama administrations), we are going to be met with, “We got it; now get out of our way.” The incremental step of Medicare Advantage for All will ensure a solid rock foundation shoring up the medical-industrial complex, likely for decades to come.

We’re very good at inertia, and it is going to kill any semblance of a single payer, publicly-administered Medicare for all, as we perceive it. Are you just going to sit there? Are all of us just going to sit here?

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