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Tallinn Charter: Health systems for prosperity and solidarity

Tallinn Charter: Health systems for prosperity and solidarity

Health systems for prosperity and solidarity: Tallinn 2018

The Lancet, Editorial, June 23, 2018

Last week, ministers of health, policy makers in health and finance, patient organisations, and academic advisers met in Tallinn, Estonia, to discuss the future of European health systems. Under the stewardship of WHO’s Regional Office for Europe (WHO EURO), and hosted by Estonia’s President, Kersti Kaljulaid, and Minister of Health and Labour, Riina Sikkut, 250 or so representatives of WHO EURO member states celebrated the tenth anniversary of the Tallinn Charter and agreed on principles for building sustainable people-centred health systems.

In 2008, the Tallinn Charter shaped thinking about the importance of health systems and the inter-relatedness of health and wealth. The Charter committed signatory WHO EURO member states to improve health by investing in and strengthening their health systems, and to promote the shared values of solidarity, equity, and participation. Underpinning the Charter were the principles that high-performing health systems contribute to better health and economic development, and that no one should become poor because of ill health.

But later in 2008, the financial crisis hit, leading to hardship and widespread austerity measures in many member states and, in some, to deep cuts to health budgets. Tallinn Charter commitments were derailed, out-of-pocket health expenditure increased, and investment in health systems decreased in many countries. Nevertheless, the past decade has seen some metrics improve, such as life expectancy at birth and tuberculosis case detection. But progress is variable between and within countries, slow in many, and widespread inequalities persist.

Where now for the Tallinn Charter? Last week saw renewed commitment to the fundamental principles of the Charter through adoption of three themes to achieve faster and more equitable health gains. Participants agreed to “include, invest, and innovate” to strengthen their health systems. Ministers of health and policy makers agreed that the health needs of their populations can best be met by improving coverage, access, and financial protection; making the case for investing in health systems; and harnessing innovations in health care.

How to improve inclusion, to ensure universal health coverage, was discussed in the context of financial protection. Health systems play a crucial part in protecting individuals from the financial hardship caused when out-of-pocket payments for health, such as prescription charges or dental care, are greater than a household’s ability to pay. New evidence on financial protection was presented in Tallinn based on analyses across 25 European countries. Even with “universal health coverage”, up to 8% of households in Europe cannot afford to pay for basic needs (food, rent, utility bills) after paying out-of-pocket charges, especially for medicines and dental care. These costs are still causing people to fall into poverty or to do without care; for many in Europe, medicines or dental care, or other health-care costs, are simply not affordable. The risks are greatest where out-of-pocket payments are over 15% of total spending on health, especially if pro-poor policies are absent.

It is still necessary to make the economic case for investing in health systems. Competing demands upon ministries of finance serve to emphasise the need to demonstrate good stewardship of public resources, including measures to reduce health-system inefficiencies and waste, but there is now strong evidence that spending on health contributes to better health outcomes, promotes macroeconomic growth, supports societal wellbeing, and enhances fiscal sustainability of health systems.

It is important to strive for continuous improvement to health systems to benefit populations. Health systems have been slow to innovate in many countries, but key factors that help include supportive leadership, early involvement of clinical staff, dedicated resources including funding, staff, and time, and evaluation of the benefits and costs. Remembering the needs of the public and patient is paramount—innovations that are not needed, wanted, or are too complex will fail.

Inclusion, investment, and innovation are useful themes to build sustainable health systems for the future. The key message from Tallinn 2018 is European solidarity to improve health outcomes, decrease inequalities, and deliver universal health coverage. “Everything we do to improve health outcomes, decrease inequalities, and strengthen health security is fundamentally driven by our European social values of solidarity, equity, and universalism”, Hans Kluge (WHO EURO) told The Lancet. Health systems must be person-centred and flexible to allow change and innovation. Leadership from health ministers, policy makers, academics, and clinicians will be crucial to implementing the recommendations from Tallinn 2018.

https://www.thelancet.com…

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Comment:

By Don McCanne, M.D.

Ten years ago the Tallinn Charter established principles for building sustainable people-centered European health systems. Unfortunately the Great Recession prompted governments to implement austerity measures – a politically difficult time to increase investment of public funds in their health care systems, though Keynesians may not agree.

On the tenth anniversary of the Charter representatives of the WHO EURO member states met again in Tallinn in a renewal of European solidarity to improve health outcomes, decrease inequalities, and deliver universal health coverage. As Hans Kluge from WHO EURO told The Lancet, “Everything we do to improve health outcomes, decrease inequalities, and strengthen health security is fundamentally driven by our European social values of solidarity, equity, and universalism.”

Why should these be foreign concepts to the United States? We are already spending more than enough money to improve health outcomes, decrease inequalities, and deliver universal health coverage. Just think of what the European social values of solidarity, equity, and universalism could do for us.

As we celebrate Independence Day keep in mind that our American exceptionalism does not mean that we should reject solidarity and egalitarianism. Those have served our European friends very well, and at a much lower monetary cost. You would think that there would be considerable support for that.

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Health care spending in late life is usually appropriate

Predictive modeling of U.S. health care spending in late life

By Liran Einav, Amy Finkelstein, Sendhil Mullainathan, Ziad Obermeyer
Science, June 29, 2018

Abstract

That one-quarter of Medicare spending in the United States occurs in the last year of life is commonly interpreted as waste. But this interpretation presumes knowledge of who will die and when. Here we analyze how spending is distributed by predicted mortality, based on a machine-learning model of annual mortality risk built using Medicare claims. Death is highly unpredictable. Less than 5% of spending is accounted for by individuals with predicted mortality above 50%. The simple fact that we spend more on the sick—both on those who recover and those who die—accounts for 30 to 50% of the concentration of spending on the dead. Our results suggest that spending on the ex post dead does not necessarily mean that we spend on the ex ante “hopeless.”

From the article

In sum, although spending on the ex post dead is very high, we find there are only a few individuals for whom, ex ante, death is near certain. Moreover, a substantial component of the concentration of spending at the end of life is mechanically driven by the fact that those who end up dying are sicker, and spending, naturally, is higher for sicker individuals. Of course, we do not—and cannot—rule out individual cases where treatment is performed on an individual for whom death is near certain. But our findings indicate that such individuals are not a meaningful share of decedents.

These findings suggest that a focus on end-of-life spending is not, by itself, a useful way to identify wasteful spending. Instead, researchers must focus on quality of care for very sick patients—identifying the impact of specific health care interventions on survival rates and, just as importantly, on palliation of symptoms; such research should focus not just on averages but also on potentially heterogeneous impacts across different individuals.

http://science.sciencemag.org…

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Cut Spending In Final Year Of Life? MIT Study Finds Death Too Unpredictable

By Carey Goldberg
WBUR, June 28, 2018

Medicare, the federal health coverage mainly for people over 65, spends about $700 billion a year, and it’s estimated that about one-quarter of that spending on seniors goes to health care in the final year of life.

That end-of-life spending has drawn scrutiny as potentially wasteful, involving heroic measures taken even though death looms inevitably.

If health costs must be contained, the argument follows, why not cut that relatively futile end-of-life spending?

The answer, according to a new study that used machine learning on a huge trove of more than 6 million Medicare medical records to train a computer algorithm to predict deaths, is this:

In most cases, it’s not clear that the treatments are futile at the time. Because even with state-of-the-art artificial intelligence, it’s much harder than you might think to predict who’s going to die soon.

Question: So what are the policy implications?

Amy Finkelstein, co-author of the paper: First, it is true that we spend an enormous amount of money on people who die. What our research suggests is it isn’t obvious that that means it’s a waste. The implicit assumption is that we’re spending a lot of money on people we know are going to die in the next year or the next 30 days, and we show in the paper that’s just not true. So don’t focus so much on end of life spending as a symptom of waste, because it’s not obviously waste.

Second, there’s hard work we need to do rather than just point to spending at the end of life and say, “Let’s lop that off.” Instead, we need to figure out which medical interventions and health care policies are actually producing a lot of value and which aren’t. We need to look at specific interventions, both late life and at other points in life, and estimate with rigorous empirical methods what the benefits of those interventions are.

Question: You could do this study because you could use machine learning on great Medicare data, but what actually triggered you to do it?

Amy Finkelstein: Those two factors — and on the more casual or humorous side, I remember picking my son up from ski school, and he told me his instructor said you always need to be careful at the end of the day because most ski accidents happen on the last run of the day. And my immediate response was: “Of course they do, when you have an accident that becomes the last run!”

Obviously, that’s facetious, but it made me start thinking about it. In the ski example, I think the instructor is right. It is actually true that more accidents occur late in the day. But as framed, it sounds absurd in the same way as saying, “Look, we spend a lot on the dying, let’s stop spending so much on the dying.” It’s like, “Stop skiing your last run of the day.”

http://www.wbur.org…

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Comment:

By Don McCanne, M.D.

When our very high national health care costs are discussed, almost invariably the subject of wasteful spending at the end of life is brought up. This important study of predictive modeling shows that spending at what proves to be near the end of life is not obviously wasteful. It is usually appropriate, testimonials aside. Efforts to reduce spending by reducing end of life care will not be particular productive in management of our national health expenditures.

It is astonishing to see brought up repeatedly the same ill-advised, ineffectual, and sometimes harmful policies to control health spending, such as consumer-directed health care (very high deductibles), paying for value instead of volume (accountable care organizations), or taking away choices in care (narrow provider networks), when we know what does work – a single payer national health program, aka an improved Medicare for all.

Measures that would have a real impact on controlling spending include reduction in our profoundly wasteful administrative excesses, and controlling our “stupid” prices through public administration. Improved allocation of our health care resources through planning and capital budgeting might not make much of a dent in total spending, but it would redistribute funds to more effectively cover those who are currently uninsured or have excessive out-of-pocket health care expenses. Obviously these are beneficial policies that characterize a single payer health care financing system.

Instead of wasting more time and money on the wish lists of the market ideologues, we should move forward with what does work – improved Medicare for all. The good news is that, based on current election results, it appears that the word is getting out.

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Indiana’s impending health care crisis calls for action throughout the entire U.S.

Rob Stone, M.D. of Bloomington, Indiana has provided us with the following background information on the effort by twenty state attorneys general to invalidate the remaining elements of the Affordable Care Act (ACA). That is followed by an op-ed he wrote for the Bloomington Herald-Times on this topic and then by a Bloomington Herald-Times editorial in support of Rob Stone’s position.

Background Information

February 26, 2018: Indiana Attorney General Curtis Hill Jr. announced that Indiana had joined 19 other states* in a suit filed in Federal court in Texas to invalidate the remaining elements of the Affordable Care Act (ACA).  In his statement Hill said “The whole house of the Affordable Care Act must come crumbling down.”

The ACA helped over 340,000 Hoosiers obtain healthcare.  According to the nonpartisan Kaiser Family Foundation [kff.org] 1.1 million Hoosiers under 65 have pre-existing conditions that would have made them uninsurable before the ACA’s reforms were enacted.

June 6, 2018: US Attorney General Jeff Sessions announced the Justice Department would not defend against the suit from the 20 states and the provisions of the ACA that protect consumers with pre-existing medical conditions, meaning that insurance companies could again deny coverage or charge higher rates to Hoosiers with pre-existing illnesses like diabetes, cancer, or high blood pressure.

* The other 19 states [tell friends from those states]: Alabama, Arkansas, Arizona, Florida, Georgia, Kansas, Louisiana, Maine, Mississippi, Missouri, Nebraska, North Dakota, South Carolina, South Dakota, Tennessee, Texas, Utah, West Virginia, Wisconsin.

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Lawsuit will hurt health of Hoosiers

By Rob Stone, M.D.
The Herald-Times (Bloomington, Ind.), June 19, 2018

This guest column was submitted by Rob Stone, M.D., of Bloomington, a practicing physician and director of Hoosiers for a Commonsense Health Plan.
 
Did anyone see the news release from the Indiana Attorney General’s office on Feb. 27 this year? The one where AG Curtis Hill announced that Indiana “has joined a 20-state coalition urging a federal district court in Texas to hold the Affordable Care Act’s individual mandate is unconstitutional.” In a speech at the Heritage Foundation in Washington, D.C., Mr. Hill went on to crow, “The whole house of the Affordable Care Act must come crumbling down.”
 
I admit I was not paying attention, either, until June 7 when the nation’s top lawyer, Jeff Sessions, announced that the Justice Department would not defend this lawsuit that Indiana is pursuing. The lawsuit aims to void the Affordable Care Act and crucial provisions in it that protect consumers with pre-existing medical conditions.
 
To be clear, anyone with a pre-existing health condition, whether it be a disability they were born with, cancer, heart disease, diabetes, high blood pressure, you name it, is in grave danger of losing their health insurance as a result of this action by Indiana’s attorney general.

We know that when people lose their health insurance it makes it difficult and expensive to receive testing and treatment, difficult to even find a doctor who will see you. We know that their health will deteriorate and people will die as a result. We know this will lead to disability, suffering and to medical bankruptcy.
 
I have practiced medicine in Indiana since 1983. For 28 years, I was an emergency physician, dealing daily with people who had no health insurance. They waited until they were desperate and in dire straights before coming into the ER for care, waited until their heart attack or their stroke was complete and no treatment would be able to reverse the damage.
 
I saw people die from delaying care because they couldn’t afford it. I saw the situation in our state get better after Obamacare. Indiana has seen a small but significant improvement in our state health rankings over the past few years. We are beginning to make progress on our infant mortality and opioid crises. All that progress could be lost if Mr. Hill is successful in his efforts as more Hoosiers lose coverage and access to care.
 
To make matters worse, Medicaid stands to be cut as well, and with Medicaid cuts, we will see rural hospitals close, which will even further aggravate problems like infant mortality and the shortage of addiction treatment options. Many rural hospitals are the largest employers in their communities.
 
Why did he feel this is something so important to pursue? How does taking health insurance away from Hoosiers come under the purview of the AG? Was he acting on his own, or at the behest of the governor?
 
I think Mr. Hill’s actions in this case are fundamentally inconsistent with the role of the attorney general and can be seen as a serious dereliction of his duty to protect the people of this state.

Either Mr. Hill should act to withdraw Indiana from this lawsuit, or else he should resign his position.

https://www.heraldtimesonline.com…

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Editorial: Indiana AG shouldn’t be cheering decision that could hurt Hoosiers

The Herald-Times (Bloomington, Ind.), June 22, 2018

Indiana Attorney General Curtis Hill has claimed victory for the state based on an action that could cost 1 million Hoosiers health insurance.

As covered in a guest column by Dr. Rob Stone in the Tuesday H-T, the issue in play here is the recent announcement that the Department of Justice will stop defending core provisions of the Affordable Care Act, otherwise known as Obamacare.

One provision is the guarantee that those with pre-existing medical conditions could get insurance coverage without paying exorbitant premiums.

Hill was one of 20 Republican attorneys general who filed a lawsuit that argues the ACA is unconstitutional since Congress got rid of the individual mandate, a tax penalty for people who did not buy health insurance.

In announcing it would no longer fight challenges to the ACA, which remains the law of the land, the Justice Department said it agreed with the lawsuit Hill is part of.

That’s terrific, says Indiana’s top lawyer.

The effect on real Hoosiers and tens of millions other Americans could be devastating.

The Kaiser Family Foundation, which focuses on national health care issues, estimates that 27 percent of adult Americans under age 65 have health conditions that the ACA guaranteed would be covered. That math adds up to the more than 1 million Hoosiers referenced above. Some of those Hoosiers will continue to be covered under employer plans or other government plans, but others could be considered uninsurable on the open market, as they were before the ACA protection.

As an aside, the Kaiser Foundation notes pre-existing conditions affect far more women than men.

The attorney general, in a news release, praised the Justice Department’s decision and suggested “Congress should allow Indiana and all the other states to exercise freedom in the ways they deal with the issue of health care for their own citizens.”

The fact is, Indiana has dealt with the issue of health care fairly well in recent years with the Healthy Indiana Plan and HIP 2.0. How did then Gov. Mike Pence come up with such a successful program?

Credit for that should go to the Affordable Care Act so widely disparaged by Hill and others in his party. The reason Indiana moved to develop a plan to cover 350,000 uninsured Hoosiers rather than the 40,000 it was covering was because the ACA provided funding to expand Medicaid or a similar program. State lawmakers never would have done that on their own.

Those in the state who want to continue to bash the ACA or Obamacare ignore the fact that hundreds of thousands of Indiana’s citizens have better access to quality health care because of it.

Hill and his GOP colleagues should not have added Indiana into this lawsuit — at least not if the health of Hoosiers matters to them.

https://www.heraldtimesonline.com…

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Rob Stone has initiated a petition at change.org directed to Indiana Attorney General Curtis Hill Jr. Individuals in the other nineteen states involved may want to consider initiating similar petitions:

https://www.change.org…

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Comment:

By Don McCanne, M.D.

Our number one imperative is to enact and implement a health care financing system that will bring health care justice to every single person in the nation – a well designed, single payer, improved Medicare for all – and we should not allow anything to distract us from that goal… with one major caveat.

Because of obvious political barriers, enactment of an improved Medicare for all does not seem to be imminent, though our efforts in support should continue at a level as if it is imminent. We cannot relax in the least in our advocacy for single payer reform. That said, in the interim it is important that we do what we can on a state level to protect and improve what we do have. As Rob Stone’s op-ed and the Herald-Times editorial indicate, this cruel lawsuit by the twenty attorneys general, if successful, will cause physical suffering and financial hardship and even result in death for far too many innocent residents of the United States, since an adverse outcome would apply to the entire nation and not just to the twenty states.

We must take up (virtual) arms against these attorneys general to ensure that their sick effort is defeated, this while we continue our march forward to win health care justice for all through the enactment of a single payer, improved Medicare for all.

Also keep in mind the utmost importance of casting your vote, even for the down-ballot offices such as attorney general.

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Iowa shows the nation how not to finance health care

The Road Not Traveled: How Policy, Business Decisions in Iowa Led to Higher Premiums

By Sabrina Corlette and Kevin Lucia
The Commonwealth Fund, June 28, 2018

This year, Iowa’s legislature took the extraordinary step of abdicating the state’s authority to regulate health insurance products. The bill, enacted in April, exempts health plans offered by the state’s Farm Bureau from state and federal insurance regulation, including Affordable Care Act (ACA) provisions designed to protect people with preexisting conditions and provide a minimum standard of benefits.

Proponents argue that such a law is needed to provide individual market consumers with cheaper health plan options than available under the ACA. Critics point out that younger, healthier consumers are most likely to benefit from these plans. And while details haven’t been provided yet, the Farm Bureau plans are expected to be medically underwritten, and not cover the ACA’s minimum set of benefits. As a result, older Iowans, those with preexisting conditions, and those who need comprehensive coverage are unlikely to find these plans affordable or attractive. And many could be denied enrollment outright. As enrollment in the ACA-compliant individual market becomes older and sicker, marketplace consumers who do not qualify for the ACA’s income-related premium subsidies will face increasingly higher premiums.

Iowa’s Farm Bureau statute is making a bad situation worse for the state’s individual market. Thanks to a number of decisions by state policymakers and the dominant insurance company – Wellmark Blue Cross Blue Shield – premiums in the state’s individual market are already among the highest in the country, with an average annual marketplace plan premium in excess of $10,000 in 2018.

A Study of Market Failure: Iowa’s Individual Health Insurance Market

The current dismal state of the ACA individual market in Iowa was not a foregone conclusion. In 2014, when the marketplaces launched, Iowa had four insurers competing in the ACA’s marketplace. In 2018, only one insurer is selling ACA-compliant health plans; it agreed to do so only after implementing an average 50 percent increase to unsubsidized premiums.

Iowa’s marketplace enrollment has also lagged that of other states. As of 2016, only 20 percent of eligible Iowans had enrolled (by comparison, that number was 40 percent in Illinois, 43 percent in Missouri, and 57 percent in Maine). Iowa is an outlier for a critical reason. Wellmark BlueCross BlueShield declined to participate in the marketplace for the first three years, entered only briefly in 2017 and then declined to participate in 2018, but is returning to the market in 2019. The insurer also maintained a large block of pre-ACA grandfathered and transitional, or “grandmothered,” health plans (see table).

Because the enrollees in these plans must pass a health screen before being allowed to enroll, they are relatively healthy. Because Wellmark was able to hang on to these healthy enrollees, the pool of people available for the ACA-compliant market was much smaller and sicker than it otherwise would have been.

Looking Ahead

Iowa’s experience offers important lessons. The more the individual market is segmented between healthy and the less-healthy consumers, the more likely unsubsidized enrollees are to face unaffordable premiums. Federal proposals such as those to expand the availability of short-term and association health plans, to the extent they are not limited by state policies, could result in more state individual markets resembling Iowa’s. The primary losers in such a scenario are the working middle-class consumers: entrepreneurs who run their own businesses, freelancers and consultants, farmers and ranchers, and early retirees who earn too much to qualify for the ACA’s premium subsidies.

https://www.commonwealthfund.org…

Wakely’s Analysis of Alternative Policy Decisions in Iowa’s Individual Market:
https://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

We know how to craft a health care financing system that is truly universal, accessible, comprehensive and equitably funded making it affordable for everyone. No state in our nation has achieved those goals, but some, such as Iowa, are far worse off than others, largely for ideological and parsimonious reasons. As a result, their people suffer – physically and financially.

The Affordable Care Act (ACA) was supposedly designed to address many of these health care financing issues. But look at ACA and compare it to a model that many of us said should have been used instead – Medicare, or actually an improved version of Medicare. The provisions of ACA did not ensure coverage for everyone whereas Medicare does ensure some coverage (Part A) for the designated population covered regardless of which state the beneficiaries live in (though the improved version would include absolutely everyone in every state). There are considerable inequities in health care financing under ACA, especially for those just above 400 percent of poverty, whereas the funding of Medicare is more equitable by virtue of using progressive taxes (though it could be even more equitable through better designed tax policies). Accessibility is highly variable under ACA whereas Medicare covers almost the entire health care delivery system and thus improves choice and accessibility (though with an improved Medicare, planning and budgeting of capital improvements would further expand access). But one of the more important differences is that ACA provides state bureaucrats greater leeway in implementing their health care financing systems, whereas Medicare is fairly standardized through the nation. This leeway for states under ACA is what has allowed Iowa and other states with similar political views to deprive their citizens of a more egalitarian health care system.

We are allocating a huge amount of federal tax funds for our health care system. Thus we have a responsibility to see that each individual in each state is treated well by their health care systems. The current experience has shown us that we cannot rely on states to design their own systems because too many will deprive their residents of the care that they should have. Like Medicare, a universal health care financing program should be a national program so that everyone who needs health care can benefit.

Yes, until we have a national, single payer, improved Medicare for all, states should continue to do what they can to improve their health care systems. But we cannot allow that to slow down our efforts to create the political environment that will facilitate the enactment of a universally accessible, equitable and affordable national health program. Iowa is showing us how not to do it.

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The role of health policy in presidential elections

Getting Ready for Health Reform 2020: What Past Presidential Campaigns Can Teach Us

By Jeanne M. Lambrew
The Commonwealth Fund, June 26, 2018

Abstract

Issue: The candidates for the 2020 presidential election are likely to emerge within a year, along with their campaign plans. Such plans will include, if not feature, health policy proposals, given this issue’s general significance as well as the ongoing debate over the Affordable Care Act.

Goal: To explain why campaign plans matter, review the health policy components of past presidential campaign platforms, and discuss the likely 2020 campaign health reform plans.

Methods: Review of relevant reports, data, party platforms, and policy documents.

Findings and Conclusions: Proposals related to health care have grown in scope in both parties’ presidential platforms over the past century and affect both agendas and assessments of a president’s success. Continued controversy over the Affordable Care Act, potential reversals in gains in coverage and affordability, and voters’ concern suggest a central role for health policy in the 2020 election. Republicans will most likely continue to advance devolution, deregulation, and capped federal financing, while Democrats will likely overlay their support of the Affordable Care Act with some type of Medicare-based public plan option. The plans’ contours and specifics will be developed in the months ahead.

Likely Republican Campaign Plan: Replace the ACA with Devolution and Deregulation

President Trump has indicated he will run for reelection in 2020. His fiscal year 2019 budget included a proposal “modeled closely after the Graham-Cassidy-Heller-Johnson (GCHJ) bill.” It would repeal federal financing for the ACA’s Medicaid expansion and health insurance marketplaces, using most of the savings for a state block grant for health care services. It would also impose a federal per-enrollee spending cap on the traditional Medicaid program. States could waive the ACA’s insurance reforms. The congressional bill also would repeal the employer shared responsibility provision (i.e., the employer mandate) and significantly expand tax breaks for health savings accounts, among other policies. The framework for this proposal — repealing parts of the ACA, replacing them with state block grants, reducing regulation, and expanding tax breaks — is similar to the 2016 Republican platform.

One policy initiative in the recent Republican platforms but not embraced by the president is Medicare reform. The idea of converting Medicare’s defined benefit into a defined contribution program and raising the eligibility age to 67 was supported by Vice President Mike Pence when he was a member of Congress and by Speaker of the House Paul Ryan.

Likely Democratic Campaign Plan: Improve the ACA and Add a Public Plan

It is possible and maybe probable that the ultimate Democratic Party platform in 2020 will resemble that of 2016: build on the ACA and include some sort of public plan option.

The Democrats will inevitably discuss a public plan in their platform, although the primary contenders will most likely disagree on its scale (e.g., eligibility) and design (e.g., payment rates, benefits). In September 2017, Senator Bernie Sanders introduced the Medicare for All Act (S. 1804). It would largely replace private insurance and Medicaid with a Medicare-like program with generous benefits and taxpayer financing. “Medicare for more” proposals have also been introduced: Medicare Part E (Merkley, S. 2708), an option for individuals and small and large businesses; Medicare X (Bennet, S. 1970), which is available starting in areas with little insurance competition or provider shortages; and a Medicare buy-in option, for people ages 50 to 65 (Higgins, H.R. 3748). A Medicaid option (Schatz, S. 2001), similar to Medicare Part E, offers a public plan choice to all privately insured people, aiming to capitalize on the recent popularity of that program. Publicly sponsored insurance plans have long been included in Democratic presidents’ platforms, although the government’s role has ranged from regulating the private plans (Carter, Clinton) to sponsoring them (Truman, Obama). It may be that the candidate who prevails in the primaries will determine whether the Democratic platform becomes “Medicare for all” or “Medicare for more.”

From the Discussion

The direction and details of the campaign plans for 2020 will be developed in the coming months and year. Given such plans’ potential to shape the next president’s agenda, now is the time to scrutinize, modify, and generate proposals for health reform.

https://www.commonwealthfund.org…

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Alexandria Ocasio-Cortez Defeats Joseph Crowley in Major Democratic House Upset

By Shane Goldmacher and Jonathan Martin
The New York Times, June 26, 2018

Representative Joseph Crowley of New York, once seen as a possible successor to Nancy Pelosi as Democratic leader of the House, suffered a shocking primary defeat on Tuesday, the most significant loss for a Democratic incumbent in more than a decade, and one that will reverberate across the party and the country.

Mr. Crowley was defeated by a 28-year-old political newcomer, Alexandria Ocasio-Cortez, a former organizer for Bernie Sanders’s presidential campaign, who had declared it was time for generational, racial and ideological change.

Mr. Crowley’s loss left Democrats in Washington stunned.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

The debate over health care will likely play a significant role in the 2020 presidential election. Jeanne Lambrew has considerable political experience in health reform, having worked for President Obama as deputy assistant for health policy. She has studied health care reform proposals in prior presidential elections. What does she predict for 2020?

Lambrew predicts that the Republicans will propose replacement of the Affordable Care Act with devolution and deregulation. She predicts that the Democrats will support improving the Affordable Care Act and propose adding a public plan, presumably a public option or perhaps a Medicare buy-in.

Yet public support for a single payer Medicare for all program is at an all time high. It may have played a role in the impressive victory of Alexandria Ocasio-Cortez over stalwart Democratic leader Representative Joseph Crowley in yesterday’s New York congressional Democratic primary. Ocasio-Cortez was an organizer for Bernie Sanders’s presidential campaign and supports progressive policies, including Medicare for all. Crowley is a cosponsor of the Medicare for All Act but is also “an outspoken supporter of Obamacare” according to his campaign website – a position inconsistent with advancing bona fide single payer legislation. The fact that Democrats in Washington were stunned by his defeat may awaken them to the fact that the voters really do want an improved Medicare for all.

Lambrew writes, “now is the time to scrutinize, modify, and generate proposals for health reform.” Actually it’s late for that, rather now is the time to show the politicians how strong the support is for Medicare for all. After the presidential campaign begins, the political parties will have already decided on their policy positions and it will be too late to change their strategies.

Don’t forget the Republicans. Medicare for All may be a welcome antidote for Trump fatigue.

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John Arensmeyer on association health plans

Association Health Plans Will Destabilize Small Group Market

By John Arensmeyer, Small Business Majority Founder & CEO
Small Business Majority, June 19, 2018

We are disappointed and disturbed that the U.S. Department of Labor released a final rule today authorizing the expansion of association health plans (AHPs) over the objections of virtually everyone who weighed in on the proposed rule, including small businesses. This is yet more evidence that this administration will do all it can to undermine the Affordable Care Act (ACA) regardless of the consequences. The new rule will allow groups of businesses to band together to buy insurance across state lines, which will be bad for small firms and their employees because it will lead to higher premiums, unbalanced risk pools and lower-quality insurance.

While the new rule may make it easier for a select number of small businesses with younger and/or healthier employees to purchase association health plans that might be cheaper in other states, the tradeoff is that this will cause the insurance market for small businesses to split in two, leading to major spikes in premiums for small firms that remain in the small group market.

What’s more, these multi-state plans will offer fewer consumer safeguards. In fact, they will not have to include protections for people with pre-existing conditions nor will they be required to cover things like maternity care because they will not be subject to certain rules established by the ACA.

The AHP rule is also redundant because small businesses are already allowed to work together to purchase health insurance. That system is called the small group market, and the more people we have in this pool, the lower premiums will be for its participants. Encouraging people to leave the small group market, however, will only harm small businesses by raising their premiums.

This administration has shown that it will do anything and everything possible to destroy policies it disagrees with, regardless of whether or not those policies are working for small businesses. It is simply fact that the ACA has helped millions of small business owners, their employees and solo entrepreneurs gain quality, affordable health insurance. Since the administration has no interest in improving healthcare for small firms, we implore states to do all they can to strengthen ACA marketplaces so that insurance remains affordable for America’s job creators.

http://www.smallbusinessmajority.org…

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Comment:

By Don McCanne, M.D.

John Arensmeyer is one of the most credible voices in the small business community. We should listen to him when he discusses the association health plans (AHPs) that are now being advanced by the Trump administration, supposedly to benefit small business owners.

The need is for affordable access to essential health care for the owners and employees of small businesses. AHPs may make the insurance product more affordable, but they will make health care access less affordable because of gaps in benefits and excessive out-of-pocket cost sharing, not to mention possible inability to obtain coverage because of preexisting conditions. The current problems with excessive cost sharing and impaired access due to narrow provider networks will only be made worse with these inadequate association health plans.

The small group market was previously in disarray and thus was one of the primary motivating forces behind the enactment of the Affordable Care Act. As healthier individuals leave the small group market to purchase cheaper association health plans, the small groups will experience adverse selection, driving premiums further up to even less affordable levels.

Arensmeyer provides us with one more reason to replace the current Congress and administration since the current people in charge seem to remain unresponsive to the nation’s needs.

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