By Tricia Neuman, Karen Pollitz, and Jennifer Tolbert
KFF, October 2018

As policymakers debate next steps for expanding health insurance coverage and lowering health costs, some have introduced legislation that would broaden the role of public programs, such as Medicare and Medicaid. During the 115th Congress, eight such proposals were introduced, ranging from bills that would create a new national health insurance program for all U.S. residents, replacing virtually all other sources of public and private insurance (Medicare-for-All), to more incremental approaches that would create a new public plan option, as a supplement to private sources of coverage and public programs.

These eight legislative proposals differ in ways that have important implications for consumers, health care providers and payers, including employers, states, the federal government, and taxpayers. Key policy differences relate to eligibility, the size and scope of the public plan, covered benefits and cost sharing, premiums, subsidies for premium and cost sharing, cost containment strategies, and the likely interactions with current public programs and private sources of coverage. They also vary in their level of detail; some bills, according to their sponsors, are intended to serve as blueprints for reform, and are expected to include greater specificity over time. Given the timing of the legislative calendar, these bills are unlikely to advance in the current Congressional session; however, they illustrate the range of options that will likely serve as prototypes for legislation that may be introduced in the next session of Congress.

Greatly simplified, these public plan proposals fall into four general categories:

• Two proposals would create Medicare-For-All, a single national health insurance program for all U.S. residents (Senator Sanders, S. 1804; Rep. Ellison, H.R. 676)1;
• Three proposals would create a new public plan option, based on Medicare, that would be offered to individuals and some or all employers through the ACA marketplace (The Choice Act by Rep. Schakowsky, H.R. 635, and Sen. Whitehouse, S. 194); The Medicare-X Choice Act by Sen. Bennett, S. 1970, and Rep. Higgins, H.R.4094; and the Choose Medicare Act by Sen. Merkley, S. 2708 and Rep. Richmond, H.R. 6117)
• Two proposals would create a Medicare buy-in option for older individuals not yet eligible for the current Medicare program (Sen. Stabenow, S. 1742; Rep. Higgins, H.R. 3748); and
• One proposal would create a Medicaid buy-in option that states can elect to offer to individuals through the ACA marketplace. (Sen Schatz, S. 2001 and Rep. Luján, H.R. 4129).

This policy brief summarizes key features of these proposals, highlights similarities and differences, and discusses key questions, trade-offs and potential implications.

Key Policy Considerations

1. HOW WOULD THE PROPOSALS PROVIDE AND EXPAND COVERAGE?
2. HOW WOULD THE PROPOSALS AFFECT THE AFFORDABILITY OF COVERAGE FOR CONSUMERS?
3. HOW WOULD THE PROPOSALS AFFECT MARKETPLACE COVERAGE?
4. HOW WOULD THE PROPOSALS AFFECT PRIVATE EMPLOYER-SPONSORED HEALTH COVERAGE?
5. WOULD THE NEW PUBLIC PLAN OPTIONS BE THE SAME AS THE CURRENT MEDICARE PROGRAM?
6. HOW WOULD THE PROPOSALS AFFECT THE CURRENT MEDICARE PROGRAM?
7. HOW WOULD THE PROPOSALS AFFECT THE CURRENT MEDICAID AND CHIP PROGRAMS?
8. HOW WOULD THE PROPOSALS ADDRESS THE NEEDS OF SPECIFIC POPULATIONS?
9. HOW WOULD THE PROPOSALS AFFECT PAYMENTS TO PROVIDERS?
10. WHAT COST CONTAINMENT FEATURES ARE IN THE PROPOSALS?
11. WHAT ARE THE COSTS AND POTENTIAL TRADE-OFFS?
12. HOW WOULD THE PROPOSALS BE FINANCED?

From the Discussion

With health care reemerging as an issue for voters in the mid-term elections, the debate over the role of public programs in our health care system appears to be intensifying. Current proposals offer a range of approaches from those that would transform the existing system by creating a new national, Medicare-for-All plan to more incremental approaches that would offer a new public plan option alongside existing private coverage and public programs. With many details yet to be provided, these proposals raise a number of questions, the answers to which will have important implications for consumers, health care professionals, and health care payers, including employers, states, and the federal government.

http://files.kff.org…

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Comment:

By Don McCanne, M.D.

This 16 page KFF issue brief summarizes various legislative proposals that would expand public coverage of health care. Because they vary in their impact, the authors have suggested questions that should be asked in evaluating each proposal. Single Payer Medicare for All supporters can certainly come up with several other important questions.

Some in the legislative and policy communities would consider these proposals to be on a level paying field, and that choices would be based on various policy trade-offs that might be preferred by a majority of legislators and policy wonks. Although that process could bring us to an optimal system, it very well might not. It risks neglecting fundamental goals that should be a moral imperative such as universality, equity, accessibility, comprehensiveness, efficiency and affordability.

The proposed and other pertinent questions should be asked not only regarding the Medicare for All, public option and buy-in proposals, but they should also be asked about the state versus federal proposals, especially Single Payer Medicare for All. Under any circumstances would it ever be right to leave out certain socioeconomic sectors in states other than yours?

By asking the right questions, we can identify the policy pathway to health care nirvana. That would be either a national health service or Single Payer Medicare for All. The latter would not only be more feasible, it would also align more closely with perceived American cultural values, even if the former might actually be a superior model.

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

By Matt Pearce
Los Angeles Times, November 7, 2018

Liberal-backed ballot measures — especially those involving criminal justice reform or healthcare — had greater success than Democratic candidates.

Party identification is one of the most powerful forces in politics, with many people voting strictly on party lines when it comes to choosing their politicians.

But ballot measures, while often pushing policies favored by one party more than another, don’t come with “D” or “R” labels. Voters can make their choices without feeling like they’re casting their ballots for one party or another.

Most Americans “aren’t particularly ideological,” said Lilliana Mason, a government professor at the University of Maryland and author of a recent book, “Uncivil Agreement,” about identity in politics.

Though Americans are polarized around “who you are, what your identity is,” polling shows that “the public holds fairly liberal positions” on a lot of issues, Mason said.

State-level Medicaid expansion under Obamacare, a major Democratic-supported policy, also saw several victories in deep-red states.

Republican candidate Brad Little trounced Democrat Paulette Jordan 60% to 38% to become governor of Idaho, but voters there approved a Medicare expansion measure 60.5% to 39.5%.

It was a similar story in Nebraska, where voters expanded Medicaid while handily reelecting incumbent Republican Sen. Deb Fischer, another expansion skeptic.

In Utah, Republican Mitt Romney vaulted into the Senate as voters there approved Medicaid expansion and legalized medical marijuana. Romney opposed both measures, saying the issues should instead be addressed by elected officials.

http://www.latimes.com…

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Comment:

By Don McCanne, M.D.

As if we didn’t need another lesson, the midterm election demonstrates again a very important point. Essentially everyone should be able to agree on health care reform (who could ever be opposed to better health for everyone?), and thus we should be able to bypass partisan politics and join together in fixing our system. The midterm election showed that voters can separate policy from partisanship.

A recent American Barometer poll (HillTV/HarrisX) showed that 52 percent of registered Republicans support Medicare for all (“Would you support or oppose providing Medicare to every American?”). That is in spite of the fact that the Republican politicians spent years trying to repeal the Affordable Care Act. Policy and partisanship are not welded together.

Initially the process that led to the Affordable Care Act was bipartisan, even if some memories suppress that fact. It was only because of a political decision made by Senate Republican leader Mitch McConnell to use this process to discredit President Obama that the Republicans in the committees shifted to an adversarial position. On the Democratic side they had already decided to abandon single payer in an effort to meet the Republicans on common ground (in spite of the popularity of Medicare for all).

A clear majority of the people want Single Payer Medicare for All, but the opposition remains primarily in the ranks of the politicians. The midterms show that Republican voters can vote for their candidates while still supporting policies that have widespread public support.

Advocates for Single Payer Medicare for All should expand their target for their educational endeavors beyond the the progressives and include conservatives as well. It will be the political base in each party that sends the messages to the politicians. Essentially everyone, except the extreme fringe, wants health care for all. All politicians need to understand that.

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

By John Tozzi
Bloomberg, November 7, 2018

Obamacare repeal is officially dead. On to the battle over Medicare for All.

Tuesday’s midterm victories by Democrats mean that Republicans no longer have a path to make major changes to the Affordable Care Act. It also sets up a debate between Democrats’ liberal and moderate wings over whether to embrace a broad expansion of insurance to all Americans as they prepare to challenge President Donald Trump for the presidency in 2020.

Tuesday’s midterm victories by Democrats mean that Republicans no longer have a path to make major changes to the Affordable Care Act. It also sets up a debate between Democrats’ liberal and moderate wings over whether to embrace a broad expansion of insurance to all Americans as they prepare to challenge President Donald Trump for the presidency in 2020.

Once considered an outlier position, Medicare for All has gained substantial support among Democrats thanks to midterm primary victories by progressives who embraced it.

In its broadest terms, the proposal would expand benefits in Medicare — which covers more than 50 million elderly or disabled Americans — and offer it to working age people. It would be a radical change to U.S. health care, potentially dismantling much of an existing system where people get health benefits through work. It would also shift trillions of dollars that the country currently spends on private insurance.

“Medicare for All has really been a slogan that has not been well-defined, and it was weaponized by the Republican party as some kind of an attempt to socialize the medical system,” said Dan Mendelson, founder of the consulting group Avalere Health.

“It’s really going to be important for anyone running for president to define what they mean by Medicare for All,” he said.

https://www.bloomberg.com…

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Quick: What’s The Difference Between Medicare-For-All and Single-Payer?

By Samantha Young
Kaiser Health News, November 5, 2018

Across the country, catchphrases such as “Medicare-for-all,” “single-payer,” “public option” and “universal health care” are sweeping state and federal political races as Democrats tap into voter anger about GOP efforts to kill the Affordable Care Act and erode protections for people with preexisting conditions.

Voters have become casualties as candidates toss around these catchphrases — sometimes vaguely and inaccurately. The sound bites often come across as “quick answers without a lot of detail,” said Gerard Anderson, a professor of public health at the Johns Hopkins University Bloomberg School Public Health.

“It’s quite understandable people don’t understand the terms,” Anderson added.

For example, U.S. Sen. Bernie Sanders (I-Vt.) advocates a single-payer national health care program that he calls Medicare-for-all, an idea that caught fire during his 2016 presidential bid.

But Sanders’ labels are misleading, health experts agree, because Medicare isn’t actually a single-payer system. Medicare allows private insurance companies to manage care in the program, which means the government is not the only payer of claims.

What Sanders wants is a federally run program charged with providing health coverage to everyone. Private insurance companies wouldn’t participate.

In other words: single-payer, with the federal government at the helm.

https://khn.org…

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Comment:

By Don McCanne, M.D.

The concept of Medicare for all has grown in popularity to the extent that many of the pundits have stated it was a significant driving force in the midterm election. But the media reports suggest that there is confusion as to just what Medicare for all means.

“Medicare for all” for many years has referred rigidly to a single payer national health program – an improved and expanded version of Medicare that includes everyone. Because of the popularity of the term, many politicians latched onto it, suggesting that the ultimate goal was to make health care coverage universal but without defining what that coverage would be, while, in the meantime, they suggest perhaps Medicare could be offered as another option in the health insurance marketplace. They then use the Medicare for all label to refer to this strategy. Of course, when it has already been defined as a single payer system, this is a clear misuse of the Medicare for all label.

Now this mislabeling is getting worse, further confusing the general public. The very reliable Kaiser Health News says that Bernie Sanders’ use of Medicare for All is misleading because his is not a single payer system since Medicare allows the option of selecting private Medicare Advantage plans, even though the intent of single payer is to eliminate private plans. The Bloomberg article says that, in its broadest terms, Medicare for all would be offered to working age people – not exactly a broad definition.

Little does it matter that the improved version of Medicare that is called Medicare for all would be a true single payer system. Not only have the incrementalists lifted the Medicare for all label, they now seem to want to deny its use for the single payer model that not only was the original model for that label but is also the model for which the label is actually descriptive – Medicare for all.

We need to keep the Medicare for all label to be used to describe the real thing, perhaps making it clear by calling it “Single Payer Medicare for All,” as mentioned in in prior commentary. And what should we call those models such as the Medicare public option that leaves much of the dysfunctional system in place? In this age of Trump rhetoric, perhaps we should label those alternate proposals “Fake Medicare for Some.”

(Thanks to John Walsh for the suggestion of the “Fake” label.)

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

Health care: Embrace single payer but maybe settle for less

By Elizabeth Aguilera
CALmatters, November 6, 2018

As the incoming Newsom administration prepares to unveil its legislative priorities, the single-payer health care concept he has touted will generate a lot of talk. But Capitol skeptics say that despite his promises to make it happen, action will be much more difficult—especially given the idea’s federal obstacles and huge costs.

Newsom may be more likely to initially pursue a less ambitious strategy: getting more of the uninsured covered under current government programs.

Except that is not what he promised the California Nurses Association, the powerful union that then endorsed and enthusiastically campaigned for him. The union says it’s not going to take no for an answer, and plans to insist on meetings with the governor-elect about how to move forward as soon as he takes office.

“Given the statements that Newsom made at our convention a year ago, we believe he is fundamentally committed to changing the health care system,” said Stephanie Roberson, director of government relations for the union. “He said that in a room full of nurses. His sentiments were very clear.”

Extending health care to all Californians has been, hands down, Newsom’s signature health issue.

In a January gubernatorial debate, he said: “I’m also very enthusiastic about taking a system that’s fragmented, that’s disjointed, that’s complicated and wasteful, and building a new system. Not on top of it, but replacing the existing system with a single payer financed system of universal quality health care.”

Newsom, the one-time mayor of San Francisco, pledged to create a statewide universal health care program of the sort he backed when he was leading that city. The Healthy San Francisco program, primarily funded from city coffers, provides basic insurance to residents who lack access to health insurance regardless of legal status.

Although it is not a single-payer system, the governor-elect has often cited it to illustrate his commitment to coverage.

The model would not work across the state but it has the right goals and values, said Anthony Wright, executive director of Health Access California, which advocates for consumers.

“He’s talked about wanting to take concrete tangible steps toward to the goal of affordable health care for all,” said Wright. “He’s talked about the vision of Medicare for all and universal coverage. He’s also been wide-eyed about the barriers to that goal.”

Those challenges will likely keep Newsom from pushing for single-payer out of the gate, said Gerald Kominski, senior fellow at the UCLA Center for Health Policy Research. “He understands the barriers are difficult to overcome,” said Kominski. “I suspect he’ll support ways to reduce the remaining uninsured further.”

As lieutenant governor, Newsom praised a bill that aimed to set up universal health care, but failed. It would have barred private insurers, and set up a state system funded by taxes and required for all residents. It was a tough sell.

Roberson of the nurses union said a new bill in the works will be a fine-tuned version of that bill. “What it’s going to take is political will, to sit in a room and not emerge until we find a way to reach that goal,” she said.

https://calmatters.org…

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California Dreamin’? With Newsom’s Win, Single-Payer Unlikely To Follow Anytime Soon

By Samantha Young
California Healthline, November 6, 2018

Californians on Tuesday elected a governor who campaigned for a complete overhaul of how people get their health coverage — but they shouldn’t hold their breath.

Rather, as Gov.-elect Gavin Newsom and the Democratic-controlled legislature take steps to provide more people with health insurance, they’ll likely approach it piecemeal over several years.

Newsom himself is already tempering expectations about California’s move to a single-payer system, saying it will take more than the will of one person to realize.

“I’m not going to hesitate to be bold on this issue, and I also want to set expectations,” Newsom told reporters last week at a campaign stop in Sacramento. “It’s a multiyear process.”

Undaunted, the California Nurses Association said it intends to bring another single-payer bill before the legislature next year and has launched a national campaign to pass single-payer in other states and convince Congress of its merits.

Lawmakers earlier this year directed a council to study the feasibility of a publicly funded health insurance plan, and its findings aren’t due until 2021 — giving the new governor and lawmakers time to punt on the issue.

http://californiahealthline.org…

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Comment:

By Don McCanne, M.D.

Single payer advocate Gavin Newsom has been elected governor of California, and it looks like he will have a supermajority of Democrats in the state legislature. Sounds like the ideal time to move forward with the first state-level single payer system to serve as an example for the nation, much as Saskatchewan did in Canada. Sounds like the ideal time, but is it?

In a personal conversation I had with Lt. Gov. Newsom a few years ago, he indicated to me his strong support for single payer as being the most efficient and effective model of reform, but he also indicated that there were many barriers that had to be negotiated and thus it might not happen on the state level in one piece of legislation, especially since federal cooperation would be mandatory (and that would not be forthcoming right now).

Single payer supporters understandably become nervous when Newsom emphatically endorses single payer but then expresses reservations, indicating, “it’s a multiyear process.” They seem apprehensive that he may be backing off on his promise to support single payer reform. But actually his position has been consistent all along. He wants single payer, but you cannot throw pragmatism to the wind. You can only do what you can do.

Nobody should be pessimistic. In fact, this is the time for optimism. Support for Single Payer Medicare for All has grown throughout the nation. California is in a position to take a leadership role in advancing the cause.

Right now California can move forward with whatever is possible on a state level while at the same time supporting work on a national level over the next two years so that in 2020 we will be ready with definitive federal legislation for a newly elected Congress and administration that is dedicated to enacting and implementing Single Payer Medicare for All. The homework has to be done in advance. We cannot let state hurdles and Fake Medicare for Some interfere with our progress. We’re perfectly situated for a two year plan, and the time to begin instituting it is yesterday.

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

By Atul Gawande
The New Yorker, November 12, 2018

My hospital had, over the years, computerized many records and processes, but the new system would give us one platform for doing almost everything health professionals needed—recording and communicating our medical observations, sending prescriptions to a patient’s pharmacy, ordering tests and scans, viewing results, scheduling surgery, sending insurance bills. With Epic, paper lab-order slips, vital-signs charts, and hospital-ward records would disappear. We’d be greener, faster, better.

But three years later I’ve come to feel that a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me. I’m not the only one. A 2016 study found that physicians spent about two hours doing computer work for every hour spent face to face with a patient—whatever the brand of medical software. In the examination room, physicians devoted half of their patient time facing the screen to do electronic tasks. And these tasks were spilling over after hours. The University of Wisconsin found that the average workday for its family physicians had grown to eleven and a half hours. The result has been epidemic levels of burnout among clinicians. Forty per cent screen positive for depression, and seven per cent report suicidal thinking—almost double the rate of the general working population.

Something’s gone terribly wrong. Doctors are among the most technology-avid people in society; computerization has simplified tasks in many industries. Yet somehow we’ve reached a point where people in the medical profession actively, viscerally, volubly hate their computers.

Human beings do not only rebel. We also create. We force at least a certain amount of mutation, even when systems resist. Consider that, in recent years, one of the fastest-growing occupations in health care has been medical-scribe work, a field that hardly existed before electronic medical records. Medical scribes are trained assistants who work alongside physicians to take computer-related tasks off their hands. This fix is, admittedly, a little ridiculous. We replaced paper with computers because paper was inefficient. Now computers have become inefficient, so we’re hiring more humans. And it sort of works.

The story of modern medicine is the story of our human struggle with complexity. Technology will, without question, continually increase our ability to make diagnoses, to peer more deeply inside the body and the brain, to offer more treatments. It will help us document it all—but not necessarily to make sense of it all. Technology inevitably produces more noise and new uncertainties.

https://www.newyorker.com…

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Comment:

By Don McCanne, M.D.

Almost no one should be surprised by Atul Gawande’s observations on the physicians’ role in the use of computerized medical records. The trade-offs have been almost unbearable. He discusses the solution of using medical scribes, yet “research has found error rates between twenty-four and fifty per cent in recording key data.”

Although he says that the use of scribes “sort of works,” that really isn’t a satisfactory solution. Does anyone think that Gawande will do much better as he crafts the Bezos/Buffett/Dimon-sponsored solution to the problems with our health care system? At least it seems clear that we should not take a wait-and-see approach before we decide to move forward with Single Payer Medicare for All. We should do that right now.

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

By Suzanne Gordon
Cornell University Press

The publisher’s book description:

U.S. military conflicts abroad have left nine million Americans dependent on the Veterans Health Administration (VHA) for medical care. Their “wounds of war” are treated by the largest hospital system in the country—one that has come under fire from critics in the White House, on Capitol Hill, and in the nation’s media. The resulting public debate about the future of veterans’ health care has pitted VHA patients and their care-givers against politicians and policy-makers who believe that former military personnel would be better served by private health care providers.

This high stakes controversy led Suzanne Gordon, award-winning health care journalist and author, to seek insight from veterans and their families, VHA staff and administrators, advocates for veterans, and proponents of privatization. Gordon spent five years closely observing the VHA’s treatment of patients suffering from service related injuries, physical and mental.

In Wounds of War, Gordon describes how the VHA – tasked with a challenging patient population – does a better job than private sector institutions offering primary and geriatric care, mental health and home care services, and support for patients nearing the end of life. The VHA, Gordon argues, is an integrated health care system worthy of wider emulation, rather than piece-meal dismantling for the benefit of private contractors. In the unusual culture of solidarity between patients and providers that the VHA has fostered, the author finds a working model for higher quality health care and a much-needed alternative to the practice of for-profit medicine.

Brief excerpts from the book, “Wounds of War”:

In this book I focus on how the VHA accomplishes its multiple missions and functions differently from its private-sector counterparts, whose care delivery is more costly, fragmented, and market-driven. As the largest health care system in the country, the VHA has its share of problems. But overall, as the studies and experiences I will cite convey, the VHA provides high-quality care to a very complicated patient population.

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Several years ago, when I was visiting the VA Medical Center in West Haven, Connecticut, where my daughter worked, I joined a meeting with visiting staff from the UK’s National Health Service. The assembled British doctors, nurses, psychologists, social workers, and administrators had just trooped through one of the most prestigious teaching hospitals in the United States, the nearby Yale New Haven medical center. They were clearly grappling with the contradictions of what they had just seen. At a well-endowed institution, patients arrived in the emergency room with no insurance, they were discharged prematurely, medical specialists commanded huge salaries unheard of in their own country, primary care seemed undervalued, inter-professional training was spotty, caregivers of all kinds had no union voice, and coordination of care was, well, not exactly “world class.”

And then the UK delegation toured the veterans’ hospital just a few miles away from Yale New Haven. As they sat with VHA caregivers afterward, asking questions and exchanging information in a government-issue conference room, the same realization sank in: they had finally landed in a system – an actual system in the United States – that worked much like their own back home. One doctor finally asked the question on every visitor’s mind. “Why,” he wondered out loud, “do you have to be a military veteran to get this level of care in America? Why isn’t it available to all Americans?” Why indeed.

http://www.cornellpress.cornell.edu…

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Unreliable Sources: How Corporate Funders Influenced Mass Media Coverage of Veterans’ Healthcare

By Suzanne Gordon and Jasper Craven
Veterans Healthcare Policy Institute

Phoenix is where today’s deep disdain of the VA first germinated. In the summer of 2014, evidence emerged that administrators at the VA Phoenix hospital had tampered with scheduling data, leaving veterans to wait months for an appointment. The scandal spurred passage of the Veterans Access, Choice and Accountability Act, which made it much easier for veterans to seek care in the private sector, and ignited a deeply divisive national debate over the government’s ability to deliver health care.

When the Phoenix scandal broke, Concerned Veterans for America (CVA) was a fledgling advocacy group working from the fringes. As the Washington Monthly reported, the group’s staff – led by telegenic veteran Pete Hegseth – brilliantly packaged, framed and fed the Phoenix story to a salivating news media desperate for a scandal in the Obama administration. The most serious charges out of Phoenix – that veterans died because they were unable to access care – were never substantiated. The cover up of wait times was more indicative of the agency’s chronic capacity and funding challenges than anything else – issues that to this day have not been meaningfully addressed.

Today, CVA holds incredible sway in Washington. Numerous CVA officials have entered President Donald Trump’s White House, or his Department of Veterans Affairs. Hegseth is now an anchor on the president’s favorite morning news show, Fox & Friends. And the group has built an incredibly effective organizing and messaging apparatus.

What is left out of most coverage is the voices of veterans who have been helped by the VA, as are studies demonstrating the high quality of VA care or explaining the countless challenges of privatization.

The RAND Corporation has been studying VA care since at least the early aughts, and its findings have consistently given the VA high marks while warning that the private sector is unprepared to deal with the complex needs of veterans.

This year alone, RAND has released two comprehensive studies: one that documented the excellence of VA healthcare; the other which revealed the gross inadequacies of New York state’s private healthcare system to treat veteran patients. Neither report attracted serious media attention.

https://www.veteranspolicy.org…

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Comment:

By Don McCanne, M.D.

Believe it or not, we have several individuals in our government who do not believe in government, but rather claim to believe that the private sector can always do things better. Right now the privatizers are taking advantage of a few problems that exist in the Veterans Health Administration (VHA), and they are attempting to switch more veterans’ services to the private sector. The media has been complicit in covering only the problems and leaving out the real story of the VHA. Suzanne Gordon’s thoroughly researched and highly credible book – “Wounds of War” – describes the phenomenal accomplishments of the VHA and what that means for our veterans with service-connected health care needs.

“Wounds of War” should be mandatory reading for all legislators and government administrators who really do care about the welfare of our veterans. At the same time, we all need to be aware of the distortion of the perception of the VHA caused by the selective reporting of the supposedly reliable media of only the problems, and nothing about the great care veterans are receiving. The disinformation campaign is so intense that even many of the veterans themselves believe that the VHA is bad everywhere except at the facility where they happen to be. Their view? “Don’t fire anyone here – everyone here is a great, dedicated caregiver, driven by their commitment to veterans. As for everywhere else, heads should roll.”

If a cockroach crawled across Leonardo da Vinci’s “The Last Supper” would the painting be condemned and sent to a flea market? No? Then why do they want to take comparable action against the VHA?

At the national PNHP meeting in San Diego this weekend, Saturday, November 10, Suzanne Gordon will be conducting a workshop on this topic. If you can’t make it, at least read her book. Even if you do go, read it anyway.

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

Notice of Proposed Rule Making

Department of the Treasury
Department of Labor
Department of Health and Human Services

Published in the Federal Register, October 29, 2018

Summary: This document sets forth proposed rules to expand opportunities for working men and women and their families to access affordable, quality healthcare through proposed changes to regulations under various provisions of the Public Health Service Act (PHS Act), the Employee Retirement Income Security Act (ERISA), and the Internal Revenue Code (Code) regarding health reimbursement arrangements (HRAs) and other account-based group health plans. (For simplicity, this preamble generally refers only to HRAs, but references to HRAs should also be considered to include other account-based group health plans, unless indicated otherwise.) Specifically, these proposed rules allow integrating HRAs with individual health insurance coverage, if certain conditions are met. The proposed rules also set forth conditions under which certain HRAs would be recognized as limited excepted benefits. Also, the Department of the Treasury (Treasury Department) and the Internal Revenue Service (IRS) propose rules regarding premium tax credit (PTC) eligibility for individuals offered coverage under an HRA integrated with individual health insurance coverage. In addition, the Department of Labor (DOL) proposes a clarification to provide plan sponsors with assurance that the individual health insurance coverage the premiums of which are reimbursed by an HRA or a qualified small employer health reimbursement arrangement (QSEHRA) does not become part of an ERISA plan, provided certain conditions are met. Finally, the Department of Health and Human Services (HHS) proposes rules that would provide a special enrollment period in the individual market for individuals who gain access to an HRA integrated with individual health insurance coverage or who are provided a QSEHRA. The goal of these proposed rules is to expand the flexibility and use of HRAs to provide more Americans with additional options to obtain quality, affordable healthcare. The proposed rules would affect employees and their family members; employers, employee organizations, and other plan sponsors; group health plans; health insurance issuers; and purchasers of individual health insurance coverage.

https://s3.amazonaws.com…

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Administration Moves To Incentivize Health Reimbursement Arrangements

By Katie Keith
Health Affairs Blog, October 26, 2018

On October 23, 2018, the Departments of Health and Human Services, Labor, and Treasury issued a new proposed rule to expand the use of health reimbursement arrangements to fund access to health insurance and health care. The proposed rule was developed in response to President Trump’s executive order from October 2017 that directed the federal government to expand access to short-term, limited-duration insurance, association health plans, and health reimbursement arrangements (HRAs).

In the executive order, President Trump directed the Departments to “increase the usability of HRAs, to expand employers’ ability to offer HRAs to their employees, and to allow HRAs to be used in conjunction with nongroup coverage.” As expected by many health policy watchers, the new rule would reverse prior Departmental guidance by allowing HRAs to be used to fund both premiums and out-of-pocket costs associated with individual health insurance coverage.

The proposed rule would also create a new “excepted benefit HRA” option that employees could use to pay premiums for excepted benefits policies and short-term, limited-duration insurance policies.

From the Implications

The rule could lead the loss of coverage if employers stop offering group health plans in lieu of an HRA, and their employees do not accept the HRA or obtain other coverage. The rule could also affect individuals who currently qualify for and receive marketplace subsidies while working for an employer who does not offer health coverage. Under the proposed rule, the offer of an “affordable” HRA-IIHIC would make an employee ineligible to receive a premium tax credit. As a result, some employees could pay more for coverage under the HRA-IIHIC option than they were paying if they received a premium tax credit through the marketplace. Consumers may also face higher cost-sharing in the individual market relative to what they received through a group health plan, and the HRA-IIHIC option could impose higher administrative and compliance burdens on consumers who must navigate a seemingly new system.

Whether these changes would be good for the individual market risk pool remains to be seen and would depend largely on the risk profile of employees offered the new HRA-IIHIC option. The Departments repeatedly note the concern that expanding access to HRAs could lead to employers offering coverage options to employees in a way that discriminates based on health status. At one point, the Departments state their goal to “prevent large-scale destabilization of the individual market” through the proposed rule.

On the other hand, there is the possibility that employees who enter the individual market through an HRA-IIHIC would be healthier on average, which could lead to a better risk profile for the individual market, and thus lower premiums and an even more stable marketplace. This could be especially true if sicker employees hold on to their group health plans, which might be more comprehensive than individual market coverage.

Overall, the proposed rule comes at a seemingly odd time. In the preamble, the Departments describe the various market reforms and structure of the ACA as “intend[ed] to create a robust and competitive individual market, in part by ensuring that risk pools included both higher risk and lower risk individuals.” Given this, the Departments seem comfortable with incentivizing—or at least opening up the possibility for—employees to receive coverage through the individual market, thereby further expanding that market. They do so even as President Trump and senior political leaders continue to argue, as recently as yesterday, that the ACA and the individual market are deeply flawed and broken with “deteriorating market conditions.”

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

The Trump administration is now proposing expanding the use of health reimbursement arrangements (HRAs) with the intent of moving more individuals from employer-sponsored plans and into the individual market, fulfilling the administration’s ideological preference for competition in the private marketplace.

If you are really curious about the details of their proposal, you can read the couple hundred pages of the proposed rule, or the long article by Katie Keith, briefly excerpted above. But understanding this proposal is not the purpose of today’s message. Rather it is to get a glimpse of the bizarre machinations in health care by this administrations.

Without going into any of the boring details, they are greatly increasing the administrative complexity of health care financing through health reimbursement arrangements, employer-sponsored plans, and plans in the individual market – this by an administration that says that it wants to increase choice and competition, giving more freedom to individuals to exercise their choices in the marketplace.

Administrative complexity is one of the worst features of health care financing in the United States, and yet this administration continues to compound the problem, not only increasing the waste, but further disrupting the important insurance function of pooling risk as they continue to increase fragmentation in health care financing.

Right now they are celebrating CMS Administrator Verma Seema’s tweet: “this year’s scariest Halloween costume – a tee shirt emblazoned with ‘Medicare for All.'” She followed up with, “Did I get your attention? Good. Medicare for All isn’t a joke. It’s a multi-trillion dollar drain on the American economy that will bankrupt future generations. It’s government controlled health care that will strip choice away from millions. It’s a bad idea. And it IS scary.”

Seema Verma has the solution to our health care financing problems right in front of her in her own department, and she ridicules it. What’s really scary is leaving these people in charge.

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Mark Farrah Associates, October 31, 2018

As of October 1, 2018, total Medicare Advantage (MA) membership stood at over 21 million, representing approximately 34% of the 63.3 million Americans eligible for Medicare. Medicare Advantage plans can either be acquired individually through direct purchase policies or through employer/group retiree programs, commonly known as Medicare Advantage Employer Group Waiver Plans (MA-EGWPs). Since the inception of Medicare Advantage in 2003, Individual MA policies have historically dominated the market as 17.1 million beneficiaries purchased MA plans as of October 1, 2018. However, despite a decrease over the years in the number of private sector employers offering retiree health benefits, membership trends in MA-EGWPs have demonstrated notable enrollment growth, especially within the past two years.

Since December 2017, employer-group Medicare Advantage enrollment has increased by over 443 thousand. In fact, over the past four years, group market enrollment has increased by approximately 1 million members, nearly a 125% increase in enrollment since December 2015. This brief provides insights about the current employer-group Medicare Advantage market and assesses membership trends over the past four years by carrier and state.

https://www.markfarrah.com…

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Comment:

By Don McCanne, M.D.

The continued growth in enrollment in private Medicare Advantage plans should be of concern to those who support Single Payer Medicare for All. The privatized Medicare program would not be suitable for a single payer system for the obvious reason that it would be a multi-payer system using private sector insurance plans.

This report shows that there is even more rapid growth in Medicare Advantage Employer Group Waiver Plans (MA-EGWPs) – plans that are used for employer/group retiree programs. Locking retired employees into these plans would make it even more difficult to transition into Single Payer Medicare for All since retirees tend to be quite supportive and defensive of their health benefit programs.

Right now there is an intensive effort taking place to defer, perhaps forever, the enactment of Single Payer Medicare for All through a strategy to create a Medicare for Some by offering the purchase of Medicare as an option (a public option) for those currently not yet qualified for Medicare. It is highly likely that the public option will be private health plans comparable to the Medicare Advantage plans, just as the plans offered in the government exchanges under the Affordable Care Act are private health plans.

In the meantime, the traditional Medicare program is being neglected, likely by design, and, as such, it would be unsuitable for Single Payer Medicare for All without significant improvements. However, as the private Medicare Advantage plans become more pervasive within the system, there is great risk that the traditional Medicare program will be reduced to a Medicaid-style welfare program, if not entirely abandoned.

The more we accept these incremental changes such as the Medicare Advantage Employer Group Waiver Plans and the pending Medicare Advantage public option – Medicare for Some – the greater the likelihood that we will never see Single Payer Medicare for All. As a reminder, Single Payer Medicare for All corrects the major deficiencies in health care financing, making health care equitable, accessible, and affordable for everyone, whereas the Public Option Medicare for Some perpetuates our highly dysfunctional, fragmented, inequitable, and often unaffordable health care financing system and merely adds one more option that increases the administrative complexity of our system.

The Medicare Advantage Employer Group Waiver Plans may seem relatively benign and perhaps even an incremental benefit, but these creeping programs are locking in stone a privatized system that is not even worthy of the name “Medicare.” The longer we wait, and the more we tolerate creeping incrementalism, the less likely we’ll ever see Single Payer Medicare for All.

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