PNHP

CMS fails to verify benefits of waivered Medicaid demonstration projects

CMS fails to verify benefits of waivered Medicaid demonstration projects

As Trump Pushes Medicaid Testing, the Grading Falls Short

By Robert Pear
The New York Times, March 4, 2018

The Trump administration is hoping to transform Medicaid by allowing states to test work requirements, premiums and other conservative policies, but a new government report says federal and state officials do not properly evaluate whether such experiments improve patient care or reduce costs.

Evaluations “generally lacked rigor,” and the findings were often kept secret for years, so they were of little use to policymakers, the Government Accountability Office, a nonpartisan investigative arm of Congress, said in the report issued last month.

Under federal law, the secretary of health and human services can waive certain Medicaid requirements so states can use federal money for the program in ways that would not ordinarily be allowed — for example, to cover people and services that would not otherwise be covered.

These waivers have been used for demonstration projects testing innovative ideas and involving millions of people and tens of billions of federal dollars. The Government Accountability Office said the number and scope of Medicaid waivers had grown in recent years, with demonstration projects now accounting for one-third of all federal Medicaid spending — and more than 75 percent in 10 states, including Texas.

The main purpose of the waivers, according to the report, is to test and evaluate new ways of providing coverage and care to people with modest incomes. But, it said, waivers have become a vehicle for wholesale changes in Medicaid, and neither federal nor state officials adequately assess the results. The evaluations have been plagued by “significant methodological weaknesses” and often leave critical questions unanswered, the report said.

The Trump administration has been flooded with requests from states seeking Medicaid waivers. They want to impose work requirements, charge premiums, suspend coverage for people who fail to pay premiums, and restrict eligibility or benefits in other ways. A few states would like to impose time limits on Medicaid coverage for some beneficiaries.

The Government Accountability Office found particular problems in the evaluation of a Medicaid waiver granted to Indiana. The state expanded Medicaid, as permitted under the Affordable Care Act, but obtained a federal waiver for policies emphasizing “personal responsibility,” including monthly premiums and incentives for healthy behavior.

The federal government wanted to know how Medicaid beneficiaries were affected by those changes, but it could not get the data it needed from the state, so its evaluation was severely limited, the Government Accountability Office said.

Conservatives see Indiana’s Medicaid program as a model, and other states are following suit. The architects of the Indiana plan include Vice President Mike Pence, who was the governor of Indiana from 2013 to January 2017, and Seema Verma, a consultant to the state who is now the administrator of the federal Centers for Medicare and Medicaid Services.

https://www.nytimes.com…

Government Accountability Office; Medicaid Demonstrations:
https://www.gao.gov…

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Success of Pence’s Medicaid expansion far from settled

By Virgil Dickson
Modern Healthcare, July 25, 2016

The success of the conservative approach to Medicaid devised by Indiana Gov. Mike Pence—Donald Trump’s pick for vice president—is a mixed bag so far, according to a report that offers fodder for both sides of the political spectrum.

A new analysis funded by the state shows both positive and concerning elements to Indiana’s alternative Medicaid expansion.

The report also comes as Indiana state officials continue to raise objections to the CMS performing its own analysis to see if Pence’s Medicaid expansion has been harmful to beneficiaries. Pence has argued there is no need for the agency to perform its own evaluation because the state already commissioned a report by the Lewin Group, an independent consultancy.

http://www.modernhealthcare.com…

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Trump approves Arkansas Medicaid work requirements

By Nathaniel Weixel
The Hill, March 5, 2018

Arkansas on Monday became the third state to get the Trump administration’s permission to impose work requirements on Medicaid beneficiaries.

The Centers for Medicare and Medicaid Services approved a Medicaid waiver that included a requirement for recipients to work, or participate in job training or job search activities for 80 hours a month.

State officials said they will begin implementing the work requirements June 1, making them the first state to do so. If a person fails to meet the requirements for three months, he or she will lose coverage for the rest of that calendar year.

http://thehill.com…

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Comment:

By Don McCanne, M.D.

Section 1115 Medicaid waivers allow states, with the approval of CMS, to establish demonstration projects that waive certain requirements of the Medicaid program as long as the objectives of the program are met. At the end of the waiver period, the results are to be formally evaluated. The GAO report shows us that these evaluations “lack rigor” and have not been released to provide important research results to the policy community.

Particularly important was the evaluation of the Indiana Medicaid waiver since it put into effect the conservative ideological preferences of Gov. Mike Pence (now vice-president) and Medicaid consultant Seema Verma (now CMS administrator). They contracted for a private study by the Lewin Group while fighting off a CMS evaluation. That is important because they both have touted the great advantages of their patient-empowerment Medicaid program when there is virtually no objective public data to show benefit – only the biased (and not all that impressive) report purchased from the Lewin Group.

Today, Arkansas followed Kentucky and Indiana to become the third state to be granted work requirements for Medicaid beneficiaries – a policy move based on conservative ideology rather than on patient benefit. We can anticipate a further expansion of anti-welfare warfare by the current administration.

When health care coverage is eventually expanded to cover everyone, it will be important to avoid segregating low-income individuals and families into an isolated welfare program. Such a program would always be vulnerable to attacks from anti-government political ideologues. Instead we need a universal egalitarian program that treats everyone fairly – a national single payer improved Medicare for all.

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Americans already believe that everyone should have the right to affordable health care

Americans’ Views on Health Insurance at the End of a Turbulent Year

By Sara R. Collins, Munira Z. Gunja, Michelle M. Doty, Herman K. Bhupal
The Commonwealth Fund, March 1, 2018

The Commonwealth Fund Affordable Care Act Tracking Survey interviewed a random, nationally representative sample of 2,410 adults ages 19 to 64 between November 2 and December 27, 2017.

Do you think all Americans should have the right to affordable health care?

92% – Yes
7% – No
1% – Don’t know/Refused

Asked of the 8% who said no or don’t know/refused:

What if everyone had to contribute financially over their lifetime in order to have the right to affordable health care? Under those circumstances would you consider affordable health care to be a right?

29% – Yes
58% – No
13% – Don’t know/Refused

From the Policy Implications:

This survey’s finding that strong majorities of U.S. adults, regardless of party affiliation, believe that all Americans should have a right to affordable health care suggests there may be popular support for a discussion over our preferred path.

http://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

It has often been said that we cannot enact single payer Medicare for all until Americans agree that health care is a right. This survey shows that 94 percent of adults under 65 already agree that “all Americans should have the right to affordable health care.” Most of those over 65 already have it.

Let’s move on. We have work to do.

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The Kerner Commission 50 years later

The Unmet Promise of Equality

By Fred Harris and Alan Curtis
The New York Times, February 28, 2018

“Our nation is moving toward two societies, one black, one white – separate and unequal.”

Fifty years ago, on March 1, 1968, these were the grim words of the National Advisory Commission on Civil Disorders, called the Kerner Commission after its chairman, Gov. Otto Kerner of Illinois.

President Lyndon Johnson had established the commission to examine the disorders and violent protests in Detroit, Newark and well over 100 other American cities during the summer of 1967, and earlier. What it found was searing. “What white Americans have never fully understood – but what the Negro can never forget – is that white society is deeply implicated in the ghetto,” the commission concluded. “White institutions created it, white institutions maintain it, and white society condones it.”

The Kerner Commission recommended “massive and sustained” investments in jobs and education to reduce poverty, inequality and racial injustice. Have we made progress in the last 50 years?

A Return to Segregation

In many ways, things have gotten no better — or have gotten worse — since 1968. Public schools have been re-segregating for decades.

Inequality That Would Shock the Commission’s Members

The disheartening percentage of Americans living in extreme poverty — that is, living on less than half the poverty threshold — has increased since the 1970s.

The Tragedy of Mass Incarceration

At the time of the Kerner Commission, there were about 200,000 people behind bars. Today, there are about 1.4 million. Mass incarceration has become a kind of housing policy for the poor.

Fifty Years Later, We’ve Figured Out What Works

Policies based on ideology instead of evidence. Privatization and funding cuts instead of expanding effective programs.

We’re living with the human costs of these failed approaches. The Kerner ethos — “Everyone does better when everyone does better” — has been, for many decades, supplanted by its opposite: “You’re on your own.”

Today more people oppose the immorality of poverty and rising inequality, including middle-class Americans who realize their interests are much closer to Kerner priorities than to those of the very rich.

We have the experience and knowledge to scale up what works. Now we need the “new will” that the Kerner Commission concluded was equally important.

What Doesn’t Work and What Does

The Economic Playing Field

Doesn’t – Reduced health care for workers and low-income Americans
Does – Insured health care through a single-payer system

Doesn’t – Small, grudging increases to minimum wage
Does – Substantial increases to minimum wage

Doesn’t – No new tax credits or child allowances
Does – Expansion of the Earned Income Tax Credit to reduce gaps in wealth and income

Doesn’t – Supply-side, trickle-down economics for the rich and corporations; enterprise zones with corporate tax breaks
Does – Demand-side, full-employment Keynesian economics for all Americans

(Use the link to view what doesn’t and does work in the other categories of Jobs, Education, Housing, and the Justice System.)

Fred Harris, a former senator from Oklahoma, is a professor emeritus of political science at the University of New Mexico and the lone surviving member of the Kerner Commission. Alan Curtis is the president and chief executive of the Eisenhower Foundation, the private-sector continuation of the 1968 Kerner Commission and the 1969 National Violence Commission. The two are the co-editors of “Healing Our Divided Society: Investing in America Fifty Years After the Kerner Report.”

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

There was some good news following the release of the Kerner Commission report half a century ago and that was that the nation made gains in addressing some of the social injustices described in the report. The bad news is that we have since regressed and in some ways are worse off, especially considering the negative consequences of the massive shift to greater inequality in income and wealth.

When you access the article through the link above, the tragic backsliding becomes obvious when glancing at the graphs presented.

However, there is a potential for good news in the future if we listen to the authors of this article – Fred Harris, the lone surviving member of the Kerner Commission, and Alan Curtis, the chief executive of the Eisenhower Foundation. In a table they show us what we have learned about what doesn’t work and what does. Social justice advocates will recognize that they have organized the basics.

One category – the economic playing field – is reproduced above. Single payer advocates do not need an explanation as to why the very first item listed that does work is “insured health care through a single-payer system.” But the other items in the original article are very important as well. That is why it is not enough to limit our advocacy to the one issue of single payer reform, even though that remains the mission of PNHP. We all have to work together in coalition efforts to move forward with the other policies that do work in order to achieve a more just and equitable society – one in which we all do well.

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The End Of Insurance?

Andrew Coates On Fixing Our Broken Healthcare System

By Tracy Frisch
The Sun, March 2018

As a boy growing up in rural upstate New York, Andrew Coates dreamed of becoming a physician. After high school he went through a period of rebellion, dropping out of college and supporting himself with jobs as a carpenter and in factories and restaurant kitchens. Returning to his education, he earned a master’s degree in American history before finally entering medical school at Columbia University at the age of thirty-two. Coates jokes that, unlike most doctors, he “once worked for a living,” adding that he believes his experiences as a young man have benefited him as a physician.

After a residency in internal medicine, Coates took a position at an Upstate New York hospital. There he saw how patients and their families were often made destitute by the high cost of healthcare. In particular, nursing-home care, a necessity for many who survive a devastating illness, is unaffordable for most people. Medicare covers everyone over the age of sixty-five but allows only limited stays in nursing facilities. Medicaid — a joint state-and-federal program for poor Americans — does cover long-term nursing-home care. But to become eligible for Medicaid, people must first empty out their bank accounts and sell their homes and other assets to pay medical bills. Coates saw medical expenses lead to the forfeiture of a family farm, even though three generations were living on the land.

Coates went on to further specialize in hospice and palliative care, which focuses on relieving the pain and stress of serious illnesses. (Hospice patients, for whom death is expected, make up a limited number of palliative-care patients.) In his palliative-care practice he helps people make difficult decisions about care, finding choices that reflect what’s most important to them, with an emphasis on quality of life for the patient and the family. Presently a full-time hospital-medicine physician, he also teaches medical students, interns, and residents at patients’ bedsides as well as in the classroom as a professor of medicine at Albany Medical College.

Coates’s early experiences in the profession have made him an advocate for a single-payer healthcare system, in which the government pays the medical bills of all its citizens, not just the poor and elderly. A public, national health-insurance program would eliminate the need for private health insurance altogether. Vermont senator Bernie Sanders made support for single-payer healthcare a centerpiece of his campaign for president in 2016. Coates believes we need to go a step further than Sanders proposes and also abolish profit-seeking in medicine.

I first became aware of Coates’s work many years ago when I heard him speak at a rally. He is the founder of the healthcare advocacy group Single Payer New York (singlepayernewyork.org) and past president of Physicians for a National Health Program, a physician organization that advocates for a single-payer healthcare system (pnhp.org). He and I spoke on a muggy evening last fall at his home, an old farmhouse surrounded by a suburban neighborhood. We talked for several hours about the inadequacies of the current U.S. healthcare system and his vision of what might replace it. He told me that he continues to find medicine an “incredibly compelling human endeavor.”

Frisch: You’ve been an outspoken champion of a single-payer (publicly funded) healthcare system, which is sometimes known as Medicare for All.

Coates: In my view, single-payer is an incremental step, a reform that pushes us toward a truly efficient and responsible system of healthcare. Single-payer is far from perfect and will not work without a few hard rules, including the elimination of out-of-pocket patient spending for necessary care, a system to annually budget for anticipated health needs for each community, and completely banning profiteering in medicine.

Frisch: Including for pharmaceutical companies and medical-equipment manufacturers?

Coates: Yes. There should be no profiteering in the delivery of healthcare. I’m not talking about whether highly trained physicians, nurses, or their support staff should be able to make a handsome middle-class living. As a society we should be proud to support professional caregivers. That’s different from people making money simply because they own the laboratory or the hospital or the distribution system. For example, nursing homes in the U.S. are mostly owned by private-equity firms like Warburg Pincus, Bain Capital, GE Capital, the Carlyle Group, and others. These corporate owners in turn hire myriad subcontractors to run every aspect of the home, from the kitchen to the janitorial service to the electronic health records to the laundry. And at every step there is someone taking a profit out.

I think it’s appalling that one person’s illness would be an opportunity for another to make money. The care of human beings should not be a commodity. Since the dawn of time people have done their best to tend to the injured or sick. That’s something very basic to humanity. When caregiving becomes a commodity, the goal of health collides with the goal of wealth. In American healthcare today an unbelievable number of interlopers have entered the fray. Their job is to figure out how to extract funds that could otherwise have gone to help the sick.

But the problem isn’t just that there’s money going out of the system. It’s also that this enormous, unnecessary insurance bureaucracy sits on top of the system, making it extremely inefficient.

Research shows that for-profit medical institutions produce inferior outcomes compared to not-for-profit institutions. If we change to a single-payer system, a bedrock requirement should be that all medicine be not-for-profit.

Frisch: What’s wrong with a for-profit system?

Coates: For one, money is often spent in the wrong places. In our town there are two big hospitals, and both have fancy parking garages and gleaming pavilions with pianos that play themselves. I’m not sure how all of this has improved the quality of care.

Frisch: It sounds like they’re just trying to attract patients.

Coates: Sure, if you have a spiffy parking garage and a nice pedestrian bridge that leads right into the ambulatory-surgery center, maybe that gives you a leg up on the competition. These hospitals are not-for-profit, by the way, but they’ve learned to operate like for-profit hospitals in order to compete. Wouldn’t it be something if the people of the community could decide what the experience of getting care should be like, rather than having competition drive showy expenditures? We could address real concerns, such as preventive care.

Frisch: The Affordable Care Act — also known as Obamacare — required that certain preventative services, such as cancer screenings and immunizations, be offered without deductibles, to make it more likely that people will get them.

Coates: Ending out-of-pocket costs is another part of what I see as the bedrock of healthcare reform. When people have to pay out of pocket for necessary care, they often avoid getting it. The policy term for out-of-pocket payments — whether it’s copays, deductibles, coinsurance, or cash payments — is “user fees.” Study after study finds that user fees amount to bad health policy.

Frisch: But if there’s no cost to the patient, what will prevent people from willy-nilly asking for all kinds of tests and procedures and specialists? Wouldn’t we have a hypochondriac’s paradise?

Coates: There’s almost no evidence that this would happen. In places where there’s been an expansion of access to healthcare — like when the U.S. enacted Medicare in 1965 — the system was not sunk by a glut of people seeking unnecessary treatment.

Frisch: A few days ago I spoke to a man who had retired from the police force with good health coverage and was now on Medicare and purchasing supplemental private insurance. He insisted that everyone should pay for healthcare, even poor people on Medicaid.

Coates: What about the nursing-home patients who can’t possibly work because they need round-the-clock care? What about sick children who aren’t yet old enough to have a job or will never be able to work? Is there a right time of life to get cancer, or have a heart attack, or contract an overwhelming infection?

Frisch: I think this former police officer feels he paid his dues. Why should he pay more to care for someone who doesn’t work?

Coates: If we all pay a small percentage of our income into the system, we can ensure that everyone gets care. Sure, some of us, disabled by illness, will not be able to pay. But the rest of us should proudly contribute, with the understanding that we are building a system that protects us all. Who knows when we might suffer an illness that renders us unable to work and therefore unable to contribute? Providing care to the most vulnerable is not altruism. It’s a form of social solidarity that benefits us, too, because someday we will likely need that system ourselves.

Frisch: Some people think undocumented immigrants are abusing the system.

Coates: If you’re undocumented and receive a paycheck, as most undocumented workers do, money is withheld from that check for Social Security and Medicare benefits that you will never be eligible for, because you don’t have a legitimate Social Security number. All of that money goes into the public till. Incidentally, the retired police officer you mentioned, who’s getting Medicare benefits, has his healthcare paid for in part by undocumented laborers. Meanwhile an undocumented worker who paid into Medicare and Social Security will never receive either. Our country’s cruelty toward undocumented immigrants is most shockingly revealed by medical deportations. Sick, hospitalized patients are flown by air ambulance back to their country of origin. This is unethical and a violation of human rights. Some are patients who need dialysis to stay alive after kidney failure. Many times the patient’s home country lacks the infrastructure to provide dialysis, so deportation can amount to a death sentence.

Frisch: Was the Affordable Care Act a step forward?

Coates: The ACA was one step forward, two steps back. It expanded Medicaid eligibility — in the states that chose to participate in the expansion — and also increased funding to health centers that provide care for underserved populations. These measures helped patients gain access to healthcare who previously couldn’t afford it.

Frisch: What about the individual mandate, which requires everyone to buy insurance?

Coates: The mandate has a curious history. Originally thought up by the Heritage Foundation, a conservative think tank, it was first implemented in Massachusetts by the private-equity millionaire and Republican governor Mitt Romney. The idea was to bring the magic of the marketplace to health insurance by forcing everyone to buy it or pay a fine. Barack Obama, the Democratic president, chose to champion the idea for his signature reform effort, initially expecting bipartisan support.

Under the ACA around 20 million Americans gained coverage, mostly through the expansion of Medicaid. These people would not have had insurance otherwise, and I’m sure this saved lives. But many features of Obamacare got much more credit than they deserved. For example take the policy of letting parents keep grown children on their insurance up to the age of twenty-six. The twenty-somethings who benefited all had parents with adequate insurance. That’s a relatively affluent portion of the population. Millions of young adults whose parents had inadequate or no coverage were left out. Nevertheless, within that group who did benefit, there were people who had life-threatening illnesses caught early and as a result got treatment.

Frisch: That’s the one step forward.

Coates: Yes. Then there are the two steps back. To make premiums as low as possible, the Obama reform opened the door for more plans with high deductibles or narrow networks of providers. Deductibles have risen and risen. We routinely hear about patients spending thousands of dollars out of pocket before the insurance kicks in. In short, costs have been pushed onto the sick.

In addition, the Affordable Care Act led to an enormous wave of corporate conglomeration — among hospitals, primary-care networks, insurance companies, and pharmacies — creating huge new entities, all in the search for profit and market share. Large corporate healthcare companies drive costs up, not down.

Frisch: If we had a publicly funded system, wouldn’t there be a constant danger that the party in power might deprive it of resources?

Coates: Sure, but healthcare funding always requires public vigilance, scrutiny, and participation. What better way is there to monitor health outcomes than to make the system public? Some government services are already widely viewed as necessities: having an adequately equipped fire department, for example. An effort to turn firefighting to a private, profit-seeking venture seems ludicrous. In healthcare, if people were used to having access to top-quality care, I believe it would be difficult to starve the system of resources. The health of the people — I can’t think of a more legitimate topic of public discourse for any modern democracy.

Frisch: Would health-insurance companies disappear?

Coates: Hopefully, yes. Competing private health-insurance companies are a very inefficient way to fund healthcare. The idea of insurance is that the larger the risk pool, the more evenly the costs are distributed. So the most perfect risk pool would be everyone in, nobody out. But that’s not how private insurance works. Instead it’s a perverse competition. Insurance companies are not competing to give the best coverage to those who need it most: the sickest among us. They don’t even want those customers. Health-insurance companies compete to find the patients who are both healthy and wealthy, so they will buy policies but not use them.

Frisch: Many employers offer some form of health insurance to their employees. Does that system work?

Coates: Big corporate employers spend so much on healthcare that it affects other decisions they make. Some employers are starting to realize that universal access to healthcare would give them more freedom. There was an entrepreneur in West Virginia who wanted to start an aerospace manufacturing company about a decade ago. I met him. He wanted to put the plant near his hometown, but his investors insisted he put it in Ontario, Canada, because the company’s healthcare costs would be so much less there.

On the other hand, some employers use employer-sponsored health insurance as a form of control over workers.

Frisch: Because employees don’t dare quit?

Coates: There’s job lock. If you have a sick person in your family on your plan, you’re afraid to leave your job, because your loved one needs the coverage. But I’m also thinking of how messed up it is to depend on your employer or your spouse or your parents for health coverage. Other forms of social control include how some employers demand a note from a doctor if you take sick days. And when you start a new job, if it offers health insurance, there’s a probationary period — three, six, or even twelve months — before you have access to the benefits. And I’ve heard of other insidious practices, like smokers having to pay more than nonsmokers and employees having to prove that they exercise.

Frisch: Some employees go on strike because their healthcare is so bad.

Coates: If you try to organize a strike, you will find your health insurance canceled as soon as the strike starts. Most union contract bargaining gets stuck over health benefits these days. With universal healthcare, unions could instead focus on wages and working conditions. Single-payer reform would strengthen the unions and prove incredibly liberating for working people.

Frisch: What do you think fuels the intense antipathy toward universal healthcare among so many politicians in both major parties?

Coates: I can’t say. In my interactions with everyday people, I don’t find much, if any, antipathy toward universal healthcare. Last week I was in Long Lake, New York, in the Adirondacks. I didn’t hear opposition there to the idea that every human being who needs medical attention should get it. Politicians loudly oppose universal healthcare, and yet they stop short of openly advocating that some human beings should be denied the care they need. The author of a U.S. Senate bill that would have enormously curtailed Medicaid across the country, throwing millions of people off the rolls, went on TV and lied and said his bill wouldn’t hurt those people. Talk-show host Jimmy Kimmel, whose son was recently born with a congenital heart condition, called out his lies on late-night TV.

Virtually all developed nations provide universal access to healthcare in some way. The single-payer model has worked well in Taiwan and Canada. Germany is an example of a multi-payer system, but government regulation ensures that all costs are uniform, whether you’re insured through a community organization or a company or a religious group. Scotland has a purely public health service, where every physician and nurse gets a paycheck from the government. Spain has the right to healthcare in its constitution. We could go on. The only developed country that has designed its healthcare system to leave people out is the United States.

Frisch: How do U.S. health outcomes stack up against those in nations with universal healthcare?

Coates: Compared to other developed, wealthy nations, the U.S. comes in last across many indicators of health status. On a worldwide scale, dozens of countries have better health indicators than the U.S. Over the last couple of decades maternal mortality — the preventable death of pregnant women — has gone down in almost every nation on earth, but in the U.S. it has gone up. It’s shocking to think that our country, with so much talk about family values and so much debate about the unborn and so much attention to healthcare, would have worsening maternal mortality.

Frisch: Why is maternal mortality going up here?

Coates: The reasons are myriad, but the most glaring is that the wealthy have gotten super-wealthy, while the poor, who are many times more numerous than the rich, have gotten so much poorer. Women at the bottom aren’t getting proper prenatal care. Some life-threatening conditions that occur during pregnancy, such as eclampsia and gestational diabetes, can be prevented or treated if they are caught early. Too often they aren’t.

Frisch: Aren’t per capita healthcare expenditures in the U.S. also much higher than in other developed countries?

Coates: The U.S., on average, spends twice as much as most other developed nations on healthcare. That’s both per person and as a percentage of gross domestic product. We’re talking about a total of $3 trillion a year, or about ten thousand dollars per person annually. And more than half that money already comes from taxpayer dollars. In effect, we’re paying for national health insurance, but we’re not getting it.

Frisch: Where does all that taxpayer funding go?

Coates: Toward Medicare and Medicaid, health benefits for public employees, and tax credits that help employers pay private insurance companies. Of course taxes also fund veterans’ hospitals, the Indian Health Service, federally funded health centers, and research institutions like the Centers for Disease Control and Prevention and the National Institutes of Health and many other programs. The point is that public spending already allocated should be adequate to meet our full healthcare needs.

Cuba is an interesting comparison. It spends something like a fourth of what the U.S. spends on healthcare per person, but Cuban people have about the same health outcomes as Americans, including life expectancy, infant mortality, and so on. One reason for this is that Cuba has trained so many doctors. In fact, there are more doctors per person in Cuba than anywhere else in the world. And Cuban doctors learn not only to spend more time with their patients but to care for entire communities. What Cuba lacks in monetary resources appears to be compensated for by their many doctors.

Frisch: Could it be that our healthcare outcomes are worse because the pressures of contemporary American life and the food we eat are making us sick?

Coates: There are indeed great pressures. And it’s important for everyone to eat healthy, which is challenging for the poor, who often don’t have access to fresh fruits and vegetables in their neighborhoods. Yet comparative studies have been done, and controlling for the American diet and other lifestyle choices does not explain the inferior health outcomes in the U.S. For example, European nations with longer life expectancies actually have more smokers. In the U.S. we have many more people who live in poverty than European countries do. And we lead the world in incarceration. Poverty and the stress that comes with it have devastating health consequences. With growing income inequality, there’s a case to be made that Americans’ health is becoming worse, mostly for those at the bottom. People work two and three jobs and still can’t make ends meet. Intense social pressure leads to personal disaster. People become more prone to alcoholism and opiate addiction. Domestic violence devastates families. With economic insecurity people find themselves constantly on the move and without a sense of community. Many who are better off are now facing growing insecurity as the middle class disappears. In the hospital I see a stark picture that connects statistics with real human lives.

I’ve written about an uninsured landscaper who didn’t have a steady winter job. He ran a snowblower and drove a plow, but the work was pretty sporadic. When there was a major snowstorm, he tried to work a twenty-hour day, to make up for lost wages. But because he had an infected tooth and had not been able to eat much for a few days, he collapsed after sixteen hours. I ended up admitting him to the hospital.

Frisch: Did he survive?

Coates: Yes, he’s OK. I felt a little helpless, because all I could do for his tooth infection was prescribe antibiotics. We see so many social problems at the hospital, which often provides a refuge for people who have no place else to go. It’s distressing and makes me even more determined to fight for a single-payer healthcare system.

Frisch: Why didn’t the U.S. adopt some form of universal healthcare when other countries did?

Coates: The U.S. began to discuss national health insurance around the same time as European nations: in the early twentieth century. At the start of the 1930s a blue-ribbon commission called the Committee on the Costs of Medical Care recommended a system of compulsory insurance and healthcare planning for the whole country. The American Medical Association [AMA] attacked the idea as a communist plot, even though the panel was led by the Republican president of Stanford University, a medical doctor who had also once been the head of the AMA! President Franklin D. Roosevelt, who was inaugurated within weeks of the report’s release, chose to avoid the matter.

When World War II came along in the 1940s, the country entered an enormous industrial boom, and the government imposed a wage freeze to help the war effort. Looking to attract workers, employers offered healthcare benefits instead of higher wages. By the end of the war, employer-sponsored private health insurance was entrenched. After the war, in the United Kingdom, the Labour Party established the National Health Service, guaranteeing necessary medical care to everyone. As the troops came home in the U.S., the government expanded benefits and guaranteed healthcare for veterans, and President Harry Truman began to champion the idea of national health insurance. In response the AMA hired a Madison Avenue advertising firm to counter Truman’s initiative. They came up with the term “socialized medicine” to defeat Truman’s agenda, again disparaging the idea as a communist plot.

Frisch: Did the AMA represent the way most physicians felt?

Coates: That’s a good question. Probably not. I think the AMA was dominated by the most money-conscious members of the profession, who feared national healthcare would mean lower pay for the wealthiest doctors.

Frisch: One of the arguments against single-payer is that it can cause long waits for treatment. How do waits under Canada’s single-payer system compare with what we face in the U.S. today?

Coates: Let me tell you a story. I see many low-income patients. For example, a man may have a meniscus tear — a chronic knee injury that can be repaired with arthroscopic surgery — but he has no insurance. The elective surgery would require an exorbitant cash payment. His wait time for arthroscopic surgery is effectively infinite — or, at least, until he gets insurance that covers it. But no one is tracking those kinds of wait times in our country.

It’s true that, in Canada, wait times for elective surgeries — especially orthopedic surgeries — have sometimes been frustratingly long. A Canadian who needs arthroscopic surgery might not get into the operating room for many weeks. This has provoked public outrage in Canada, because it’s seen as a disgrace to the nation, as it should be. As a result of all this hue and cry, wait times for elective procedures are improving there. And I should emphasize that we’re talking about elective, not emergency, interventions.

Can we compare wait times in Canada and the U.S. if we don’t keep records on wait times here, while the Canadian data is public? Wait times are an ideological talking point used by people who want to privatize even more of the healthcare system.

Frisch: Are you satisfied with the sort of care people get in the U.S. when they do go to the doctor?

Coates: No. In my experience it’s too often undignified. Countless patients have been refused care or misdiagnosed or given inappropriate prescriptions. We recently discharged a man from the hospital to home hospice because he had a terminal brain tumor. During the discharge meeting, his daughter and son told us how over the previous year his insurer had refused to pay for a scan of his brain, even though his cardiologist and his primary-care physician had ordered it. The man ended up in the hospital, where the emergency-room doctor ordered a CT scan and found the brain tumor within an hour. His children were left to wonder whether their father’s life could have been extended if the insurance company had allowed the test a year earlier.

This patient had a type of Medicare called Medicare Advantage: a program through which private insurers are paid to administer Medicare benefits. Medicare Advantage plans may offer frills like a gym membership to attract patients, but in return the insurers are allowed to chisel away important benefits, things that traditional Medicare would cover without question. This is what you get when you privatize Medicare.

These days, in almost every case, there’s some way in which profiteering intervenes. I discharged a woman with a prescription for a medication that was decades old and generic. It turned out that a big pharmaceutical company had recently cornered the market on it, and a medication that a few years ago cost pennies per pill now costs more than a thousand dollars a month. She couldn’t afford it, because her insurance required her to pay a percentage of the cost of each prescription.

Sometimes an ambulance ride is not covered. I once had a clinic patient who needed to be in the hospital, but she refused to take an ambulance after having previously been billed a large amount for one. So I drove her forty miles myself. Some of my colleagues were shocked to hear this, asking, “What if something had happened while she was in your car?”

Or take hepatitis C. Medications can now cure hepatitis C. So what’s the holdup? The pharmaceutical companies charge tens of thousands of dollars for these medications. Doctors have been fighting with state Medicaid agencies to cover these drugs, but the sky-high retail price remains an obstacle.

Frisch: Are most physicians upset about the things you’ve described?

Coates: I think there’s enormous moral distress within the profession. Physicians don’t feel able to live up to their calling. They don’t have good job satisfaction. They want to spend more time with patients.

Frisch: Senator Claire McCaskill claims this isn’t a good time for the U.S. to transition to single-payer, because we’re already having trouble paying for all the baby boomers going on Medicare.

Coates: Warnings that the Medicare trust fund is going bankrupt come and go despite the fact that the system basically works. Politicians have the nerve to talk about the impending bankruptcy of Medicare when out-of-pocket spending on healthcare is bankrupting families right now. The best way to save Medicare would be to expand it to include everyone. The real reason the powerful are so opposed to single-payer is not because it won’t work but because it will.

When Canada enacted its Medicare system in the early 1970s, Canada and the U.S. were tracking even in terms of per capita healthcare costs. Today Canada is spending half of what the U.S. spends and getting better outcomes, better access to care, and better quality of life. This shows that a single-payer model absolutely will work if the goal is to cover everyone and save costs. It won’t work if the goal is to protect the interests of private insurers. It won’t work if the goal is to maximize profits.

Frisch: I’ve noticed there are no longer any independent medical practices in my county. Now they’re all under the umbrella of a single hospital.

Coates: The advent of most physicians becoming employees within a large corporate structure is something the medical profession hasn’t really come to terms with. Physicians continue to have the small-shopkeeper mentality, and we do retain a great deal of professional autonomy. But now, as employees in vast systems, we have begun to lose say over many aspects of care.

Frisch: Some opponents of healthcare reform have proposed that patients should shop around by cost for tests, drugs, and hospital stays.

Coates: With healthcare there’s no way to be a fully informed consumer, because you can’t know precisely what your future needs will be. If you develop the worst headache of your life and are in excruciating pain, you can’t know whether you’re having a migraine or a brain hemorrhage. You might need ibuprofen, or you might need a neurosurgeon. The idea of going shopping during a possible intracranial hemorrhage is just silly. The only solution that makes sense is having a healthcare infrastructure at the ready when we need it.

Frisch: How should individual physicians be paid for seeing patients?

Coates: Personally I think the full-time-salary model is the most honorable, but that may not be for everyone. There’s no perfect way to pay doctors. If you pay them a fee for service, it may encourage some to provide unnecessary services. If you pay them by the hour, it may encourage some to work too many hours. If you pay them a salary, it may encourage some to go home early. The best system would be to assume that doctors are doing the best they can for patients and let them organize themselves to decide how they want to be paid.

Frisch: Uninsured people tend to be charged more for healthcare than people who are insured. Overall who pays more under the present system: the insured or the uninsured?

Coates: The uninsured pay with their lives. For every million people without health insurance in the U.S., about a thousand deaths occur that could have been prevented. But the costs of a catastrophic illness are unpredictable even for those with insurance. I met a colleague, a senior physician, in the supermarket the other day. She told me that she had taken early retirement. I was about to congratulate her when she explained that her granddaughter had been hit by an automobile and her daughter had been fired for missing too much work, because she had to be at the hospital. The daughter was able to regain employment, but the care needs of my colleague’s granddaughter remained so significant that my colleague was taking early retirement to be there for her family. How can we measure the cost of that to society?

Studies show that the burden of providing care near the end of life falls disproportionately on women family members. The costs are great: not just financially but also to the health of the caregiver. Data also show that if your spouse dies, you have a higher likelihood of dying soon after. This often has to do with the stress of providing care: the lost sleep, the lost resources, and, many times, the lost jobs. Who pays? We all do.

Frisch: Many people don’t have the option to provide care when family members need it.

Coates: I have patients who are hospitalized but can’t afford to miss work. They fear being fired, or they simply can’t do without the income. I’ve written letters to their employers in hopes of helping them negotiate a little more time for recovery.

Frisch: Is it legal to fire people because they’re sick?

Coates: They’re not fired because they’re sick. They are fired because they’re not at work. It’s cruel.

Frisch: Is it different in other countries?

Coates: Absolutely. Other countries have not only sick-leave protections but also maternity and paternity leave.

Frisch: Let me see if I understand the basics of the system you’re pushing for: The government would provide free healthcare for everyone, paid for by taxes. You would not have to enroll; you would just have it. And I assume you’d be able to choose your physician.

Coates: Right. Physicians who participated in the system would be forbidden from having a private practice on the side, outside of the system. Doctors who wanted to have a private, for-cash practice could conceivably do so. But with the entire population covered by public healthcare, that would make little sense. With almost all doctors taking part in the system, patients could choose from a wide selection of providers. This kind of competition for the best-quality providers might turn out to be healthy for all of us.

The role of the government in this system would be to pay the costs and protect the patient-provider relationship. Medical decisions should be made privately — by the patient and the doctor — and the government should respect whatever decision they make, providing that decision is within the realm of medical science.

Frisch: Would there be limits on allowable treatments for a given condition?

Coates: If a physician is proposing treatments that lack any credible evidence, then those treatments won’t be funded. On the other hand, if a treatment is supported by the medical evidence — and the patient and physician believe it’s worth a try — then that should be the patient’s personal decision.

Frisch: What are the chances that the system you envision will be enacted here?

Coates: I think the profound contradictions of the current system make it more likely: We have the contradiction that healthcare is so essential and yet so undignified in its delivery, with money always the underlying issue. Then there’s the contradiction that we’re paying so much more for healthcare compared with other nations but getting such inferior results. So everyone involved in the system gets progressively more frustrated and ground down. Yet we all know it doesn’t have to be this way.

I’m optimistic. Of all the social reforms that could transform the country, single-payer seems to me the most likely to happen. Still, we don’t have a mass movement of millions of people pushing for this, and that is what it will take.

https://www.thesunmagazine.org…

Expect more fragmentation of our dysfunctional health care system

A Big Divergence Is Coming in Health Care Among States

By Margot Sanger-Katz
The New York Times, February 28, 2018

Little by little, the Trump administration is dismantling elements of the Affordable Care Act and creating a health care system that looks more like the one that preceded it. But some states don’t want to go back and are working to build it back up.

Taken together, experts say, the administration’s actions will tend to increase the price of health insurance that follows all the Affordable Care Act’s rules and increase the popularity of health plans that cover fewer services. The result could be divided markets, where healthier people buy lightly regulated plans that don’t cover much health care, lower earners get highly subsidized Obamacare — and sicker middle-class people  face escalating costs for insurance with comprehensive benefits.  

But not everywhere. Several states are considering whether to adopt their own versions of the individual mandate, Obamacare’s rule that people who can afford insurance should pay a fine if they don’t obtain it. A few are looking to tighten rules for short-term health plans. Some states are investing heavily on Obamacare outreach and marketing, even as the federal government cuts back.

The result is likely to be big differences in health insurance options and coverage, depending on where you live. States that lean into the changes might have more health insurance offerings with small price tags, but ones that are inaccessible to people with health problems and don’t cover major health services, like prescription drugs. States pushing back may see more robust Obamacare markets of highly regulated plans, but the price of those plans is likely to remain higher.

The Affordable Care Act was drafted with room for state customization, but one of its primary goals was to make health insurance around the country more uniform. Thanks to state resistance to the health law, varying local conditions and a Supreme Court decision that made the Medicaid expansion optional, results have been much more uneven. Some states have seen much bigger reductions in the share of the uninsured than others. Only some states have seen insurance premiums stabilize.

“Without question I think we’re going to see a natural experiment in the states and a growing divergence in outcomes,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute.

https://www.nytimes.com…

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Finally, a universal healthcare proposal that would work for everyone

By Michael Hiltzik
Los Angeles Times, February 27, 2018

But now take a look at “Medicare Extra for All.”

It’s not single-payer, exactly, but only single-payer dead-enders could object to its payer provisions. It’s the best solution to the realities, politics and drawbacks of the U.S. health insurance system yet to appear, and the time to start pushing it is now.

http://www.latimes.com…

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Comment:

By Don McCanne, M.D.

We should have learned something from the history of health care reform in this nation since we now have by far the most expensive system but the least efficient considering our deficiencies in coverage, access, equity and affordability. So where are we headed?

With the states assuming greater leadership in reform, we can anticipate more of the same with variations – more fragmentation, more administrative excesses, more financial barriers to care, more restrictions in choice of health care professionals, more destabilization of health care coverage – this and more with a failure to control health care spending.

The article by Margot Sanger-Katz describes well the divergence in approaches by the various states, with the best states falling miserably short on application of optimal health policy, whereas other states will perpetuate and possibly expand disastrous policies which can negatively impact the personal finances and health of their residents.

Although there has been an increase in public support for single payer reform, attention is being diverted to proposals such as CAP’s Medicare Extra for All – a proposal that has stolen the single payer rhetoric in order to sell a “politically feasible” public option that protects the private insurance industry. The media have totally bought into the rhetoric. Even highly-respected, progressive Los Angeles Times columnist Michael Hiltzik says that “the time to start pushing it is now,” as he dismisses us as “single-payer dead-enders.” Ouch!

Again, we have to change the politics, but we can’t sell out on policy on our way to health care nirvana.

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ACA exchange plans are under attack

The Potential Impact of Short-Term Limited- Duration Policies on Insurance Coverage, Premiums, and Federal Spending

By Linda J. Blumberg, Matthew Buettgens, and Robin Wang
Urban Institute, February 2018

In Brief

On February 20, 2018, the Departments of Treasury, Labor, and Health and Human Services released a proposed regulation that would increase the maximum length of short-term, limited-duration insurance policies to one year. These plans, sold to individuals and families, are not federally required to comply with the Affordable Care Act regulations that prohibit annual and lifetime benefit limits, require coverage of all essential health benefits, and otherwise prohibit insurers from setting premiums or choosing whether to sell coverage to particular people based on applicants’ health status and health history. As such, these plans do not meet minimum essential coverage standards under the law; thus, the Congressional Budget Office does not consider them private insurance. If implemented, the rule would permit these plans to compete against the ACA-compliant plans.

Importantly, this change would be implemented on top of an array of other significant policy changes made since the beginning of 2017. We analyze the implications of the 2017 policy changes relative to the ACA as originally designed and implemented (prior law), in addition to the potential consequences of the proposed expansion of short-term limited-duration policies. In estimating the effects of these changes on insurance coverage, premiums, and federal spending, we take into account the variations in state circumstances and state-specific laws on short-term plans.

Key findings include the following:

* The elimination of the individual-mandate penalties and the other policy changes, such as the withdrawal of cost-sharing reduction payments and the diminution of federal investments in advertising and enrollment assistance during 2017 that affected the 2018 open enrollment period, will lead to an additional 6.4 million people uninsured in 2019 compared with prior law (12.5 percent of the nonelderly population uninsured compared with 10.2 percent).

* The introduction of expanded short-term, limited-duration policies, consistent with proposed regulations, would increase the number of people without minimum essential coverage by 2.5 million in 2019. Of the 36.9 million people without minimum essential coverage, 32.6 million would have no coverage at all (completely uninsured), and 4.2 million would enroll in expanded short-term limited-duration plans.

* The combined effect of eliminating the individual-mandate penalties and expanding short-term limited-duration policies would increase 2019 ACA-compliant nongroup insurance premiums 18.2 percent on average in the 43 states that do not prohibit or limit short-term plans.

* Federal government spending in 2019 will be an estimated 9.3 percent higher than under prior law, owing to the combined effect of expanding short-term limited-duration policies, eliminating the individual-mandate penalties, and other recent policy changes. This increase in federal spending is lower than the overall increase in premiums because of cost reductions caused by decreases in enrollment.

From the Discussion:

The expansion of short-term limited-duration policies implied in the current administration’s proposed rule has significant implications, particularly for insurance coverage and premiums in the remaining ACA-compliant insurance market. We estimate that ACA-compliant private nongroup coverage would fall by 2.1 million people in 2019 from the expansion of STLD policies alone, exacerbating the nongroup market decline of 5.5 million people already anticipated in 2019 because of the elimination of the individual-mandate penalties and other policy changes made since early 2017. The effects will vary across the states given differences in state laws and regulations as well as differences in health care costs and population characteristics. In the 43 states most affected, premiums in the ACA-compliant nongroup insurance market would increase 18 percent on average owing both to the expansion of the short-term plans and elimination of the individual-mandate penalties. This premium effect would be 20 percent or higher in nine states. Those affected by these large premium increases would be disproportionately middle-income people with health problems because they prefer health insurance that covers essential health benefits, are unlikely to have access to medically underwritten short-term limited-duration policies, and are not financially protected by the ACA’s premium tax credits. For people who have ACA-compliant coverage and are eligible for premium tax credits, these higher premiums translate into higher premium tax credits per enrollee paid by the federal government. In total, 9.0 million fewer people would have insurance (minimum essential coverage) compared with prior law.

https://www.urban.org…

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Twenty states sue federal government, seeking end to Obamacare

By Eric Beech
Reuters, February 26, 2018

A coalition of 20 U.S. states sued the federal government on Monday over Obamacare, claiming the law was no longer constitutional after the repeal last year of its requirement that people have health insurance or pay a fine.

Led by Texas Attorney General Ken Paxton and Wisconsin Attorney General Brad Schimel, the lawsuit said that without the individual mandate, which was eliminated as part of the Republican tax law signed by President Donald Trump in December, Obamacare was unlawful.

“The U.S. Supreme Court already admitted that an individual mandate without a tax penalty is unconstitutional,” Paxton said in a statement. “With no remaining legitimate basis for the law, it is time that Americans are finally free from the stranglehold of Obamacare, once and for all,” he said.

https://www.reuters.com…

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Comment:

By Don McCanne, M.D.

This Urban Institute analysis demonstrates once again that the Trump administration has been effective in reducing both the adequacy and prevalence of health insurance coverage. Elimination of the individual mandate penalties, elimination of cost sharing reduction payments, and slashing advertising and enrollment assistance funding for ACA exchange plans have already had a negative impact, and now they will be enticing healthy individuals to move from ACA-compliant plans into short-term, limited-duration junk insurance.

Linda Blumberg and her colleagues estimate that next year about 33 million people will have no insurance at all, another 4 million will be enrolled in these almost worthless junk insurance plans (total of 37 million without minimum essential coverage), and, of course, tens of millions will still be underinsured because of the inadequacies of the ACA-compliant plans. Further, adverse selection in the ACA-compliant nongroup plans is likely to cause an 18 percent increase in their premiums. Some private insurers may find these markets no longer favorable and withdraw from them. Junk plans are no substitute since they do not protect patients in need.

The ACA exchanges barely squeaked through in a Supreme Court decision that ruled that the individual mandate penalties were taxes and therefore constitutionally permissible under federal law. Since this penalty for being uninsured has now been removed, twenty states are suing to have the Affordable Care Act overturned, arguing that since the constitutional tax no longer exists,  the ACA exchanges supposedly no longer have a legal basis for their existence. There will no doubt be many varying legal opinions on this argument, but the fact remains that the attacks on ACA will continue.

It has already been established that Medicare is constitutional. In fact, the Supreme Court has ruled that individuals cannot decline to be enrolled in Part A of Medicare if they accept Social Security benefits. They are mandated to accept Medicare enrollment. Also Medicare is not as subject to absurd administrative decisions designed to trash the program, partly because of the legacy law and decisions supporting the program, and partly because it would be political insanity for Congress and the Administration to attempt to reduce or eliminate Medicare, considering its great popularity with the public.

It would be foolish to hope that the damage being done to the Affordable Care Act will somehow not have a negative impact and that tweaking it will counter the multitude of policy studies that show that it is the most expensive way of expanding health care and yet falls tragically short of our universal reform goals. With the growing popularity of the Medicare for All concept, the obvious path that we should be following is to affirm the constitutionality of Medicare by improving it and then expanding it to cover everyone.

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Single-payer health care provides opportunities

By George Jolly, M.D.
Albany (N.Y.) Times Union, Letters, February 27, 2018

Regarding the letter from Heather Briccetti, president and CEO, Business Council of New York State, (“Single-payer system would be utter disaster,” Feb. 7), I thank Briccetti for bringing the discussion of single-payer health care finance into the public eye with her response to Howie Hawkins’ commentary (Opinion on the Web: “Single-payer would save N.Y. billions,” Jan. 30). However, Briccetti’s response includes serious errors.

Briccetti writes that the “plan would remove choice in health care.” This is false. With a single-payer system, the patient has free choice of doctor, hospital or other provider. Insurance companies, for which there will no longer be choice, do not provide health care.

Briccetti writes the proposal would “raise taxes by more than $200 billion.” This also is false. Assessments on earned and unearned income will amount to $92 billion. The largest financing will come from Medicare and Medicaid. Payroll assessments replace today’s health insurance premiums. There will be no additional out-of-pocket expenses (co-pays or deductibles). In fact, 98 percent of New Yorkers will pay less for health care than they do now.

Briccetti also writes the proposal would eliminate thousands of jobs. Yes, insurance company jobs will be eliminated, but much of that talent and technology would find a place in the new system.

Briccetti does not address the business opportunities that would be created by lower health care costs for most employers and employees. There are valid issues to debate, but Briccetti’s use of scare tactics and questionable information is not helping the conversation. New Yorkers should view the New York Health Act as an opportunity to plan for optimum use of our state’s resources.

https://www.timesunion.com…

Important lessons from Canada

Canada's universal health-care system: achieving its potential

By Danielle Martin, M.D., Ashley P. Miller, M.D., Amélie Quesnel-Vallée, Ph.D., Nadine R. Caron, M.D., Bilkis Vissandjée, Ph.D., Gregory P. Marchildon, Ph.D.
The Lancet, February 22, 2018

Key messages

* Canada’s universal, publicly funded health-care system—known as Medicare—is a source of national pride, and a model of universal health coverage. It provides relatively equitable access to physician and hospital services through 13 provincial and territorial tax-funded public insurance plans.

* Like most countries that are members of the Organisation for Economic Co-operation and Development (OECD), Canada faces an ageing population and fiscal constraints in its publicly funded programmes. Services must be provided across vast geography and in the context of high rates of migration and ethnocultural diversity in Canadian cities.

* In 2017, the 150th anniversary of Canadian Confederation, the three key health policy challenges are long waits for some elective health-care services, inequitable access to services outside the core public basket, and sustained poor health outcomes for Indigenous populations.

* To address these challenges, a renewal of the tripartite social contract underpinning Medicare is needed. Governments, health-care providers (especially physicians), and the public must recommit to equity, solidarity, and co-stewardship of the system.

* To fully achieve the potential of Medicare, action on the social determinants of health and reconciliation with Indigenous peoples must occur in parallel with health system reform.

* Without bold political vision and courage to strengthen and expand the country’s health system, the Canadian version of universal health coverage is at risk of becoming outdated.

Canadian lessons for a global world

Canada’s most important accomplishment by far has been the establishment of universal health coverage, which is free at the point of care, for medical and hospital services. The preservation and enhancement of Medicare are due largely to Canadians’ pride in caring for one another—an expression of equity and solidarity that runs core to Canadian values. Hinging on a social consensus of equitable access to health care, the simplicity of the system—no variable coverage, no means testing, and no co-payments—is easy for Canadians to understand and support.

But universal health coverage is an aspiration, not a destination. All countries must continuously consider the depth and scope of coverage that is politically achievable and fiscally feasible. In Canada, that necessary work has not been done for more than 40 years. The Canadian experience thus offers a cautionary tale on incrementalism. In the absence of bold political vision and courage, coverage expansion can be very difficult to achieve, with the result that the Canadian version of universal health coverage is at risk of becoming outdated.

A powerful mechanism such as a single-payer insurance system is only as good as the willingness of system leaders to use it for reform. In turn, reform requires a willingness on the part of governments to pursue change, rather than simply managing the status quo. Clear mechanisms are lacking to consistently realign resources to meet population needs, promote evidence-based care, reduce variation, and contain costs. Health care is ultimately a local affair, and no patient or provider wants the payer in the examination room. However, much of the potential benefit of a single-payer structure is lost when institutions are independent, with little accountability. The potential of the system is further limited by the fact that physicians function alongside but outside the system, rather than as accountable participants through employment or other contractual means. Co-stewardship and accountability should be recognised as integral parts of payment systems rather than avoided or grafted on afterwards.

Conclusion

When Tommy Douglas first established public health insurance in Saskatchewan in the late 1940s, his goal was to begin by creating insurance models that would eliminate the financial barriers to care. He intended to follow that with a second reform of health service delivery that would focus on population health needs, with an emphasis on the reform of delivery models and on the social determinants of health. His government, and subsequent governments, provincially and federally, managed to overcome fragmented institutional structures and decentralisation of power to make the first stage of his vision a reality, but not yet the second. To achieve that second stage in the 21st century, determined action on the social determinants of health and a joint effort by governments, health-care providers, and the public in achieving health system reform will be needed. With bold political vision and courage, this ambitious goal is within reach.

http://www.thelancet.com…

PDF version:
http://www.thelancet.com…

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Canada’s global health role: supporting equity and global citizenship as a middle power

By Stephanie A. Nixon, Ph.D., Prof Kelley Lee, D.Phil., Prof Zulfiqar A. Bhutta, Ph.D., Prof James Blanchard, Ph.D., Prof Slim Haddad, Ph.D., Prof. Steven J. Hoffman, Ph.D., Prof. Peter Tugwell, M.D.
The Lancet, February 22, 2018

Key messages

* Canada boasts long-standing and active engagement in global health, shaped by the country’s history of nation building and middle-power status. Ongoing nation building emphasises consensus building and equity in foreign policy, and relies on strong commitment to multilateralism.

* Canada’s unique strengths in global health leadership draw from the country’s legacy and contemporary challenges of building a multicultural society, maintaining a bilingual heritage, and reconciling the injustices inflicted on Indigenous peoples. Health equity has been a key focus.

*  The quality of Canadian contributions to global health has been high, but impact has been diluted by a tendency to spread limited resources thinly, and by fragmentation among global health institutions, priorities, and policies in Canada.

* The previous Conservative federal government, led by Stephen Harper, adopted an approach to foreign policy that favoured technocratic solutions and tied global health initiatives to trade and investment opportunities benefiting Canada. It championed maternal and child health in the Millennium Development Goal era, but critics say this period was a sharp departure from traditional Canadian values of equity, human rights, and global citizenship.

* High expectations exist for the current Liberal government led by Justin Trudeau, which has signalled a return to these traditional Canadian values. Canada now has an important opportunity to assert much-needed global leadership, including in global health. Real policy change and concrete action on issues such as foreign aid assistance and Indigenous health inequities are urgently needed to demonstrate the credibility of the government’s commitment to these values.

Conclusion

Canada was formed 150 years ago, bringing together a vast land at risk of being subsumed by its larger neighbour to the south. The political forging of the country came at a considerable price, notably to Indigenous peoples, and the country has learned hard lessons about the importance of inclusion and equity. Moreover, Canada’s unique history continues to unfold. Authentically reconciling its relationship with Indigenous peoples, maintaining social cohesion amid diversity, and successfully meeting domestic needs while remaining open to globalisation will be integral to the country’s next 150 years. Against this backdrop, Canada is uniquely positioned to become a more prominent global health leader by harnessing its distinct experiences, diverse assets, and core values. Like the country itself, Canada’s role in global health remains a work in progress.

http://www.thelancet.com…

PDF version:
http://www.thelancet.com…

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Comment:

By Don McCanne, M.D.

This two part series on Canada’s health system, published in The Lancet, provides an excellent overview and update on their system. It is closest to the model that single payer advocates in the United States support. But we have much to learn from Canada – both on what does work and what doesn’t. These articles should be downloaded and retained as invaluable reference sources for our work here in the United States.

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Why are Democratic party think tanks still not backing universal health care?

The Center for American Progress is inching closer to ‘Medicare for All’ – but its version leaves some gaping holes

By Adam Gaffney, M.D.
The Guardian, Feb. 25, 2018

On Thursday, the Center for American Progress (CAP), a Democratic party-affiliated think tank, launched a proposal confusingly called “Medicare Extra for All.” For proponents of a Bernie Sanders-style single-payer “Medicare for All,” this might seem like a positive development. Well, yes and no.

On the one hand, “Medicare Extra” is a step to the left for CAP, suggesting that the Democratic establishment is following the lead of its galvanized base. On the other hand, this new proposal would exact sacrifices from patients to placate the insurance industry, and could serve to divert the single-payer movement, which has been rapidly gaining steam.

A debate over the next step on health reform has roiled the Democratic party. Some, like Hillary Clinton, have advocated incremental changes to Obamacare, such as a “public option.” Others, led by Bernie Sanders, seek to replace the hodgepodge of private and public health plans with “Medicare for All” – a single-payer program covering everyone without copays or deductibles.

Though Trump’s victory might have dampened support for the more radical road, it did just the opposite. The president swore to repeal the Affordable Care Act, and try he did – but apart from felling the individual mandate, the effort flopped in Congress. He did, however, rouse millions of Americans behind the cause of healthcare justice. Single-payer bills in both houses of Congress accrued record support in 2017, including a majority of House Democrats and more than a third of Democratic senators.

The political winds had shifted: progressives were out of power, but they were coalescing around a post-Trump plan – improved “Medicare for All” – overwhelmingly popular with the party’s base: about 69% of Democrats supported it, according to a September survey.

Enter Medicare Extra. CAP’s proposal is a response to these shifting winds. The new Medicare Extra program would automatically enroll anyone without other insurance. Premiums and out-of-pocket payments (eg copays and deductibles) would continue, with limits based on income.

Employers could choose to offer private coverage, or switch their employees into Medicare Extra. Notably, private insurers would get a big slice of the Medicare Extra market, enrolling millions in “Medicare Choice” coverage modeled on today’s wasteful, privatized Medicare Advantage plans, which in effect cost taxpayers “104% of per capita traditional Medicare spending” per enrollee, as noted in the Journal of the American Medical Association.

What’s not to like?

First, there’s the proposal’s voodoo economics. The US healthcare system hemorrhages cash through useless billing and bureaucracy, the inevitable consequence of battles between our jumble of profit-seeking insurers and the country’s providers. Transitioning to single-payer could end this waste, saving about $500bn annually; multi-payer systems such as Medicare Extra that add yet another plan to the existing slew of private insurers cannot. And without these efficiencies, expanding to fully universal coverage could prove unaffordable.

Second, because the economics don’t work, the coverage is insufficient. Although Medicare Extra would be more generous than most Obamacare plans, it would still leave millions encumbered with copayments and deductibles, which force people to choose between healthcare and other necessities. Keep in mind that one survey found that almost half of Americans couldn’t afford an unanticipated $400 expense, per the Washington Post.

Indeed, under the CAP program, some might see their coverage worsen if their employer elected to transition them to Medicare Extra. Consider that large employers’ plans cover, on average, 85.4% of healthcare costs. But Medicare Extra would cover only 80% of costs, for at least some families (depending on income). Republicans would have a field day scaremongering about the government taking away your healthcare plan. While CAP touts the political advantages of their plan, it may well be a juicier target for such scaremongering than “Medicare for All”, which would cover 100% of healthcare costs.

Medicare Extra offers an inferior policy option, when a better one is on the table. Improved “Medicare for all” can affordably provide healthcare to everyone. It’s widely supported by the progressive base – and indeed by the majority of the nation in most polls. And it can serve as a powerful political promise as we wade into the profoundly consequential 2018 and 2020 election season. Democrats would be wise to unite behind it, rather than be sidetracked by CAP’s second-rate scheme.

https://www.theguardian.com…

QOTD Extra: Frank Ticheli’s “An American Elegy”

An American Elegy

By Frank Ticheli
Gusman Concert Hall, University of Miami, Coral Gables, March 12, 2013

Performed by the Greater Miami Symphonic Band
Conducted by Gary Green
Off-stage trumpet solo by Alan Wolfe

From the Program Notes by Frank Ticheli:

An American Elegy is, above all, an expression of hope. It was composed in memory of those who lost their lives at Columbine High School on April 20, 1999, and to honor the survivors. It is offered as a tribute to their great strength and courage in the face of terrible tragedy. I hope the work can also serve as one reminder of how fragile and precious life is and how intimately connected we all are as human beings.

The work begins at the bottom of the ensemble’s register, and ascends gradually to a heartfelt cry of hope. The main theme that follows, stated by the horns, reveals a more lyrical, serene side of the piece. A second theme, based on a simple repeated harmonic pattern, suggests yet another, more poignant mood. These three moods – hope, serenity, and sadness – become intertwined throughout the work, defining its complex expressive character. A four-part canon builds to a climactic quotation of the Columbine Alma Mater. The music recedes, and an offstage trumpeter is heard, suggesting a celestial voice – a heavenly message. The full ensemble returns with a final, exalted statement of the main theme.

Performance of An American Elegy:
https://www.youtube.com…

Program Notes:
http://issuu.com…

***

By Frank Ticheli, Pasadena
Los Angeles Times, Letters, February 20, 2018

When I composed “An American Elegy” nearly 20 years ago in response to the Columbine shooting in 1999, I thought it would be a singular episode, or at least a rare one, in our nation’s history. Sadly, I am constantly reminded how wrong I was.

Nothing will improve until more lawmakers admit that the Constitution was written by mere mortals doing the best they could without benefit of a crystal ball. Those same mortals saw this themselves, thereby permitting amendments to the Constitution. In other words, they possessed a humility and wisdom that many current lawmakers seem to lack.

Commonsense gun legislation may very well save the 2nd Amendment. This may not happen in my lifetime, but I have hope that our children’s generation will show more wisdom than the small-minded legislators from our generation.

“An American Elegy” has been performed frequently in response to mass shootings occurring since Columbine. I had no idea that could ever happen. I am sad about a cultural situation that makes it so.

***

Comment:

By Don McCanne, M.D.

Today’s Quote of the Day Extra requires no explanation to single payer supporters who understand and support social justice for all. Frank Ticheli’s “An American Elegy” provides us with eleven minutes of contemplation that helps to fine tune our values.

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Exposing the value-based payment meme

How Value-Based Medicare Payments Exacerbate Health Care Disparities

By Rita Rubin, M.A.
JAMA, February 21, 2018

Paying physicians on the basis of the quality of their care, not the quantity, sounded like a good idea when Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which changed the way the government pays physicians.

For more than a decade, Medicare had paid physicians based on the number of services they provided to fee-for-service beneficiaries, whether or not those services were needed. Under MACRA, however, Medicare would assess the quality, value, and results of care physicians provided to these beneficiaries and reward the top performers while penalizing the worst.

The problem, health policy researchers say, is that evidence about how best to evaluate health care quality is lacking and currently used measures fail to account for differences in patients’ socioeconomic and health status that could skew quality scores in favor of practices that care for higher-income, better-educated, and less-complex patients.

Medicare’s pay-for-performance scheme is a zero-sum game, so bonuses for practices that score higher on quality measures are offset by the penalties levied on practices that score lower or don’t even submit data to play the game. “For every winner, there has to be a loser,” said Donald Berwick, MD, MPP, an administrator of the Centers for Medicare & Medicaid Services (CMS) during the Obama administration.

In this game, the losers are more likely to be physicians who care for poorer or sicker patients, and, in turn, their patients. “We are literally taking money from providers that serve the poor and giving it to providers that serve the rich,” said Karen Joynt Maddox, MD, MPH, a cardiologist and health services researcher at the Washington University School of Medicine in St Louis.

Continuing the Cycle

With the incentives stacked as they are, medical practices could game the current payment system by cherry-picking the patients who are more likely to try to stay healthy and, as a result, have better outcomes, thus making it appear that their physicians provide higher-quality care, said J. Michael McWilliams, MD, PhD, a general internist and professor of health care policy at Harvard Medical School.

He said he is more concerned that pay-for-performance incentives could discourage large organizations from opening or acquiring practices in poorer areas.

In a recent study in Annals of Internal Medicine, McWilliams and his coauthors found that the PVBM (Physician Value-Based Payment Modifier Program) had no effect on the quality or efficiency of care provided and likely exacerbated health care disparities by disproportionately penalizing practices that care for lower-income or sicker patients.

As of January 2018, the PBVM was succeeded by the Merit-based Incentive Payment System (MIPS), which differs mainly by allowing medical practices to choose the quality measures on which they’d like to be assessed. “Essentially, we are going from providers knowing the test questions in advance to providers being able to pick the test questions,” McWilliams said. “It further weakens the incentives of the program and allows for a lot more gaming behavior.”

And so, the cycle will persist, said Austin Frakt, PhD, coauthor of the editorial accompanying McWilliams’ article. Without accounting for patients’ socioeconomic status, practices that are otherwise doing a good job but happen to be serving lower-income patients will continue to be disproportionately hit with penalties, which “makes it harder for them to do a good job,” said Frakt, who holds appointments with the VA Boston Healthcare System, the Boston University School of Public Health, and the Harvard T.H. Chan School of Public Health. “The resources matter,” he added.

“I could see members of Congress saying, ‘Oh, sure, we should be able to measure quality in medical practices,’” said (Karen Joynt Maddox, MD, MPH, a cardiologist and health services researcher at the Washington University School of Medicine in St Louis). “The reality of that is much further away than any of us would prefer. We don’t even have the ability to collect and report high-quality clinical data…and that’s worse in underresourced settings.” However, even in places where the data are available, “we don’t have the science behind the quality measures,” she added.

Adjusting for Case Mix

“The critics say case-mix adjustment is incomplete. It will always be incomplete. You can’t get all the right variables on the page,” said Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement. On top of that, he said, providers could manipulate data for case-mix adjustment by coding patient visits as more complex than they actually were.

Race might be an appropriate variable to use for case-mix adjustment, Berwick said. After all, “blacks have a different disease burden. They’re of lower wealth. Overall, in the United States, the consequences of racism are still with us.”

However, that approach, while more difficult to game, has its own problems, he said. “What you’re then doing is saying, ‘If I am treating a population of more African-Americans, then I can have worse care, and you’ll adjust for that. It’s kind of like excusing the performance issues. How do you feel about that if you’re black?”

Seeking the Patient Perspective

According to Berwick and others, the current approaches to assessing the quality of care physicians provide leave out a key player: the patient. “We need to shift the question from ‘How are we [physicians] doing?’ to ‘How are you [patients] doing?’” said Berwick.

“It’s a paternalistic argument to say that we—CMS, scholars—are going to decide what high-quality means, and we’re just going to try to impose that or incentivize that,” Frakt added.

Berwick recently served on a panel convened by the Organisation for Economic Co-operation and Development (OECD), whose 35 member countries include the United States, that recommended using patient-reported indicators to strengthen the international comparison of health system performance.

“There remain substantive gaps in what is known about the experience of patients and the outcomes of care from the patient’s point of view,” panel members wrote in a report released in January 2017.

However, patient satisfaction should not be confused with outcomes, Frakt said. “Maybe I had a great visit with a physician, and I give him 5 stars out of 5. But what I really care about is getting my tendonitis resolved so I can run again.” No matter how likeable the physician, if a patient’s tendonitis has not improved by the time of a follow-up visit, the patient is not going to consider that a good outcome, Frakt said.

In the end, though, no matter what approach Medicare uses to pay physicians, it cannot be counted on to eliminate health care disparities, Berwick said.

“Pay-for-performance on the whole may well have aggravated disparities,” he acknowledged. But, he noted, “We have problems in social justice and income inequality and unfairness that need to be addressed directly, not indirectly, through public policy.”

https://jamanetwork.com…

***

Comment:

By Don McCanne, M.D.

It seems that these days almost every forum or treatise or journal article on health care financing reform begins with the admonition that we must start to pay for the value of health care delivered rather than for the volume, or the quality instead of the quantity. But then just try to find in the discussion that follows precise methods of demonstrating true global quality or precise methods of demonstrating how quantity can be reduced by eliminating selectively only that care that is not beneficial. Yet this aspiration has been repeated so often that it has become an empty meme.

Today’s article by Rita Rubin demonstrates that trying to comply with this meme fails in achieving the goals of reducing volume while increasing quality, but, worse, it may have adverse consequences that negatively impact patients and the professionals who care for them.

Years ago, in discussing the medical-industrial complex, Arnold Relman was one of many who pointed out that paying fee-for-service incentivizes greater volume regardless of the value of the services, whereas paying capitation (a fixed amount per patient regardless of the amount of care rendered) incentivizes a lower volume of care that increases margins by reducing overhead. Some have said that physicians should be paid a salary instead, but Relman pointed out that salaries incentivize sloth – in some ways a greater evil than greed.

The policy community is spending too much time looking at policies that might change the behavior of the health care professionals, even though plenty of studies have shown that there is not much impact from their schemes. They underrate the professionalism of the practitioners of the art of medicine. Give them the infrastructure and practice environment in which they are free to apply their skills, and they will do the right thing with and for the patient. Quantity is controlled by the resources available and quality is incentivized by the favorable practice environment. Sloth is tempered by by reducing the causes of burnout, such as having to comply with intrusive protocols and measurements that have little positive impact on patient care.

Donald Berwick reminds us that it really is all about the patient, and not just in the health arena. As he says, “Pay-for-performance on the whole may well have aggravated disparities,” but “we have problems in social justice and income inequality and unfairness that need to be addressed directly, not indirectly, through public policy.”

The next time a presenter opens with “value instead of volume” or “quality instead of quantity,” please feel free to scream – as loud as you can.

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CAP’s ‘Medicare Extra for All’ – What it really is

Beyond ‘Obamacare’: New liberal plan on health care overhaul

By Ricardo Alonso-Zaldivar
Associated Press, February 22, 2018

A major liberal policy group is raising the ante on the health care debate with a new plan that builds on Medicare to guarantee coverage for all.

Called “Medicare Extra for All,” the proposal to be released Thursday by the Center for American Progress gives politically energized Democrats more options to achieve a long-sought goal.

In a nod to political pragmatism, the plan would preserve a role for employer coverage and for the health insurance industry. Employers and individuals would have a choice of joining Medicare Extra, but it would not be required.

That differs from the more traditional “single-payer” approach advocated by Vermont independent Sen. Bernie Sanders, in which the government would hold the reins of the health care system.

Even though the plan has no chance of passing in a Republican-controlled Congress, center president Neera Tanden said, “We think it’s time to go bolder.”

“There is consensus on the progressive side that universal coverage should be the goal and health care is a right,” she added.

The Center for American Progress is a think tank that was closely aligned with President Barack Obama and 2016 Democratic presidential nominee Hillary Clinton. A 2005 proposal from the center foreshadowed Obama’s Affordable Care Act.

https://www.apnews.com…

***

Medicare Extra for All

By the CAP Health Policy Team
Center for American Progress, February 22, 2018

Health care is a right: No American should be left to suffer without the health care they need. The United States is alone among developed countries in not guaranteeing universal health coverage.

To address these challenges, the Center for American Progress proposes a new system—“Medicare Extra for All.” Medicare Extra would include important enhancements to the current Medicare program: an out-of-pocket limit, coverage of dental care and hearing aids, and integrated drug benefits. Medicare Extra would be available to all Americans, regardless of income, health status, age, or insurance status.

Employers would have the option to sponsor Medicare Extra and employees would have the option to choose Medicare Extra over their employer coverage. Medicare Extra would strengthen, streamline, and integrate Medicaid coverage with guaranteed quality into a national program.

The cost of coverage would be offset significantly by reducing health care costs. The payment rates for medical providers would reference current Medicare rates—and importantly, employer plans would be able to take advantage of these savings. Medicare Extra would negotiate prescription drug prices by giving preference to drugs whose prices reflect value and innovation. Medicare Extra would also implement long overdue reforms to the payment and delivery system and take advantage of Medicare’s administrative efficiencies. In this report, CAP also outlines a package of tax revenue options to finance the remaining cost.

Medicare Extra for All would guarantee universal coverage and eliminate underinsurance. It would guarantee that all Americans can enroll in the same high-quality plan, modeled after the highly popular Medicare program. At the same time, it would preserve employer-based coverage as an option for millions of Americans who are satisfied with their coverage.

Medicare Choice

Within the current Medicare program, Medicare Advantage provides a choice of plans that deliver Medicare benefits to seniors.

Medicare Extra would reform Medicare Advantage and reconstitute the program as Medicare Choice. Medicare Choice would be available as an option to all Medicare Extra enrollees. Medicare Choice would offer the same benefits as Medicare Extra and could also integrate complementary benefits for an extra premium.

Medicare Extra would make payments to plans that are equal to the average bid, but subject to a ceiling: Payments could be no more than 95 percent of the Medicare Extra premium.

Administration

Medicare Extra would be administered by a new, independent Center for Medicare Extra within the current Centers for Medicare and Medicaid Services, which would be renamed the Center for Medicare. To ensure that the Center for Medicare Extra is immune from partisan political influence within the administration, the legislative statute would leave little to no discretion to the administration on policy matters. In this respect, the administration of Medicare Extra would resemble the administration of the current Medicare program and not of the Medicaid program.

Administrative efficiencies

Excessive administrative costs are a key reason why health care costs are so much higher in the United States compared to other developed countries. Medicare Extra would take advantage of the current Medicare program’s low administrative costs, which are far lower than the administrative costs of private insurance. In particular, the cost and burden to physicians of administering multiple payment rates for multiple programs and payers would be greatly reduced.

In addition to having economies of scale and no need to make a profit, Medicare Extra would implement several administrative efficiencies. Providers would only need to report one set of quality measures and physicians would only need to submit one set of clinical credentials. Medicare Extra and providers would transmit claims information and payment electronically. Electronic health records would automatically convert clinical entries into claims information. Importantly, so-called churning between Medicaid and the individual market—in which individuals must frequently enroll and unenroll due to changes in eligibility—would be eliminated.

From the Conclusion

America, the most powerful and wealthiest nation in the history of civilization, has endured a long journey spanning decades to fulfill these principles. The country has slowly added step upon step toward universal health coverage. The ACA was a giant step, and the sustained political fight over the law showed that the American people want to expand coverage, not repeal it.

https://www.americanprogress.org…

***

A Better Single-Payer Plan

By David Leonhardt
The New York Times, February 22, 2018

A new single-payer health care proposal has just come out, and I think it has a better chance of eventually becoming law — in whole or in part — than Bernie Sanders’s plan.

It comes from the Center for American Progress, the influential liberal research group (often known as CAP). The proposal would create a program called Medicare Extra through which any American, regardless of age, could buy health insurance.

The crucial difference between the Sanders plan and the CAP plan is that the CAP version would not force people to give up their current employer insurance coverage. Those who are covered through their jobs could either keep that plan or enroll in Medicare Extra. The Sanders plan, by contrast, would eliminate employer-provided insurance in favor of a single federal system.

Substantively, the Sanders approach has a huge advantage: simplicity. But the experience of the last 25 years — across both Bill Clinton’s and Barack Obama’s presidencies — shows the dreadful politics of pushing people out of their current insurance plan.

There is a lot that I like in the CAP plan.

Ultimately, though, I still favor more modest health care proposals to sweeping, ambitious plans, for reasons of realpolitik.

https://www.nytimes.com…

***

Several years ago, David Himmelstein and Steffie Woolhandler explained during the debate over Obamacare what was wrong with the public option. It bears repeating today:

The “public plan option” won’t work to fix the health care system for two reasons.

1. It forgoes at least 84 percent of the administrative savings available through single payer. The public plan option would do nothing to streamline the administrative tasks (and costs) of hospitals, physicians offices, and nursing homes, which would still contend with multiple payers, and hence still need the complex cost tracking and billing apparatus that drives administrative costs. These unnecessary provider administrative costs account for the vast majority of bureaucratic waste. Hence, even if 95 percent of Americans who are currently privately insured were to join the public plan (and it had overhead costs at current Medicare levels), the savings on insurance overhead would amount to only 16 percent of the roughly $400 billion annually achievable through single payer — not enough to make reform affordable.

2. A quarter century of experience with public/private competition in the Medicare program demonstrates that the private plans will not allow a level playing field. Despite strict regulation, private insurers have successfully cherry picked healthier seniors, and have exploited regional health spending differences to their advantage. They have progressively undermined the public plan — which started as the single payer for seniors and has now become a funding mechanism for HMOs — and a place to dump the unprofitably ill. A public plan option does not lead toward single payer, but toward the segregation of patients, with profitable ones in private plans and unprofitable ones in the public plan.

https://pnhp.org…

***

Comment:

By Don McCanne, M.D.

What is this “Medicare Extra for All” proposal by the Center for American Progress (CAP), and where does it or should it stand in the movement for health care for all?

First of all, it is not a single payer proposal. It leaves in place much of our multi-payer system, including Medicare, Medicare Advantage, employer-sponsored health plans, the individual and small group market plans, TRICARE, Veterans Affairs medical care, and FEHBP – the Federal Employees Health Benefits Program. Private insurers continue to thrive – selling us risk-bearing plans favorable to them and/or excessive administrative services. Their iniquitous tools such as excessive cost sharing and narrow provider networks will not go away. The fundamental health care infrastructure remains in place in spite of the fact that some admittedly beneficial tweaks are recommended in this proposal.

What this proposal really is is a glorified version of the public option – a Medicare-like government plan that would be used to attempt to cover those who are uninsured and could be a replacement for those who are underinsured. If you carefully review the CAP proposal you will see that it adds both costs and administrative complexity to our existing health care financing system. It forgoes much of the cost containment and administrative simplicity of a bona fide single payer system.

As one example, look at their description of the administrative efficiencies they tout in their plan. They claim that they “would take advantage of the current Medicare program’s low administrative costs,” but their Medicare Extra plan adds other administrative costs and yet it would represent only a small fraction of health care financing considering that most of the existing multi-payer system would remain in place. They claim that electronic submission of claims through electronic health records would provide efficiencies, yet yesterday’s Quote of the Day demonstrated that those savings have not been realized and costs were actually increased when considering investments in the technology. They have not seriously addressed the profound administrative waste in our system.

A particular irony in this proposal is that they suggest replacing the private Medicare Advantage plans with private Medicare Choice plans. This reverts to the prior Medicare + Choice plans which were paid at rates of 95 percent of the costs in the traditional Medicare program, allowing them to prove that they could provide higher quality at lower costs. They couldn’t, and the program began to tank until it was rescued by the Medicare Advantage program which gave the private plans a tremendously unfair advantage at taxpayer expense. The authors of Medicare Extra don’t even give us a hint as to how they will entice the private insurers to jump back into their Medicare Choice plans.

A little bit of history of the Center for American Progress is enlightening. It was founded by John Podesta – Bill Clinton’s Chief of Staff. It has professed to represent and advance progressive/liberal values, but it really represents the neo-liberal element that has assumed control of the Democratic Party. Their current CEO is Neera Tanden who lead the forces that successfully blocked the Sanders camp from inserting a single payer plank in the Democratic Party platform, protecting Hillary Clinton who considered single payer to be a threat. The neo-liberals have been very protective of the private insurance insurance industry and have been successful to the degree that they lured many single payer progressives into their camp in support of the Affordable Care Act – legislation designed to protect and enhance the the interests of the private insurance industry. How could we have expected more out of the Center for American Progress than this highly deficient proposal with a pro-industry bias?

Already the media is jumping on this as a new, liberal, Medicare for All proposal. Even the progressive New York Times columnist David Leonhardt is calling this “A Better Single-Payer Plan.” Worse, he is falling into line with the comment, “I still favor more modest health care proposals to sweeping, ambitious plans, for reasons of realpolitik.” Shades of HCAN and the erection of political barriers to single payer reform. We’ve said repeatedly, single payer policy is right but it’s the politics that are wrong. Don’t change good policy; change bad politics!

We can’t leave this topic without acknowledging the one bit of good news here. Single payer Medicare for All is a vastly superior model of financing health care – a model we desperately need in this nation – and a majority of the public now realizes that. The neo-liberal Democrats realize that they cannot go into an election touting a model that many feel has fallen far short of our needs, especially when the concept of an improved Medicare for all has gained so much traction. CAP recognizes the threat and takes this challenge so seriously that they have elected to “go bolder” by dummying up a fake Medicare for all plan, calling it “Medicare Extra for All.” We just have to be sure that the public is not lured by this siren song. They want the real thing.

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