PNHP

Trumpcare is like a vampire, set on sinking its teeth into the poor

Trumpcare is like a vampire, set on sinking its teeth into the poor

The relationship of the Republican bills to tax breaks resembles that of water crackers to cheese: a delivery device with little independent function of its own

By Adam Gaffney, M.D.
The Guardian, June 23 2017

“Dead on arrival,” some said. That was to be the fate of the House’s Obamacare repeal bill in the Senate. Yet Trumpcare has risen again: on Thursday, the Senate released its Obamacare repeal bill, though its fate is still uncertain. The Senate draft is in some respects a watered-down version of the House’s, yet it is no less toxic: watering down cyanide, you see, only makes it so safe.

But first, some credit where it is due. Senate majority leader Mitch McConnell was faced with a daunting task after the American Health Care Act (AHCA) slithered its way through the House last month: the creature was about as popular as Count Dracula.

In a late May Quinnipiac poll, a measly 20% of voters approved the bill, not surprising when one considers that the AHCA was arguably more vampiric than the Romanian nobleman. Whereas the latter would drain his victims one by one, the AHCA would extract health coverage from some 23 million to engorge the bank balances of the wealthy few.

Yet McConnell and colleagues rose to the challenge, and it is hard to not be impressed by their ruthless stealth and speed. The baker’s dozen of white men that crafted the bill kept it hidden not only from the public, but from their fellow Republican Senators.

The secrecy – nary a single committee hearing! – kept it out of the headlines, an admittedly savvy strategy in light of the AHCA’s utter unpopularity. As one senior aide told Axios, “We aren’t stupid.” Certainly not, though they are a coldblooded bunch.

Now the Senate bill is with us, and suffice it to say that Trumpcare hasn’t much changed. There is one major exception: the Senate bill features subsidies to help people buy private insurance plans that resemble those under Obamacare, though they are less adequate.

These subsidies would be indexed to income and available to those earning under 350% of the federal poverty level (as opposed to under 400% with Obamacare). Libertarians can whine with some justification that, in this respect, they are being served a glass of Diet Obamacare.

But in other respects, the Senate bill looks very much like the House’s, retaining, of course, the lavish tax cuts for healthcare corporations and the rich. Over a decade, the House version of the bill was estimated to redistribute $230.8bn to high income earners, $144.7bn to insurance companies, $28.5bn to pharmaceutical companies, and $19.6bn to medical device manufacturers (healthcare stocks are jumping accordingly).

The relationship of the Republican bills to these tax breaks increasingly seems to be that of water crackers to cheese: an effective delivery device with little independent function of its own.

Yet hundreds of billions of dollars of tax cuts do not, as the saying goes, grow on trees. And who easier to take the money from then the poor? Thus, the Senate bill, like the House’s, goes for Medicaid’s jugular, and in the long term, actually sinks its teeth deeper.

To be fair, the Senate bill does bleed the program a bit slower at first – funding for Obamacare’s Medicaid expansion will be phased out over three years. Yet like the House bill, it ends Medicaid as an entitlement program wherein state spending is matched by federal dollars, constraining it instead to a per capita capped system – a long-winded way of saying that Republicans will shrink the program. Indeed, the hemorrhage of cash will ultimately be more brisk in the Senate version, as the bill dials down the rate of growth of the program beginning in 2025.

Like the House bill, the Senate bill also aims to appease conservative true believers by allowing states to apply for waivers to weaken Obamacare’s insurance regulations (albeit now via Obamacare’s 1332 waiver program). The true believers assert that jettisoning such regulations – like those that require coverage of a full set of healthcare benefits – would bring down premiums.

They are obviously right. Similarly, as Megan McArdle recently argued in Bloomberg, requiring sprinklers in tall residential buildings like the one that burned to a crisp in London last week (current death toll: 79) increases, to some extent, the cost of housing construction.

Which is not to say that, as with housing, the affordability of healthcare is not an issue. When conservatives critique Obamacare by asserting that premiums and deductibles are unaffordable for many, they are right, albeit disingenuously so. Just as the solution to unaffordable housing is not to let more buildings go up in flames, the solution to high healthcare costs is not to make health insurance plans increasingly worthless.

In the case of healthcare, the answer to this conundrum is simple: fund the healthcare system not through premiums or deductibles, but instead through progressive taxes, such that nobody is liable to pay more for healthcare than they can afford.

Of course, if you are trying not to reduce inequality, but to exacerbate it, this makes little sense: better to bleed Medicaid, transfuse the cash into the pockets of the rich, and call the whole bloodsucking endeavor an exercise in “freedom.”

https://www.theguardian.com…

The Senate’s ‘Better Care Reconciliation Act of 2017’

Senate Health Care Bill Includes Deep Cuts to Medicaid

By Robert Pear and Thomas Kaplan
The New York Times, June 22, 2017

Senate Republicans, who have promised a repeal of the Affordable Care Act for seven years, took a major step on Thursday toward that goal, unveiling a bill to cut Medicaid deeply and end the health law’s mandate that most Americans have health insurance.

The 142-page bill would create a new system of federal tax credits to help people buy health insurance, while offering states the ability to drop many of the benefits required by the Affordable Care Act, like maternity care, emergency services and mental health treatment.

The Senate bill — once promised as a top-to-bottom revamp of the health bill passed by the House last month — instead maintains its structure, with modest adjustments. The Senate version is, in some respects, more moderate than the House bill, offering more financial assistance to some lower-income people to help them defray the rapidly rising cost of private health insurance.

But the Senate measure, like the House bill, would phase out the extra money that the federal government has provided to states as an incentive to expand eligibility for Medicaid. And like the House measure, it would put the entire Medicaid program on a budget, ending the open-ended entitlement that now exists.

It would also repeal virtually all the tax increases imposed by the Affordable Care Act to pay for itself, in effect handing a broad tax cut to the affluent, paid for by billions of dollars sliced from Medicaid, a health care program that serves one in five Americans, not only the poor but almost two-thirds of those in nursing homes. The bill, drafted in secret, is likely to come to the Senate floor next week, and could come to a vote after 20 hours of debate.

https://www.nytimes.com…

H.R. 1628 – “Better Care Reconciliation Act of 2017”:
https://www.budget.senate.gov…

Senate Budget Committee overview of H.R. 1628 (highly deceptive rhetoric):
https://www.budget.senate.gov/bettercare

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Comment:

By Don McCanne, M.D.

No surprises. The discussion draft of the Senate repeal and replace legislation reveals that the legislators would reverse some of the beneficial features of the Affordable Care Act (ACA), which we knew, but the most important measure is the deep reduction in Medicaid funding, allowing them to repeal the tax increases that have paid for the expanded benefits of ACA.

At this point it does not seem that they have the votes to pass this legislation primarily because it does not repeal the fundamental structure of ACA, though negotiations are still taking place. The intent is to vote on it next week. That is a very short time to resolve deeply held ideological differences within the Republican caucus.

If the bill were to pass and be signed into law, it would open the floodgates of activism on behalf of Medicare for all. The Republicans surely do not want that. Yet a loss with the defeat of this legislation would equate to a phenomenal victory for the Republicans because it would have distracted us from following through on the surge of support for single payer reform that has been escalating this past year.

Even if the bill fails, the numbers who remain uninsured, the financial hardships that even many of the insured are facing, and the expensive and wasteful dysfunction of our fragmented health care financing system should still drive us to demand an improved Medicare for all. We cannot walk away from this pretending that a defeat of the Better Care Reconciliation Act of 2017 would equate to a victory for us. Real victory would be in finally achieving health care justice for all.

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

The cruelty of using Medicaid as a tool to reduce budget deficits

The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of Research Findings

By Samantha Artiga, Petry Ubri, and Julia Zur
Kaiser Family Foundation, June 1, 2017

Key Findings

Recently, there has been increased interest at the federal and state level to expand the use of premiums and cost sharing in Medicaid as a way to promote personal responsibility, prepare beneficiaries to transition to commercial and private insurance, and support consumers in making value-conscious health decisions. This brief reviews research from 65 papers published between 2000 and March 2017 on the effects of premiums and cost sharing on low-income populations in Medicaid and CHIP. This research has primarily focused on how premiums and cost sharing affect coverage and access to and use of care; some studies also have examined effects on safety net providers and state savings. The effects on individuals, providers, and state costs reflect varied implementation of premiums and cost sharing across states as well as differing premium and cost sharing amounts. Together, the research finds:

* Premiums serve as a barrier to obtaining and maintaining Medicaid and CHIP coverage among low-income individuals. These effects are largest among those with the lowest incomes, particularly among individuals with incomes below poverty. Some individuals losing Medicaid or CHIP coverage move to other coverage, but others become uninsured, especially those with lower incomes. Individuals who become uninsured face increased barriers to accessing care, greater unmet health needs, and increased financial burdens.

* Even relatively small levels of cost sharing in the range of $1 to $5 are associated with reduced use of care, including necessary services. Research also finds that cost sharing can result in unintended consequences, such as increased use of the emergency room, and that cost sharing negatively affects access to care and health outcomes. For example, studies find that increases in cost sharing are associated with increased rates of uncontrolled hypertension and hypercholesterolemia and reduced treatment for children with asthma. Additionally, research finds that cost sharing increases financial burdens for families, causing some to cut back on necessities or borrow money to pay for care.

* State savings from premiums and cost sharing in Medicaid and CHIP are limited. Research shows that potential revenue gains from premiums and cost sharing are offset by increased disenrollment; increased use of more expensive services, such as emergency room care; increased costs in other areas, such as resources for uninsured individuals; and administrative expenses. Studies also show that raising premiums and cost sharing in Medicaid and CHIP increases pressures on safety net providers, such as community health centers and hospitals.

Conclusion

Recently, there has been increased interest at the federal and state levels to expand the use of premiums and cost sharing in Medicaid as a way to promote personal responsibility, prepare beneficiaries to transition to commercial and private insurance, and support consumers in making value-conscious health decisions. Current rules limit premiums and cost sharing in Medicaid to facilitate access to coverage and care for the low-income population served by the program, who have limited resources to spend on out-of-pocket costs. This review of a wide body of research provides insight into the potential effects of increasing premiums and cost sharing for Medicaid enrollees. It shows that premiums serve as a barrier to obtaining and maintaining coverage for low-income individuals, particularly those with the most limited incomes, and that even relatively small levels of cost sharing reduce utilization of services. As such, increases in premiums and cost sharing result in increased barriers to coverage and care, greater unmet health needs, and increased financial burdens for families. Further, the research suggests that state savings from premiums and cost sharing in Medicaid and CHIP are limited and that increases in premiums and cost sharing in Medicaid and CHIP can increase pressures on safety-net providers.

http://www.kff.org…

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Republicans see Medicaid as welfare. Most Americans don’t.

By Drew Altman
Axios, June 21, 2017

Republicans want to roll back the Medicaid expansion, cap federal Medicaid spending increases, and add work requirements, drug testing, time limits, copays and premiums to some state Medicaid programs. But almost no one else wants to do these things. One poll finding goes a long way toward explaining why: Republicans view Medicaid as a form of welfare, and pretty much everyone else views it as a government insurance program.

Why it matters: Welfare remains unpopular in our country; it’s always popular to limit or cut “welfare”. Whether it should be, and what this says about us, is a different question.

Perceptions of Medicaid as welfare don’t seem bothered much by facts, such as, for example, that two thirds of Medicaid spending goes for the low income elderly and disabled who don’t fit the Ronald Reagan era image of the welfare king or queen. But it’s not the majority view in any case. A little less than a third of voters identify as Republicans today, and about half of them see Medicaid as welfare.

https://www.axios.com…

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Comment:

By Don McCanne, M.D.

Tomorrow the Republicans in the Senate are expected to release their proposal to repeal and replace the Affordable Care Act. Although there will likely be some modest detrimental changes recommended for the individual market insurance exchanges, the largest impact will likely be in changes recommended for the Medicaid program. Today’s message explains why that would be a grievous mistake.

Medicaid is the largest insurance program in the United States, serving over 74 million people. These are low-income individuals who do not have assets that could pay for their proportionate share of America’s health care bill. Most of us consider Medicaid to be an essential insurance program for these individuals and families (in the absence of a single payer system). However, new poll results by Kaiser Foundation show that one-half of Republicans (Republicans being one-third of the population) consider Medicaid to be predominantly a welfare program, and those Republicans now control our government. The political representatives of one-sixth of our population are about to take a budget ax to this crucial program, because, after all, it is merely a welfare program and one that we can no longer afford to maintain (Republican view).

The consequences of the various policies under consideration are dire. They are considering allowing states to impose premiums that would create a barrier to Medicaid coverage, leaving those vulnerable without insurance. They are considering allowing the states to use cost sharing to make Medicaid beneficiaries better health care shoppers, but it has been shown that even small out-of-pocket costs create barriers to care for this population. They likely will dramatically reduce over time the federal contribution to the state Medicaid programs which may cause even more states to limit eligibility, keeping out individuals who may be impoverished but still have barely enough income to have a cellphone (as if cellphone fees were enough that they could be used instead to purchase health plans in the individual market).

What we will see tomorrow will be legislative recommendations to the Republicans in the Senate. It remains to be seen whether or not they will conveniently fail to find the votes to pass their proposal so that they will not all be labeled as having stone-cold hearts.

Even if Medicaid does get a reprieve, we still cannot relax. It will continue to be vulnerable to attacks by those who consider it to be welfare and thus a tool to reduce budget deficits. Medicaid must be replaced by a program that provides access to comprehensive health care benefits while removing financial barriers to care – not just for lower-income individuals, but for all of us. Regardless of the Republican replacement proposal we need to intensify our advocacy for replacement with an improved Medicare for all.

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

Universal coverage should be health goal

By Richard A. Damon, M.D.
The Billings (Mont.) Gazette, June 21, 2017

Everyone knows the Senate is trying to ram through their version of the GOP House health care bill called the American Healthcare Act behind closed doors and in secret. Both political parties routinely resort to underhanded ways to gain political advantage, placing party politics before population.

Gov. Steve Bullock, along with three other Democratic governors and three Republican governors, is urging the Senate to rethink the health care bill, which as yet has not been scored by the CBO. McConnell hopes to pass the Senate version before Americans can respond to knowing the devastating impact the bill will have on millions of Americans while giving tax breaks to the wealthiest Americans.

Major health insurers are fleeing the ACA market. The underlying reasons we are in crisis are that for-profit health insurers and drug maker stakeholders remain in legislative control of health care policy. There is no legislative congressional admission that the reasons for the health care crisis is because of the private insurer multi-payer system, while drug makers continue to be exempt from drug price regulation.

Transition to a Medicare for All single payer system, funded by modest equitable taxes, would initially be cost neutral because of increased expansion of coverage to every American. After initial transition costs, every American from birth to death would enjoy comprehensive benefits, saving over $450 billion a year in administrative costs, making Medicare for All an equitable sustainable system. We must not allow Congress to pass the underhanded, perverse bill excluding 23 million Americans from coverage and giving tax breaks to the wealthy.

http://billingsgazette.com…

Universal coverage should be health goal

By Richard A. Damon, M.D.
The Billings (Mont.) Gazette, June 21, 2017

Everyone knows the Senate is trying to ram through their version of the GOP House health care bill called the American Healthcare Act behind closed doors and in secret. Both political parties routinely resort to underhanded ways to gain political advantage, placing party politics before population.

Gov. Steve Bullock, along with three other Democratic governors and three Republican governors, is urging the Senate to rethink the health care bill, which as yet has not been scored by the CBO. McConnell hopes to pass the Senate version before Americans can respond to knowing the devastating impact the bill will have on millions of Americans while giving tax breaks to the wealthiest Americans.

Major health insurers are fleeing the ACA market. The underlying reasons we are in crisis are that for-profit health insurers and drug maker stakeholders remain in legislative control of health care policy. There is no legislative congressional admission that the reasons for the health care crisis is because of the private insurer multi-payer system, while drug makers continue to be exempt from drug price regulation.

Transition to a Medicare for All single payer system, funded by modest equitable taxes, would initially be cost neutral because of increased expansion of coverage to every American. After initial transition costs, every American from birth to death would enjoy comprehensive benefits, saving over $450 billion a year in administrative costs, making Medicare for All an equitable sustainable system. We must not allow Congress to pass the underhanded, perverse bill excluding 23 million Americans from coverage and giving tax breaks to the wealthy.

http://billingsgazette.com…

Burden of prior authorization getting worse

Payer prior authorization requirements on physicians continue rapid escalation: increasing practice overhead and delaying patient care

MGMA Poll, May 16, 2017

Medical practice leaders say that the burden of submitting prior authorization requests and supporting documentation to health plans is getting worse.

A May 16 MGMA Stat poll found 86% of respondents saying that prior authorization requests have increased in the past year, while 3% report those requests decreasing and another 11% saying they’ve stayed the same in the past year.

Agreements between health plans and their participating physicians routinely include a statement that the insurer has the right to determine the medical necessity of surgery, imaging studies, medication and many other procedures. Physician practices then devote clinical and administrative staff time and resources to submit preauthorization requests for each service, increasing overhead and often delaying patient care.

“Health plan demands for prior approval for physician-ordered medical tests, clinical procedures, medications, and medical devices ceaselessly question the judgement of physicians, resulting in less time to treat patients and needlessly driving up administrative costs for medical groups,” said Halee Fischer-Wright, MD, MMM, FAAP, CMPE, MGMA President and CEO.

http://www.mgma.com…

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Comment:

By Don McCanne, M.D.

Prior authorization requirements have always been a pain, and now, according to this poll, they’re getting worse. Not only do they add to our profound administrative waste in health care, they also may interfere with patient care by delaying or even preventing the delivery of appropriate services. They also waste valuable time of physicians and their staffs.

This report states, “Agreements between health plans and their participating physicians routinely include a statement that the insurer has the right to determine the medical necessity of surgery, imaging studies, medication and many other procedures.” Really? Insurers and other intermediaries have the right to determine medical necessity? Doesn’t that right belong to the patients in consultation with their health care professionals? Sure, insurers make payment decisions, and prior authorization may prevent retroactive denial of coverage. But how can they have to gall to usurp clinical judgment?

But suppose the services are unnecessary. Wouldn’t it be better to identify outliers and then attempt to educate them, reserving penalties for those remaining refractory to educational efforts? Taiwan has shown that that can work with a single payer system.

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

The Washington Post Is Selling Snake Oil

Our friends at the Washington Post are waging a brave campaign against Medicare for All.

By Adam Gaffney, M.D.
Jacobin, June 20, 2017

Over the weekend, the Washington Post editorial board took a bold stance: they argued that universal health care with single-payer financing is simply beyond reach.

That the Post felt the need to issue the editorial at this particular moment is a testament to single payer’s rising fortunes. From coast to coast, activists are on the march: against the widely loathed, upward-wealth-redistributing, health-care-stripping abomination known as Trumpcare, for sure — but also for real universal health care.

Yet the Post’s frail arguments should be confronted, because they repeat a number of common talking points that rest on flawed assumptions and that could do real harm.

The Post editorial board begins by briefly conceding that single payer does have “some strong advantages.” It notes that single payer would be less of a hassle for many people (a good point), that it would get employers out of the messy role of providing health-care benefits (reasonable), and finally that it would facilitate cost-effectiveness research by government investigators (fine I suppose, although this is unlikely to galvanize the average person).

At the same time, however, the Post entirely neglects any of single payer’s actual “strong advantages”: the elimination of uninsurance (28.6 million uninsured in 2016), the ending of underinsurance (most single-payer proposals and bills say that care will be free at point-of-use), or the expansion of health-care benefits (for example, long-term care and dental care).

After neglecting to mention the benefits that actually animate most single-payer advocates, the Post proceeds to critique what it views as single payer’s “astonishing” price tag. It notes that while single-payer proponents point to the much less expensive public health-care systems of other nations, public health-care spending in the United States is already quite high:

The public piece of the American health-care system has not proven itself to be particularly cost-efficient. On a per capita basis, US government health programs alone spend more than Canada, Australia, France and Britain each do on their entire health systems. That means the US government spends more per American to cover a slice of the population than other governments spend per citizen to cover all of theirs.

At first glance it seems here that the Post is making something of an argument for single payer, arguing — as colleagues have put it — that we are already “Paying For National Health Insurance — And Not Getting It.” But they aren’t. They are contending that US public health-care spending is inefficient relative to international comparators, so making the whole system public wouldn’t bring costs in line with other nations.

Now they are right that transitioning to single payer would not reduce US health-care spending, as a percentage of GDP, to the levels seen in the United Kingdom (nor would we want it to: the UK is currently spending too little on its National Health Service).

Nonetheless, the underlying logic of the editorial board’s argument is still very flawed. The Post fails to acknowledge a widely known fact: Medicare is run at a far lower rate of overhead as compared to private insurers, while a single-payer system would produce additional efficiencies throughout the system via reduced spending on administration and billing. Even if we didn’t reduce overall health-care spending through Medicare for All, there would still be enormous savings from the transition that we could use to cover single payer’s costs: more than $500 billion annually, by one estimate.

After essentially dismissing this as a source of savings, the Post proceeds to assert that if single payer is to wring any real savings out of the system, they will be by necessity painful and divisive. Here it engages in a divide-and-conquer approach which we will likely see more of in coming days: doctors will have to be paid less, rural America will have to give up its “expensive medical facilities that serve relatively few people,” and “patients would have to accept different [i.e. worse] standards of access and comfort.”

This is nonsense. Canadian doctors get reimbursed perfectly well for their labor. Rural areas might actually be better served, not worse, under a national health program (NHP) that consciously plans the construction of new health-care capital. And the whole point of single payer is to improve access for all patients: as we replace insurance networks with “one big network” of NHP providers, and eliminate uninsurance and underinsurance, barriers to care — financial and otherwise — will decline.

The editorial concludes by noting that “universal coverage” and controlling costs should still remain the goal, albeit within the edifice of the “Obamacare system.” Yet they neglect to demonstrate how any incremental reforms would actually take us to universal coverage.

The fact is, the major added cost of single payer is the price of covering the uninsured and expanding coverage for the rest of us. So if universal health care is “too expensive” with single-payer financing — with its widely agreed upon efficiencies and capacity to substantially reduce drug prices — it would be absolutely too expensive to attain without it.

It’s Washington Post editorial board writers — not single-payer proponents — that are selling snake oil.

https://jacobinmag.com…

New survey shows a majority of Chicago-area doctors support Medicare for all

90% of regional physicians believe that health care is a basic human right

FOR IMMEDIATE RELEASE, June 20, 2017

For a copy of the report please contact: Clare Fauke, communications specialist, Physicians for a National Health Program, clare@pnhp.org or 312-782-6006

A new poll of more than one thousand Chicago-area physicians finds that a majority support a universal, single-payer health system and an overwhelming number reject the American Health Care Act (AHCA), the Republican House plan to repeal and replace the Affordable Care Act (ACA). Chicagoland physicians prefer a single-payer plan two-to-one over the ACA, and three-to-one over the AHCA. By similar margins, physicians believe that improved Medicare for all is a preferable health financing system over both the ACA and the AHCA. The study was conducted in April and May by the Chicago Medical Society, which represents 17,000 physicians serving more than five million patients in the Chicago area.

The study’s key findings include:

  • Nearly 90% of respondents agreed that health care is a human right that should be made available to all individuals, similar to basic education, police and fire protection (70% agreed strongly and 18% agreed somewhat).
  • Asked to choose which proposal would provide “the best care to the greatest number of people for a given amount of funding,” 56% chose single-payer/improved Medicare for all, 26% chose the ACA and 18% chose the AHCA.
  • When asked to provide their views of competing health care systems, single payer was viewed favorably by 67% of doctors, the ACA was viewed favorably by 63% of doctors, and the AHCA was viewed favorably by only 23%.

“Because of our profit-driven, multi-payer health system, doctors are spending hours each day on paperwork and billing, hours that could have been spent on patient care,” said Claudia Fegan, M.D., a Chicago-based physician and national coordinator for Physicians for a National Health Program (PNHP). “Not surprisingly, a growing number of health care providers reject the AHCA and support the simplicity and efficiency of improved Medicare for all.”

Dr. Fegan notes that in contrast to the AHCA, H.R. 676, the Expanded and Improved Medicare for All Act, would provide immediate, comprehensive coverage to all Americans and yield more than $500 billion dollars in yearly administrative savings. H.R. 676 has gained a record 112 co-sponsors, which represents a majority of House Democrats.

PNHP encourages medical associations to respect the opinions of their members and formally support Medicare for all. At the recent meeting of the American Medical Association in Chicago, the AMA’s Medical Student Section unanimously adopted a resolution called “National Healthcare Finance Reform: Single Payer Solution” to “support the implementation of a national single payer system.”

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and educational organization of more than 21,000 doctors who support a single-payer national health program. PNHP had no role in funding or otherwise supporting the study described above.

Even the insured line up for charity

Even the Insured Often Can’t Afford Their Medical Bills

By Helaine Olen
The Atlantic, June 18, 2017

The current debate over the future of the Affordable Care Act is obscuring a more pedestrian reality. Just because a person is insured, it doesn’t mean he or she can actually afford their doctor, hospital, pharmaceutical, and other medical bills. The point of insurance is to protect patients’ finances from the costs of everything from hospitalizations to prescription drugs, but out-of-pocket spending for people even with employer-provided health insurance has increased by more than 50 percent since 2010, according to human resources consultant Aon Hewitt.

Even a gold-plated insurance plan with a low deductible and generous reimbursements often has its holes. Many people have separate—and often hard-to-understand—in-network and out-of-network deductibles, or lack out-of-network coverage altogether. While many plans cap out-of-pocket spending, that cap can often be quite high—in 2017, it’s $14,300 for a family plan purchased on the ACA exchanges, for example. Depending on the plan, medical care received from a provider not participating in a particular insurer’s network might not count toward any deductible or cap at all.

The fact is that nearly any illness or injury can lead to unexpected bills, and few are able to absorb those shocks without difficulty. Yet, despite the commonness of such problems, there is little in the way of a system for helping people out through these times.

(The article discusses a multitude of funds with a mission to assist patients in paying their medical bills. The following comments are typical about many of these funds.)

The evidence is clear when you visit the websites of the funds. The Patient Advocate Foundation’s chronic pain fund? Its aid is limited to $1,500 and you need to apply when it’s taking applications. “Effective 01/18/2017, we are unable to process applications that are pending or accept new or renewal applications at this time. Should additional funding for Chronic Pain Fund applicants become available in the future, it will be necessary to re-apply if assistance is still needed.” The Patient Advocate Foundation’s multiple-sclerosis and renal-cell-carcinoma funds have been closed to new applicants since 2016.

And even when medical supplicants find programs, they are not guaranteed aid even if they meet all the eligibility requirements. “Then you call these services, not just for medical help, but any help. They tell you, ‘Oh, you have to hit us on this date,’ or ‘We get funding every month, but our funding is gone by the fifth of the month.’”

As for hospital-based charity, it can vary widely. Most studies find for-profit hospitals provide less charity care than nonprofit medical centers. But getting aid from a non-profit hospital isn’t exactly a gimme. A paper published by the Brookings Institution in 2015 pointed out that the non-profit hospitals with the most funds that could be devoted to charity care—that is, covering or forgiving medical bills of those who cannot pay full—are not located in the geographic areas where the need is greatest.

In an effort to cut down on uncollectable bills, a number of hospitals are now teaming up with financial services firms like Commerce Bank to offer time-limited interest free loans to patients something that, while helpful to some, most certainly is not charity.

Little wonder, then, that an increasing number of patients turn to crowdfunding even before they investigate more established charitable giving programs.

Yet for all the attention paid to crowdfunding, the limited evidence we have shows that for most people, the hype is better than the actual results.

(Ethan Austin, the co-founder of Give Forward) spoke to a group of students at New York University’s Stern School of Business about his (crowdfunding) site. He was blunt about one of the reasons he believed this segment of the online fundraising world had taken off so dramatically. “Our health-care system is shit and it’s trending shittier,” he told the group.

But there is more than simple embarrassment arguing against this system. It’s the equivalent of taping a few bandages over a gaping wound and hoping for the best. The cost of medical care is so high, and the personal finances of many Americans so tight,  it’s all but impossible for any organization—or all of them—to keep up, and that’s whether or not the charitable contributions they accept are part of the problem or the solution.

https://www.theatlantic.com…

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Comment:

By Don McCanne, M.D.

You really don’t need a long article like this to understand that our current health care financing system falls far short of preventing financial hardship for many with health care needs, insured or not, and that our various charitable resources hardly make a dent in the need.

We need a health care financing system that ensures access for all while eliminating financial barriers to care. Patches to the current fragmented system will do neither. A well designed single payer system – an improved Medicare for all – would fix the system so it works well for all of us. That’s what the people want. So let’s do it.

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

The advantages of getting sick elsewhere

By Louis Balizet, M.D.
The Pueblo (Colo.) Chieftain, Jun 17, 2017

Last month, a Pueblo woman, while on vacation far from home, developed chest pain, cough and shortness of breath.

She had had blood clots in her lungs previously, and feared a recurrence of this potentially deadly condition.

An ambulance was called and arrived in 20 minutes, having been dispatched from the local hospital. This was soon followed by another vehicle carrying a doctor, who assessed the woman inside the ambulance.

Her physical examination revealed severe bronchospasm (tightening and narrowing of the air tubes in the lungs). Medicines to reverse the bronchospasm were administered via nebulizer; an EKG was done; and the ambulance driver was directed to proceed to the emergency room, where another doctor assumed care. Blood tests, a chest X-ray, and a follow-up EKG were performed.

The emergency room doctor concluded that the woman’s condition was due to severe asthmatic bronchitis, with recurrent lung clots ruled out by one of the blood tests. Intravenous steroids, intravenous antibiotics and additional nebulizer treatments were administered.

After seven hours in the ER, the woman’s condition had improved, but not enough to permit discharge. She was admitted to an adjacent six-bed observation unit, where a third physician (like the first two, a woman) took over, and continued the regimen started in the ER.

After 12 hours in the observation unit, she had improved enough to be discharged, with prescriptions for oral steroids, oral antibiotics and asthma medicines to be administered by nebulizer.

After she was settled back in her hotel, the woman’s husband went to a nearby pharmacy and walked out 10 minutes later with her medicines and a rented nebulizer. The woman gradually improved and after four days was able to resume her vacation schedule.

The bill for the ambulance and hospital services, including all tests and physicians’ fees, was $137. The pharmacy bill came to $38; for locals, there would have been no charge.

In what fantasy land did this episode take place? It was no fantasy — it was Italy. I know, because the woman is my wife.

Why was my wife’s care not accompanied by a backbreaking and complicated bill, as it would have been here in the U.S.? Because Italy, along with every developed country except ours, has made a societal decision that needed medical care should be provided to all residents without crushing financial consequences to the sick person, and that the national government should guarantee, finance and organize this care.

The efficiencies that result enable Italy to cover everybody for a fraction of what we pay with equal, if not superior, outcomes.

Italy spends $3,272 per capita for medical care; we spend $9,471. Italians have a life expectancy of 82 years; ours is 79. At an individual level, my wife’s care in Montepulciano, Italy, was at least equivalent to what she would have received in Pueblo.

Since a system like Italy’s (or Canada’s, or Australia’s, or Germany’s) is so superior to ours, why don’t we change?

Despite the perils for individual patients, there are some that are doing very well under the status quo — chiefly medical insurers and pharmaceutical companies. These entities enjoy privileged and protected status in the American system that they don’t elsewhere. They also have the political, financial, and public relations resources to thwart any move to a system that favors them less.

With Obamacare threatened by internal structural weaknesses and external political attacks, we should be looking for alternatives. Other countries, like Italy, offer guidance about how to achieve universal, economical and effective medical care.

Our health care debate would profit from “A Taste Of Italy.”

http://www.chieftain.com…

Single payer systems have lower drug spending than do multi-payer systems

Drivers of expenditure on primary care prescription drugs in 10 high-income countries with universal health coverage

By Steven G. Morgan, PhD, Christine Leopold, PhD, Anita K. Wagner, PharmD, DrPH
CMAJ, June 12, 2017

Abstract

BACKGROUND: Managing expenditures on pharmaceuticals is important for health systems to sustain universal access to necessary medicines. We sought to estimate the size and sources of differences in expenditures on primary care medications among high-income countries with universal health care systems.

METHODS: We compared data on the 2015 volume and cost per day of primary care prescription drug therapies purchased in 10 high-income countries with various systems of universal health care coverage (7 from Europe, in addition to Australia, Canada and New Zealand). We measured total per capita expenditure on 6 categories of primary care prescription drugs: hypertension treatments, pain medications, lipid-lowering medicines, noninsulin diabetes treatments, gastrointestinal preparations and antidepressants. We quantified the contributions of 5 drivers of the observed differences in per capita expenditures.

RESULTS: Across countries, the average annual per capita expenditure on the primary care medicines studied varied by more than 600%: from $23 in New Zealand to $171 in Switzerland. The volume of therapies purchased varied by 41%: from 198 days per capita in Norway to 279 days per capita in Germany. Most of the differences in average expenditures per capita were driven by a combination of differences in the average mix of drugs selected within therapeutic categories and differences in the prices paid for medicines prescribed.

INTERPRETATION: Significant international differences in average expenditures on primary care medications are driven primarily by factors that contribute to the average daily cost of therapy, rather than differences in the volume of therapy used. Average expenditures were lower among single-payer financing systems that appeared to promote lower prices and the selection of lower-cost treatment options.

From the Methods

This is a comparative economic analysis of market research data from calendar-year 2015 for 10 selected, high-income countries with a variety of systems of universal health care coverage: Canada, Australia, New Zealand, Norway, Sweden, the United Kingdom, France, Germany, the Netherlands and Switzerland.

We chose these countries because they are all high-income countries offering universal health coverage, and all were part of a large study involving countries that have participated in the Commonwealth Fund’s International Health Policy surveys. We did not include the United States in this analysis because it is an outlier in 2 important ways: first, it has not yet achieved universal health coverage; second, it has such exceptionally high pharmaceutical expenditures that its inclusion in this analysis would skew comparisons among the 10 more comparable countries studied here.

Residents of all countries except Canada were eligible for universal health coverage that included universal coverage of outpatient prescription drugs. The systems of drug coverage in Australia, New Zealand, Norway, Sweden and the UK can be described as universal public systems. In these countries, prescription medicines are financed predominantly by government, and either government or an arm’s-length public body manages the selection and the price-setting of medicines to be covered by the universal system of public financing. Prescription drugs in France, Germany, the Netherlands and Switzerland are financed through multiple-payer, social insurance systems with various statutory policies governing minimum coverage and pricing for brand-name and generic drugs.

From the Interpretation

Across 10 high-income countries with universal health care systems, the average expenditure per capita on 6 of the largest categories of primary care medicines varied by more than 600%. The volume of therapies purchased varied by only 41%, which meant that most of the differences in average expenditure per capita were driven by differences in the average mix of drugs selected within therapeutic categories and differences in the prices paid for medicines prescribed. In New Zealand, estimated costs per day of therapy were about one-third the level in comparator countries; in Switzerland, estimated costs per day were nearly double the level in comparator countries.

Conclusion

Substantial international differences in average expenditures on primary care medications are driven primarily by factors that contribute to the average daily cost of therapy, rather than differences in the volume of therapy used. Average expenditures are lower among single-payer financing systems, which appear to promote lower prices and selection of lower-cost treatment options within therapeutic categories.

http://www.cmaj.ca…

Commonwealth Fund report on performance of health systems of 11 high-income nations:
http://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

This study of ten high-income countries with universal coverage demonstrated that those with single payer systems spent less on prescription drugs than did those with multi-payer systems. This is one more bit of evidence confirming that the United States is correct in continuing its pursuit of a national single payer financing system – an improved Medicare for all.

The ten nations studied were from those reported previously in the Commonwealth Fund studies of eleven nations in which the United States was ranked last overall on various measures of performance (link above). The United States was omitted from this study because it does not have universal health care coverage, and it has exceptionally high pharmaceutical expenditures that would have skewed the study.

Switzerland presents a special case that should be of interest to single payer supporters in the United States. Their system is financed by highly regulated private insurance plans  – a system which has been praised by U.S. advocates of consumer-directed health care for placing a greater financial burden on patients in need. Switzerland has twice rejected ballot measures which would have established a single payer system within their nation. As a result, amongst other features of their system, they now enjoy paying the highest drug costs of these nations – nearly double the level in comparator countries (but still far less than drug costs in the United States).

We can learn much about health care financing from other high-income nations with universal health care systems. Here we see that a universal system alone is not enough. It needs to be a well designed single payer system. We have the rudiments of that in our traditional Medicare program, but it still needs a lot of work.

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

Using automatic enrollment to cover everyone

The Senate Should Build Automatic Enrollment Into Health Reform. Here’s How.

By Lanhee Chen and James Capretta
Health Affairs Blog, June 5, 2017

As the discussion over the future of health reform continues in the United States Senate, some Republicans are looking for ways to boost coverage levels, help stabilize insurance markets, and lower health costs. For years, the U.S. has had insurance enrollment levels below what was possible because of lower than desirable take-up of existing options.

Currently, under the ACA, the markets are less stable than they could be, or should be, because there are too few younger and healthier enrollees. Automatic enrollment would boost enrollment into insurance among this group of potential customers, and thus help create a more balanced risk pool.

We believe that automatically enrolling Americans eligible for tax credits into no-premium health plans should be an important component of a renewed effort at health reform. Many of the uninsured who do not make plan selections on their own can be enrolled into plans that provide true insurance against significant or catastrophic health events. Individuals who are auto-enrolled will have the opportunity to opt-out of that coverage if they prefer; they will also be given the opportunity to switch to a different plan during the next available open enrollment period.

Operationalizing The Idea

* Make State Participation A Condition Of Federal Funding Under Reform, And Provide Separate Funding For Administrative Costs

* Require Insurers To Offer Default Insurance Products In The Individual Insurance Market

* Establish Parameters For Default Insurance Plans

* Establish A Target Population For Automatic Enrollment Into No-Premium Coverage

* Repurpose And Supplement The IRS’ Income And Insurance Enrollment Data

* Establish A Process For Assigning Beneficiaries To Default Plans

* Provide Notification To Beneficiaries

* Recruit Hospital And Physician Cooperation

What Happens When The Tax Credits Exceed The Premiums Needed For Default Insurance?

In the event Congress adopts income-adjusted credits, there will be cases when people get placed into default plans with premiums that are less than the value of the credits for which they are eligible. In these cases, the person would forgo the balance of their credit until such time that they make a selection of a plan, or affirm the default option.

What Happens When The Credits Fall Short Of The Premiums For Default Coverage?

The system for identifying and placing individuals into coverage will be based on income and insurance enrollment data from two years prior to the placement into a plan. There will necessarily be cases when someone gets placed into coverage with a premium than ends up exceeding the value of the credit for which they are eligible. In these cases, the insurance plan receiving the credit, and the individual who was placed into coverage, should be held harmless for misestimated credit amounts. That is, the insurer should not be required to return the difference between the credit received for a default enrollee over the amount of the credit that should have been paid based on the person’s income. Nor should the default insurance enrollee be asked to cover the difference in a payment to the federal government or the insurance plan.

What Happens When A Person Has Had A Break In Coverage And Owes A Premium Surcharge?

In the House-passed AHCA, persons who experience a break in coverage are required to pay a surcharge equal to 30 percent of the premium of the plan which they are seeking to purchase. The main intent of an automatic enrollment process is to help people avoid breaks in coverage, and thus also the penalties associated with trying to re-enter the market. In that context, it would be best to provide some level of accommodation for people who end up being placed into default coverage after a spell of being uninsured. One approach would be to provide everyone who experiences a break in coverage a one-time waiver of the surcharge penalty when they first are placed into a default plan. After that first occasion, however, if someone experienced a break in coverage and then subsequently got placed into a default plan, the person would be required to pay the surcharge or would eventually be disenrolled from coverage.

The Value Of High-Deductible Insurance

Critics of this approach to automatically enrolling people into default insurance will argue that the coverage will be inadequate because the deductibles will be too high. It is certainly true that plans which require no premium payment from the enrollees are likely to have deductibles that are even higher than is typical in today’s marketplace. But, despite much criticism of high-deductible insurance from politicians in both parties, such coverage provides what consumers need most from these products, which is protection against major medical expenses.

From the Conclusion

For the most part, the uninsured do not have principled objections to enrolling in coverage; they remain without insurance out of inertia, or lack of information about their options or the financial assistance available to them. Automatic enrollment can give many of the uninsured coverage at no cost to themselves.

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Reader Comment:

By Don McCanne M.D.

Obviously automatic enrollment is a great idea. But why put up with the administrative complexity of the authors’ model which still leaves so many out of the system, not to mention leaving too many exposed to excessive financial barriers to care? Why not, instead, automatically enroll everyone, only once, for life? The administrative simplicity would carry through to management of health care benefits, greatly reducing the administrative waste inherent in our system. A recent estimate indicates that we would save half a trillion dollars in recoverable administrative waste, which is enough to remove financial barriers to care through the reduction of excessive patient cost sharing (Annals of Internal Medicine, online, Feb. 21, 2017).

Yes, that would be a single payer system – an improved Medicare for all – but is that any reason to dismiss it? Considering our high costs, profound waste, and inherent inequities, single payer has become an imperative. Let’s automatically enroll everyone.

http://healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Looking at policy options in isolation can be informative, but, as this article by Lanhee Chen and James Capretta demonstrates, it is crucial to understand how the particular policy meshes with the entire package of health care reform.

Automatic enrollment into the health care financing system is a great idea, assuming that we want everyone covered. When Medicare was established, everyone eligible at age 65 was automatically enrolled in Part A – the hospital coverage. That has worked very well, as far as it went. In fact, the Supreme Court has ruled that if a person were to decline enrollment in Part A they would have to relinquish their Social Security benefits as well. That is a very powerful incentive for the individual to accept automatic enrollment.

Medicare for All supporters would improve Medicare benefits and remove the financial barriers to care and then would expand it to include everyone – through automatic enrollment.

But what do Chen and Capretta propose? They would include automatic enrollment in the AHCA repeal and replace proposal currently under consideration in the Senate. For a person eligible for a premium subsidy (tax credit), they would use the subsidy to purchase a plan in which the individual would be enrolled automatically. This would fall short since it would cover only individuals eligible for subsidies, so the program would still not be universal.

Worse, they propose that the plan would, in essence, have an actuarial value based on what the tax credit would purchase. For most individuals, that would be very little insurance. They tout the benefit of very high deductibles, stating, “such coverage provides what consumers need most from these products, which is protection against major medical expenses.” But how is an individual going to cover a $40,000 deductible with an annual income of $35,000?

Automatic enrollment is a great policy concept but it needs to be an element of a system of melded beneficial policies – like a well designed single payer system – an improved Medicare for all. Let’s set that up and then automatically enroll everyone in it.