PNHP

Charity care in government, nonprofit, and for-profit hospitals

Charity care in government, nonprofit, and for-profit hospitals

By Ge Bai, Hossein Zare, Matthew D. Eisenberg, Daniel Polsky, and Gerard F. Anderson
Health Affairs, April 2021

Abstract

The different tax treatment of government, nonprofit, and for-profit hospitals implies different charity care obligations, with the greatest obligation for government hospitals and the least for for-profit hospitals. Prior research has not examined charity care provision among all three ownership types at the national level. Using 2018 Medicare Hospital Cost Reports, we compared charity care provision across 1,024 government, 2,709 nonprofit, and 930 for-profit hospitals. In aggregate, nonprofit hospitals spent $2.3 of every $100 in total expenses incurred on charity care, which was less than government ($4.1) or for-profit ($3.8) hospitals. No hospital ownership type outperformed the other two types with respect to charity care provision in a majority of hospital service areas containing all three types. Using different kinds of analyses, we also found wide variation in charity care provision within ownership types and a lack of a consistent pattern across ownership types. These results suggest that many government and nonprofit hospitals’ charity care provision was not aligned with their charity care obligations arising from their favorable tax treatment. Policy makers may consider initiatives to enhance hospitals’ charity care provision, particularly hospitals with government and nonprofit ownership.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

There has long been a concern that nonprofit hospitals fail to provide charity care commensurate with the tax advantages afforded by the government. This study indicates that nonprofit hospitals provide even less charity care than for-profit hospitals (although others have questioned whether for-profit hospitals take liberties in adjusting off bad debt or contractual reductions in charges labeled as charity care).

Although under a single payer Medicare for All system issues would remain regarding the relative status of government, nonprofit, and for-profit hospitals, nevertheless a well designed single payer system should obviate the need for charity care since the system should be truly universal, comprehensive, and equitable.

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Why do 45 million Americans feel compelled to donate to medical crowdfunding sites?

Millions of Americans Continue to Donate to Crowdfunding Sites to Help Others Pay Medical Bills Despite Economic Hardships of the Pandemic

About 1 in 5 American adults reported donating to a crowdfunding campaign to help raise money for a medical bill or treatment over the last year.

NORC at the University of Chicago, April 1, 2021

Eighteen percent of adults in America report having donated to a crowdfunding campaign to pay for medical bills or treatment at some point over the last year. This figure has held steady from surveys over the past year despite the increase in financial hardship, including record levels of unemployment due to the ongoing pandemic. The data come from the latest NORC Spotlight on Health survey powered by AmeriSpeak®.

Nearly 40 percent of Americans who donated to crowdfunding campaigns were from households with incomes of less than $60,000 per year. In 2019, the median household income in the United States was $68,703. Of the Americans who made a donation to a campaign, 36 percent were not working (unemployed or retired) and 6 percent did not have health insurance themselves at the time of the survey.

Crowdfunding is the process by which individuals raise funds from a large number of people through websites such as GoFundMe. The new survey found the numbers of Americans starting such campaigns holding steady relative to 2020. An estimated 6 million Americans started a campaign for themselves or someone in their household, and nearly 9 million Americans started a campaign for someone else. In addition, approximately 16 million Americans made donations to help strangers, a similar number to previous surveys.

Forty-five million Americans reported an estimated 61 million individual donations to campaigns for different diseases and conditions. Twenty-eight percent of Americans who made contributions to crowdfunding campaigns reported having donated to more than one campaign for different diseases or conditions. These new data indicate that, of the 61 million donations to medical campaigns, over half were related either to campaigns for cancer (17 million) or campaigns for accidental injuries (16 million). Other popular donation categories included heart disease (9 million) and mental illness (5 million). There were also an estimated 2 million donations specifically for COVID-19.

“Even as many Americans have struggled over the past year with unemployment and a lack of affordable health insurance, individuals are still donating to crowdfunding sites to help others pay for their medical bills and treatments,” said Mollie Hertel, AM, MPP, senior research scientist at NORC.

“People reported that the vast majority of donations were going to campaigns raising money for cancer treatments and accidental injuries. This information highlights again where gaps in insurance coverage—such as high out-of-pocket costs—may exist and the challenges that Americans with serious illnesses continue to face,” added Susan Cahn, DrPH, also a senior research scientist at NORC and co-author of the study.

Nearly 60 percent of adults in America believe that the government should bear a great deal or a lot of responsibility for providing health care to people who need free or lower-cost medical care. Forty-four percent of Americans think hospitals and clinics bear a great deal or a lot of responsibility when care is unaffordable and 35 percent believe doctors should bear this level of responsibility.

https://www.norc.org…

NORC AmeriSpeak Omnibus Survey:
https://www.norc.org…

Comment:

By Don McCanne, M.D.

Imagine. Forty-five million Americans felt compelled to make charitable cash donations to individuals with ongoing medical needs. What does that say about our health care financing system in America? Well, there are a few important conclusions we can draw from this survey.

  • Medical debt is common and severe enough to cause people to initiate charitable campaigns to help pay the bills.
  • People do not have enough faith in our current health care financing system to believe that it is adequate to cover medical expenses for many individuals with large medical bills (cancer, major accidents, etc.).
  • Ninety-one percent of individuals surveyed were currently insured which tends to indicate a lack of faith in the adequacy of our fragmented, public and private insurance-based system of health care financing. People realize that it is not working well.
  • The majority of adults in America believe that “the government should bear a great deal or a lot of responsibility for providing health care to people who need free or lower-cost medical care.”

The perception of excess medical debt has become quite prevalent, yet as a source of financing health care, crowdfunding hardly makes a dent in our national health expenditures. How can we delay any further the enactment and implementation of single payer improved Medicare for All? President Biden, this question is especially directed at you. Your temporary program to donate our tax funds to private insurance companies to cover high deductibles and other cost sharing takes care of the private insurers and their investors but leaves us taxpayers footing the bill.

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The health-care industry doesn’t want to talk about this single word

By Ronald Wyatt, M.D., M.H.A.
The Washington Post, April 5, 2021

When I write about health policy or speak with medical colleagues about barriers to care, there is one word — and one word only — that evokes a wide range of responses. Some respond with silence; others with avoidance. Some respond with anger and defensiveness.

The word appeared at the top of a paper I submitted to the Journal of the American Medical Association in 2015 with David R. Williams, a professor of public health and African American studies at Harvard University. The title: “Racism in Health and Healthcare: Challenges and Opportunities.”

The editor of the journal at that time, Howard Bauchner, advised us that the word could not be published and that “racial bias” would be substituted into the title before publication. Using “racism,” he said, would result in “losing readers.” As authors and scientists, we compromised. We agreed to the change, and the article was published.

Just a few weeks ago, six years after that decision to compromise, Bauchner and I spoke by phone. He apologized, saying that progress has been made since then.

Has progress been made? JAMA recently announced that following controversial comments on racism in medicine made by a deputy editor, Bauchner was placed on administrative leave on March 25 while an independent investigation is completed.

Entrenched systemic racism — and the deliberate omission of the word in patient safety circles — is the cause of an astonishing level of preventable harm and death among communities of color that have been devalued and discounted for more than 400 years.

The covid-19 pandemic has laid bare the racial inequities of the U.S. health-care system. Too many health-care executives still perpetuate the ahistoric perspective that our country’s model provides safe and equal care for all. Yet the disproportionate number of deaths to covid-19 among racial and ethnic minority groups exposes the systemic and lethal barriers to care.

Last month, a major health-care trade magazine accepted another article that I contributed to with three colleagues, once again with “racism” in the title. When our editor sent us the final authors’ agreement, we noticed the word had been removed from the title and replaced with “intolerance.” This time, we were not willing to compromise. Our editor later informed us that the article would not be published in the May/June issue as scheduled. We were not given a reason.

I have worked all over the United States and internationally as a champion of addressing health inequity. I can say without hesitation — both as a doctor and a citizen — that racism in the United States is a public health crisis.

Having lived in rural Alabama, my family experienced these inequities personally. When my great uncle, who was like a father to me, fell ill, he was taken to a clinic that was segregated by skin color, and was subsequently admitted to a hospital in Selma in 1973. He died one day later. In 2015, I learned he had a ruptured appendix and was never seen by a physician.

I have advised and worked with large, complex health-care systems in the United States, Britain, Australia and Africa. I have collaborated with organizations such as the American Medical Association, the American Hospital Association and the Joint Commission. I have even discussed race as a risk factor for death with White health leaders, such as former president of the Institute for Healthcare Improvement Don Berwick.

Yet, I still sometimes feel that survival mechanism kick in to compromise and veil the truth that structural and systemic racism is a root cause of preventable harm and death across U.S. health care. I have been warned that if I did not continue to compromise, I would be labeled an “angry Black man” and that colleagues would distance themselves from me.

The days of compromise are over.

Solving systemic racism in public health must start with naming it. We must publish the word. We must say the word. If health-care providers are to be competent in caring for communities that have been marginalized and oppressed for centuries, then they must understand the role racism plays in poor health. This includes chronic illness, delayed or denied care, barriers to access, condescension, assumptions, inadequate diagnoses and overt disregard.

But proactively addressing racism in health care requires much more than completing training modules, launching hollow PR campaigns, hosting inclusivity workshops, hiring diversity chiefs or donating to under-resourced clinics. As any doctor would attest, before a wound can heal, it must be cleansed. This can be a painful process.

The actions needed to improve health care include listening and learning with humility; acknowledging and addressing implicit bias within work cultures; and fostering environments where reporting unfair treatment, without fear of reprisal, is encouraged and celebrated.

Mid-pandemic, we have a once-in-a-lifetime opportunity to transform health care. That change begins with language and proceeds with authentic, deliberate and intentional changes to policy and practices. Specificity matters now more than ever.

The word “racism” must be spoken loudly in hospital hallways, in boardrooms, at kitchen tables, in editorial meetings and in all health professions schools. Racism is a public-health crisis.

Dr. Ronald Wyatt co-chairs the Institute for Healthcare Improvement’s equity advisory group and is faculty for the IHI Pursuing Equity Initiative. He was the first Black chief medical resident at the Saint Louis University School of Medicine.

https://www.washingtonpost.com…

Health care remains unaffordable for about one-fifth of U.S. adults

In U.S., An Estimated 46 Million Cannot Afford Needed Care

By Dan Witters
Gallup, March 31, 2021

Nearly one-in-five U.S. adults — 18%, about 46 million people — report that if they needed access to quality healthcare today, they would be unable to pay for it. These results are based on a new study conducted by West Health and Gallup.

This current measure of healthcare unaffordability runs considerably higher among Black adults (29%) and somewhat higher for Hispanic adults (21%) than for White adults (16%). And while unaffordability of care is lower for people 65 and older than for their younger counterparts, White older adults are half as likely to report such a condition as are non-White older people (8% and 16%, respectively).

Needed Care Was Skipped by 18% of Households in Prior 12 Months

While 18% of survey respondents reported that they would be unable to pay for quality care if they needed it today, the same percentage also reported that someone in their household skipped care they needed for cost reasons in the prior 12 months. That time period covers roughly the first year of the COVID-19 pandemic.

The chances of any given household suffering from this form of healthcare insecurity are inversely related to annual household income, with 35% of respondents from low-income households — those earning under $24,000 per year — reporting forgoing care in the prior 12 months. That is five times the rate reported by those from high-income households (7%), defined as earning at least $180,000.

Reduction in Household Spending Due to Cost of Care Spans All Income Groups

With nearly one in five U.S. adults forgoing some healthcare in the prior 12 months due to the cost, many Americans are cutting back on household spending to pay for the care that they currently are receiving. About one in eight adults, for example, say they cut back their spending on food (12%) and over-the-counter drugs (11%) to pay for healthcare or medicine. The proportion doing this rises to about 1/4 of those in households earning less than $24,000 annually. Additionally, 21% of those from low-income households have had to reduce spending on utilities due to the cost of care, underscoring the disproportionate sacrifices made by lower-income households in the COVID-era.

Over one-third (35%) of respondents, in turn, report that they have reduced spending on recreational or leisure activities in the previous 12 months in order to afford care, including 21% of those in households earning at least $180,000 per year.

Majority Support Exists for Cost Containment and Broader Access Policies

As substantial percentages of U.S. adults have had to reduce spending on basic household goods to pay for healthcare, public support runs high for various proposed forms of government action meant to make healthcare more affordable.

For example, over 80% of Americans — including over 70% of Republicans — favor setting caps on out-of-pocket costs for both prescription drugs and general healthcare services for those who are insured by Medicare.

Other options are viewed quite differently by the major political party groups. While 60% of all Americans favor “making Medicare available to everyone,” support ranges from 93% among Democrats to 19% among Republicans. Similarly, 59% favor “expanding and strengthening” the Affordable Care Act; but the 98% of support among Democrats contrasts with 15% among Republicans. Slight majorities of independents endorse both proposals.

Implications

As the U.S. enters its second year of the COVID-19 pandemic, economic recovery, though uneven, has also progressed with 379,000 jobs added in February, considerably exceeding projected forecasts for the month and totaling 17 million recovered jobs since April. The passage of the new $1.9 trillion COVID-19 relief bill, which was debated but not yet passed until after this survey, stands to provide additional relief to large numbers of households and businesses in need.

Despite these reasons for optimism, the cost of healthcare and its potential ramifications continues to serve as a burdensome part of day-to-day life for millions of Americans, illustrating the enduring nature of the issue as the U.S. slowly enters the closing stages of the pandemic. Over a 12-month period that roughly covers the first full year of the COVID-era, 18% of American households had to forgo some degree of needed healthcare because they were not able to afford it due to the cost. And, one year in, 18% of adults report that they would be unable to afford quality care if they needed it today. These realities can spill over into other health issues, such as delays in diagnoses of new cancer and associated treatments that are due to forgoing needed care.

The practical ramifications of widespread reductions in basic household spending to offset the cost of care are considerable and should not come with great surprise given the substantial number of Americans who suffer its effects. Dovetailing with these realities is majority support for a number of public policies currently being considered, underscoring a public that continues to remain open to government action designed to provide relief from healthcare expenses.

https://news.gallup.com…

Comment:

By Don McCanne, M.D.

We are spending almost $4 trillion per year on health care, the highest per capita spending of all nations, and yet, because of our dysfunctional health care financing system, far too many U.S. residents are facing potential financial hardship due to these costs. Although the COVID-19 relief bill will provide partial temporary relief for a portion of those affected, it is quite clear that, with the amount we are already spending, the health care financing system still needs major structural reform if we expect to provide affordable access to health care for everyone.

Perhaps the most significant finding in this survey is that the majority now supports government action to make health care more affordable. But only 19% of Republicans favor making Medicare available to everyone, and even less, only 15%, support expanding and strengthening the Affordable Care Act. And yet over 70% of Republicans favor setting caps on out-of-pocket costs for Medicare. So do they want the government involved or don’t they? Since they have come up with no reasonable alternative (medical savings accounts won’t do it), we should move ahead anyway.

U.S.-style private insurance is too expensive and inefficient, and they don’t really want that anyway based on their opposition to the Affordable Care Act. Although other models exist, the most affordable, comprehensive and effective model is single payer improved Medicare for All. The Republicans can either join us or watch, but their inaction can no longer be tolerated.

Although PNHP endeavors to avoid partisan comments, partisan factions set the terms of the debate. We cannot remain silent when health care for all is our mission.

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Californians support health care coverage for undocumented immigrants

Newsom promised healthcare for immigrants. A new poll shows strong public support for it

By George Skelton
Los Angeles Times, April 1, 2021

It was a breakthrough event befitting Cesar Chavez Day: A major poll showed that California voters support providing tax-paid healthcare for immigrants living here illegally.

In all the polling by the nonpartisan Public Policy Institute of California over many years, it had never before found support among likely voters for giving full-blown public healthcare to undocumented immigrants.

Public attitudes toward immigrants without legal status have changed dramatically since Chavez died in 1993.

During the pandemic, people soon realized that their own health largely depended on the health of their neighbors and everyone else.

In a statewide survey, the PPIC asked California adults: “Do you favor or oppose providing healthcare coverage for undocumented immigrants in California?”

When asked of all adults, regardless of whether they were registered voters, most previously have answered that they favored providing the benefit. In this poll, 66% of all adults answered affirmatively, a 12-percentage-point increase since 2015.

And for the first time, likely voters also agreed, and by a large margin: 58% to 39%.

In the 2015 PPIC poll, the answers were reversed: Only 42% of likely voters favored providing healthcare and 55% were opposed. In a 2007 survey, 32% were in favor and 63% opposed.

In the new poll, only Republican voters continued to oppose offering the benefit — a whopping 79%.

Republicans are out of sync with the majority of Californians on many issues — one reason they haven’t elected anyone to statewide office since 2006 and now are essentially irrelevant in the Legislature with a superminority in each house.

Among Democrats, 84% favored providing public healthcare. So did 55% of independents.

Mark Baldassare, the PPIC president and pollster, believes it’s the pandemic that has quickened the acceptance of healthcare for all.

“This is the first time we’ve found likely voters thinking there should be healthcare for undocumented workers,” he says.

“I relate this to the pandemic. It’s one of the most significant changes I’ve seen during the pandemic. People are recognizing that having a healthy society requires taking care of everyone. It’s something people saw during the pandemic. That strikes me as very significant.”

Assemblyman Joaquin Arambula (D-Fresno), an emergency room physician, is pushing a bill to cover everyone by 2026.

“We call a lot of these people essential workers but don’t take care of their essential needs,” Arambula says. “We could not have our bountiful harvests if not for the undocumented workers….

“The question is whether the governor will make universal healthcare a priority.”

https://www.latimes.com…

Comment:

By Don McCanne, M.D.

Of course, this is California, the Left Coast of the United States. We have not given up on single payer. AB 1400, CalCare, is our latest attempt. Unfortunately, we have fire damage, drought, a threatened recall election, and, like the rest of the world, a COVID pandemic with all of its political difficulties for our governor, Gavin Newsom. Although he promised us single payer, he does have his hands full at the moment.

We can’t say how single payer will fare in California, but this public support for including coverage for undocumented immigrants in our health care system shows that the fundamental policies underlying the single payer model have gained traction. Unfortunately, political barriers still exist as exemplified by the opposition of 79% of Republican voters.

Support for covering undocumented immigrants may not be entirely altruistic since the recent increase in support coincided with the pandemic, and common sense tells you that providing care to everyone (vaccines, treatment, isolation, etc.) improves the odds of more rapid control, lowering the risk of personally becoming a victim. But altruism likely plays a role to some extent. For those opposed to including the undocumented in the system, there must be a lack of altruism since they are exposed as well and would gain by making the system universal. Or maybe it’s simply ideology.

We’d rather have the entire nation included under a universal system, but California will continue its efforts to move forward, hoping to be a model for the nation, just as Saskatchewan was for Canada. We can still dream of the entire nation moving smartly in unison toward Medicare for All, obviating the need for transitional state efforts. Let’s see if we can’t make that more than a dream.

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

Medicare for All Explained Podcast: Episode 53

Interview with Dr. Monica Maalouf

April 1, 2021

PNHP Illinois co-president Dr. Monica Maalouf detailed the undeniable and longstanding inequities in U.S. health care, and how the pandemic has made these injustices even more glaring. COVID-19 “took a system that was already inequitable, that already had racism embedded in it, and magnified all of those issues.”

Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Winning Medicare for All Would Have Massive Implications Beyond Health Care

A Medicare for All system would benefit almost everyone in America — except health care profiteers. The only way to overcome their opposition is to build a mass movement that’s large enough and powerful enough to defeat them.

Review of Medicare for All: A Citizen’s Guide, by Abdul El-Sayed and Micah Johnson (Oxford University Press, 2021).

By Jonathan Michels
Jacobin, March 31, 2021

Rep. Pramila Jayapal (D-WA) reintroduced the Medicare for All Act into Congress in March. The bill netted a record 112 cosponsors, which amounts to more than half the House Democratic caucus. Thanks to a surprise endorsement by Rep. Frank Pallone of New Jersey, the Medicare for All Act now seems destined to pass another historic marker, with its first hearing in the powerful House Committee on Energy and Commerce sometime in the current legislative term.

Meanwhile, outside of the DC Beltway, Medicare for All enjoys widespread support among the public with 72 percent of Americans in favor of making the switch to a publicly funded national health program.

Just how long support will remain at these current levels, however, is unclear. One barrier to advocates’ ability to maintain momentum are the persistent misconceptions spread about Medicare for All by its enemies.

A poll conducted by the Kaiser Family Foundation in 2020, for example, found that nearly 50 percent of Americans mistakenly believed that they could maintain their employer-sponsored health insurance under the health reform. That should alarm Medicare for All supporters, since one of their main selling points to the public is that it will eliminate increasingly exorbitant private health insurance plans.

It’s vitally important that we know and clarify exactly what we are fighting for. Drs Abdul El-Sayed and Micah Johnson understand this. Which is why they packed useful information into their book Medicare for All: A Citizen’s Guide to help anyone who needs a better understanding of the often misunderstood “policy-in-waiting.”

The book is a useful tool for even the most seasoned organizers looking to build the mass movement necessary to take on the medical profiteers who have prevented us from achieving national health insurance for more than a century.

The biggest lesson that readers ought to walk away with is this: Medicare for All is a reform with massive implications that reach far beyond health. As El-Sayed told Current Affairs in 2019, “Why single payer is so beneficial isn’t just that it would provide everybody healthcare. That’s really important, and it should be a primary goal, but it’s not the only goal.”

Medicare for All also has the potential to serve as a massive wealth redistribution program to middle- and low-income families, a jobs creator, a promoter of unionization, a check on hospital expansion and consolidation for profit, and a way to connect other human rights struggles together. Medicare for All would put tremendous constraints on private interests that, as the history of universal social programs show, will prove difficult to dismantle.

Hospitals, El-Sayed and Johnson tell us, exemplify the human cost of getting the policy details wrong, as well as the way that Medicare for All’s potential to improve health care delivery can be used by organizers to grow the movement in their states and local communities.

Medical centers have become the dominant employers and economic drivers in former industrial centers of the United States thanks to a tremendous influx of federal money. Currently, a third of all health spending goes to hospitals. But instead of using their economic leverage to decrease the financial burden on patients and to deliver higher-quality care, for-profit and not-for-profit hospitals dominate a region, then use their market power to coerce patients and insurers into paying exorbitant prices.

Giant hospital corporations, nonprofit or for-profit, are virulently opposed to Medicare for All precisely because their ability to increase revenue through monopoly power is diametrically opposed to the interests of health care workers and patients. Tenet and the Hospital Corporation of America (HCA), two of the largest for-profit hospital operators in the world, understand their shared interest, so they funneled hundreds of thousands of dollars into an anti-single-payer front group called the Partnership for America’s Health Care Future.

HR 676, the first national health insurance legislation introduced in Congress back in 2003, called for participating for-profit hospitals to convert to not-for-profit. Unfortunately, that provision is not included in the previous House bill (HR 1384) or Sen. Bernie Sanders’s signature Medicare for All Act. This omission will hopefully be corrected during the legislative process. As long as ravenous hospital corporations continue to rule the health care “jungle,” whatever Medicare for All bill that Congress churns out will likely be unpalatable to both patients and health care workers.

Thankfully, as El-Sayed and Johnson explain, the Medicare for All Act of 2021 maintained the use of global operating budgets as called for under HR676 as the mechanism for allocating funds to the envisaged national health program. They may sound technical, but global operating budgets are used every day to pay for our police and firefighting departments, libraries, and other institutions designed to meet universal, social goals.

Much of our health care right now is fee-for-service. The more procedures that are done on a patient, the more revenue is collected by the provider. The money is then laundered through a myriad of payers and financial transactions that make up our broken health care system.

Global budgets, on the other hand, cut through the unfathomable complexity by replacing per-patient billing with lump-sum payments that would be disbursed to hospitals based on what their operating costs were the previous year. That means hospitals will no longer have to waste time fighting over each patient’s payment. It will also be easier to identify where public dollars are going, so the money is spent on services that produce healthy outcomes.

El-Sayed and Johnson also remind us that Medicare or All would give a boost to health care workers looking to unionize, since hospitals would be prohibited from using public money to bankroll union-busting campaigns. The very groups that have linked rights in the workplace with the right to health of their patients have been nurses and health care unions, most notably National Nurses United.

For all their power and influence, hospitals are extremely vulnerable, since the interests of patients and health care workers are often aligned. Connecting those common interests is the key to winning Medicare for All. Medicare for All advocates should use this fact under coronavirus to mobilize community support around health care workers at their local hospitals.

“The battle for public opinion is not just a contest of ideas,” the authors remind us. “It’s also a contest of power, with supporters and opponents deploying all the resources at their disposal to get their message in front of people and change hearts and minds.”

While El-Sayed’s unsuccessful 2018 Michigan gubernatorial campaign is never mentioned in Medicare for All, the experience clearly gave him insight into how corporate interests use their money and influence to change the conversation around health reform in their favor. Before becoming a prominent spokesperson for national health insurance, El-Sayed championed a state-based single-payer plan dubbed “MichCare” during his campaign. Like Medicare for All, MichCare also called for the expansion of health coverage to every Michigander under age sixty-five through a single, publicly funded program. Dr Micah Johnson, El-Sayed’s Medicare for All coauthor, was one of the principal architects behind MichCare.

Establishment Democrats who refused to support health care reform beyond protecting and strengthening the Affordable Care Act stood in sharp contrast to El-Sayed. The young physician endeared himself to progressives by daring to speak out against Democratic primary rival Gretchen Whitmer’s close personal and financial ties with Blue Cross Blue Shield of Michigan, including a fundraiser to boost her campaign. Not surprisingly, Whitmer dodged El-Sayed’s attempts to put single payer at the forefront of the debate and cast doubt on MichCare as an unrealistic policy proposal. Despite winning the endorsement of Sanders and Rep. Alexandria Ocasio-Cortez, El-Sayed’s antiestablishment insurgency proved no match against the powerful forces united against him.

El-Sayed’s struggle to rally public support for MichCare, like numerous other attempts to pass comprehensive health reform in the United States, proved once again that the obvious merits of single-payer policy will not be enough to win Medicare for All.

“What would it take to strengthen the consensus on M4A and build the political will for reform?” ask El-Sayed and Johnson. “There is only one foreseeable possibility: a popular national movement pushing for M4A. Quite simply, there is no other force strong enough to overcome the partisan attacks and the deep-pocketed opposition from industry.”

The difficult work of building political power in support of Medicare for All will continue to rest on supporters’ ability to effectively communicate the inordinate ways that Medicare for All directly addresses people’s material needs, with the goal of inspiring more people to join such a movement. If organizers incorporate Medicare for All: A Citizen’s Guide’s insights to guide their actions, they might yet achieve single payer in the United States in our lifetime.

https://www.jacobinmag.com…

Medicare for All would improve cancer outcomes for the near elderly

Cancer diagnoses and survival rise as 65‐year‐olds become Medicare‐eligible

By Deven C. Patel, M.D., M.S.; Hao He, Ph.D.; Mark F. Berry, M.D.; Chi‐Fu Jeffrey Yang, M.D.; Winston L. Trope, B.E.; Yoyo Wang, B.S.; Natalie S. Lui, M.D.; Douglas Z. Liou, M.D.; Leah M. Backhus, M.D., M.P.H.; Joseph B. Shrager, M.D.
American Cancer Society, Cancer, March 29, 2021

Abstract

Background: A Medicare effect has been described to account for increased health care utilization occurring at the age of 65 years. The existence of such an effect in cancer care, where it would be most likely to reduce mortality, has been unclear.

Methods: Patients aged 61 to 69 years who were diagnosed with lung, breast, colon, or prostate cancer from 2004 to 2016 were identified with the Surveillance, Epidemiology, and End Results database and were dichotomized on the basis of eligibility for Medicare (61‐64 vs 65‐69 years). With age‐over‐age (AoA) percent change calculations, trends in cancer diagnoses and staging were characterized. After matching, uninsured patients who were 61 to 64 years old (pre‐Medicare group) were compared with insured patients who were 65 to 69 years old (post‐Medicare group) with respect to cancer‐specific mortality.

Results: In all, 134,991 patients were identified with lung cancer, 175,558 were identified with breast cancer, 62,721 were identified with colon cancer, and 238,823 were identified with prostate cancer. The AoA growth in the number of cancer diagnoses was highest at the age of 65 years in comparison with all other ages within the decade for all 4 cancers (P < .01, P < .001, P < .01, and P < .001, respectively). In a comparison of diagnoses at the age of 65 years with those in the 61‐ to 64‐year‐old cohort, the greatest difference for all 4 cancers was seen in stage I. In matched analyses, the 5‐year cancer‐specific mortality was worse for lung (86.3% vs 78.5%; P < .001), breast (32.7% vs 11.0%; P < .001), colon (57.1% vs 35.6%; P < .001), and prostate cancer (16.9% vs 4.8%; P < .001) in the uninsured pre‐Medicare group than the insured post‐Medicare group.

Conclusions: The age threshold of 65 years for Medicare eligibility is associated with more cancer diagnoses (particularly stage I), and this results in lower long‐term cancer‐specific mortality for all cancers studied.

Lay Summary: Contributing to the current debate regarding Medicare for all, this study shows that the expansion of Medicare would improve cancer outcomes for the near elderly.

https://acsjournals.onlinelibrary.wiley.com…

Comment:

By Don McCanne, M.D.

This study is certainly intuitive. “Contributing to the current debate regarding Medicare for all, this study shows that the expansion of Medicare would improve cancer outcomes for the near elderly.” Think of the innumerable other studies that have shown that Medicare for All would improve health care outcomes.

Now think of the innumerable health policy studies that have shown that Medicare for All would ensure universality, comprehensiveness, affordability for individuals, affordability for society, removal of financial barriers to care, return of free choice of health care professionals and institutions, elimination of hundreds of billions of dollars of administrative waste, and, above all, it would ensure equitable health care for all.

What further studies do we need before we decide to enact and implement single payer Medicare for All? None? Well then, let’s get on with it.

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The UK’s Vaccine Rollout Is the Latest Reminder We Need Universal Healthcare

Britain’s vaccination rate has far outpaced the rest of the West. The triumph belongs to its National Health Service.

By Natasha Hakimi Zapata
In These Times, March 30, 2021

LONDON — Dr. John Lister watched in horror as the United Kingdom’s Covid-19 mortality rate climbed above 1 per 1,000, one of the highest death rates in the world since the start of the pandemic. So, when the 71-year-old Briton was informed he would receive the Oxford-AstraZeneca vaccine in late January, he could hardly contain himself.

“It was a great moment of excitement when I got the notification,” Lister tells In These Times. 

Lister, a health policy expert and associate professor at Coventry University, was one of 15 million people in the United Kingdom to receive a Covid-19 vaccine before February 15, thanks to a vaccination program that has consistently ranked among the three fastest in the world. As of mid-February, the U.K. government’s tiered plan had succeeded in vaccinating roughly 80% of its healthcare workers and more than 90% of nursing home residents and people older than 70. These groups represent 88% of the country’s Covid-19 deaths and make up roughly a fifth of its population of just over 68 million.

This development marks a turning point in a pandemic response once described as ​“a string of failures,” which has left more than 100,000 people dead. While Prime Minister Boris Johnson has met the U.K. government’s benchmarks, the real triumph belongs to the National Health Service (NHS), the universal healthcare system of more than 1,000 hospitals that spans England, Scotland, Wales and Northern Ireland.

Founded in 1948 in the wake of World War II, the NHS was the jewel of the Labour Party’s social welfare state, the first of its kind in the West. Despite decades of efforts from conservatives to privatize the NHS, its three basic principles have endured: that treatment is free at the point of service, available to everyone (including non-residents) and publicly funded. The NHS vaccination program has been arguably the West’s greatest success story: By February 15, 22% of the U.K. had received a first dose compared with 11% in the United States.

Even before it began jabbing the public, the NHS had built the infrastructure for a rapid vaccine rollout. ​“Our system is pretty unique,” says Lister, co-founder of Health Campaigns Together, a broad coalition working to protect the NHS from cuts and privatization. ​“Because everybody is covered by the NHS, we have this database [that allows us] to identify risk factors in a way that no other country is able to do.”

The private-sector parts of the U.K. response, meanwhile, have failed to achieve results. Hundreds of millions of pounds have been squandered on ​“unusable” or otherwise inadequate personal protective equipment, and the outsourced contact-tracing failed to have its intended effect. Dr. Tony O’Sullivan, co-chair of advocacy group Keep Our NHS Public, says the decision to outsource contact tracing ​“led to a failure to rely on tried and tested systems that were in place with the National Health Service [based on] the cooperation between hospitals, primary care [physicians] and local [government].”

While vaccination rates in the United States are increasing, with President Joe Biden promising ​“enough vaccine supply for every adult in America by the end of May,” the rollout looks haphazard by comparison. As of early March, the U.S. Centers for Disease Control and Prevention reported just 27% of those 75 and older had received a first dose. For those 65 – 74, it was 28%.

Dr. James Kahn, a professor of epidemiology and biostatistics at the University of California, San Francisco, attributes the trouble in the U.S. rollout to the ​“highly variable and disorderly” distribution of vaccines. A New York Times report from February 19 finds some states had been stashing up to 6 million doses, while other states struggled to obtain enough for their most vulnerable residents.

Dr. Steffie Woolhandler, who works alongside Kahn at the Physicians for a National Health Program — an organization of more than 20,000 health professionals advocating for single-payer healthcare — believes a centralized health database (like the one the NHS maintains) could have prevented these problems. Woolhandler is also quick to praise another aspect of the U.K. rollout: Primary care physicians contact their patients directly and can review their personal health records, as well as help assuage any concerns about the vaccine.

“Everyone having longstanding access to medical care means that, when an emergency comes up, you can mobilize that access and get everyone in,” Woolhandler says. ​“It’s more than just a list of names and phone numbers; it’s actually a set of relationships.”

Maryland-based pediatrician and healthcare advocate Dr. Margaret Flowers ascribes the United States’ sluggish vaccine rollout to the country’s ​“disjointed” healthcare system and decades of underfunding for public health infrastructure. Online registration portals, Flowers says, are often inaccessible to Black and Brown communities who have been disproportionately impacted by Covid-19. The closure of more than 120 rural hospitals since 2010 has made it difficult for local residents to reach vaccination sites. And several private institutions have offered wealthy donors doses ahead of the most vulnerable people.

Whereas the FBI, the Food and Drug Administration and Interpol have each issued warnings about Covid-19 treatment and vaccine fraud schemes in the United States, the NHS offer of free service at point of care has inoculated the country against this kind of profiteering. ​“If anybody is offering to sell you the vaccine,” explains Lister, ​“they’re a crook.”

Now, as every adult in the U.K. is being promised a first shot by the end of July (depending on supply), Lister says one thing is clear: ​“What [the NHS vaccine program] really does is prove the superiority of the universal health care model.”

https://inthesetimes.com…

The VA advantage in the public sector

The Importance of the ‘VA Advantage’

A new study confirms that VA patients get better health care at a lower overall cost.

By Suzanne Gordon, Russell Lemle
The American Prospect, March 25, 2021

The recent reintroduction of a Medicare for All bill in Congress, with the promise of hearings in the House Energy and Commerce Committee, offers another step on the path to providing health care for all citizens. But as the conversation continues, policymakers and single-payer advocates could take lessons from the successful system already within our borders.

More than a decade’s worth of scientific studies have established that the Veterans Health Administration (VHA) delivers care that is not only equal, but often superior, to that available in the private sector. Although studies have consistently documented that veterans with cancer, hypertension, diabetes, renal failure, and mental-health problems get better care from the VA than non-veterans with private insurance or Medicare, this data trail was missing one piece of evidence. There was no apples-to-apples study that compared the outcomes of veterans getting care from the VA with care veterans receive in the private sector.

Now, we have the crucial evidence that should settle the debate about VA privatization once and for all. This, along with many other studies, should also become part of the arsenal of Medicare for All boosters, who often rely on examples of international health care systems to argue for the public funding of our own.

The latest study on VHA care was done by three academic economists from Stanford, UC Berkeley, and Carnegie Mellon University, and affiliated with the National Bureau of Economic Research. The study categorically demonstrates that veterans who get their care at the VA live longer during and after a medical emergency than those receiving non-VA care. This trend holds not just for the VA system overall, but at every single one of the 170 VA hospitals. The economists were so impressed with the VA’s results that they coined the term “the VA advantage” to describe it.

To uncover this “VA advantage,” the economists analyzed seven-day, 28-day, and one-year outcomes of 400,000 emergency ambulance rides of veterans aged 65 and older who were “dually eligible,” able to receive care at either a VA or non-VA hospital. Ambulance drivers independently picked whether to transport to a VA or non-VA. This quasi-random assignment of patients allowed a direct comparison of the effects of VA versus non-VA care on health outcomes.

The results in the VA and private sector could not have been more different. Veterans who were treated inside the VA system for an emergency had a 46 percent reduction in 28-day mortality. Wondering whether these results might fade over time, the researchers tracked the death rates every week after the initial ambulance ride. They found that the survival advantage remained stable for the entire year. This “VA advantage” was, importantly, as large for Black and Hispanic veterans as for non-minority ones—a pivotal finding that should inform the debate about the pronounced and long-standing health care inequalities that are rampant in the private-sector system.

What was even more impressive was the fact that the VA spends less than private-sector providers in producing such markedly better outcomes. The VA reduces per-patient cumulative spending at 28 days by $2,548, approximately 21 percent less than the private sector. In short, the VA is more productive and achieves better outcomes at lower costs.

The ultimate message of this study, combined with more than a decade’s worth of other scientific evidence, is crystal clear: Privatizing VHA care by outsourcing more services to the private sector is not only irresponsible policymaking, but actually may cost veterans their lives. As the economists argue, VA privatization would “lead to both higher spending and worse health outcomes.”

In fact, studies like these shouldn’t only inform political and ethical debates about veterans’ health care but also broader policy discussions about much-needed reform to our fragmented, market-driven system. You don’t have to look to Canada, or the U.K., or Sweden for an example of a government-funded health care program that works. There’s often a homegrown one just around the corner. This isn’t just a political talking point; it’s an ethical imperative. If “VA advantage” coordinated care saves lives, improves health outcomes, and saves money, the same type of care should be available to all of us.

https://prospect.org…

NBER: Is There a VA Advantage?
http://conference.nber.org…

Comment:

By Don McCanne, M.D.

Opponents of single payer Medicare for All tell us, “The government can’t do anything right; just look at the VA system.” Yes, just look at that system – better outcomes at a lower cost.

Of course, providing VA care to everyone would be more like socialized medicine through a national health service, whereas single payer Medicare for All would be a social insurance program with a private health care delivery system. Also Medicare for All would be an improved version of Medicare over what we have right now.

The point is that our government can do it better, in this case through Medicare rather than through the private insurance industry, so let’s let them do it. After all, it is our government, so it should work for us, not the private insurers.

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What about our ubiquitous non-compliant plans?

Under-Covered: How “Insurance-Like” Products Are Leaving Patients Exposed

March 25, 2021

From the Executive Summary

Our organizations represent millions of patients and consumers across the country who live with serious, acute and chronic health conditions. These individuals need access to comprehensive, affordable health coverage to meet their medical needs. In March 2017, we adopted a core set of principles to guide and measure any work to reform, change or improve our nation’s health insurance system. Our core principles are that health care must be adequate, affordable and accessible.

The enactment of the ACA has radically improved our patients’ experience with health insurance. Now, issuers are required to provide comprehensive coverage and prohibited from unfair coverage restrictions that discriminate against people with serious or chronic illnesses on the basis of their pre-existing condition.

However, over the past several years, new insurance rules have allowed issuers across markets to discriminate against people with pre-existing conditions as they did prior to the passage of the ACA. The proliferation of these non-ACA-compliant (non-compliant) plans has weakened the overall effectiveness of the ACA by exposing consumers, particularly those with pre-existing conditions, to significant financial risk, segmenting the individual market risk pool and unnecessarily inflating insurance premiums for people who rely on comprehensive coverage provided through the ACA marketplaces.

In comparison to the consumer protections that apply to ACA-compliant health insurance, non-compliant plans utterly fail to provide the same degree of certainty and security for patients and consumers.

This report endeavors to compile what is known about the most common kinds of non-compliant plans and make recommendations for Congress, the administration and state leaders.

The plans examined include:

  • Short-Term, Limited-Duration Insurance
  • Heath Care Sharing Ministries
  • Farm Bureau Plans
  • Grandfathered Plans
  • Misuse of arrangements subject only to non-ACA federal regulations (ERISA), including
  • Multiple Employer Welfare Arrangements and Association Health Plans
  • Spurious single-employer self-insured Group Health Plans (Data Marketing Partnership Scheme)
  • Minimum Essential Coverage-Only Plans
  • Excepted Benefit Plans

Recommendations for Congress:

  • Codify Short-Term, Limited-Duration Insurance (STLDI) Protections Into Law
  • Prohibit the Use of Brokers for Enrollment
  • Revise the Federal Definition of Insurance
  • Investigate Spurious Single-Employer ERISA Plans Arrangements
  • Require Employer Plans to Cover Essential Health Benefits (EHBs) and Adhere to EHB Standards
  • Require Issuers Selling Excepted Benefits to Confirm Enrollee is Covered by Comprehensive Coverage and Prohibit the Sale of Excepted Benefits that Mimic Fully Regulated Insurance

Recommendations for Federal Agencies:

  • Revise Federal Regulations Related to STLDI
  • Revoke Proposed Rule on Health Care Sharing Ministries (HCSM)
  • Rescind the Grandfathered Plan Rule
  • Rescind the 2018 Association Health Plan (AHP) Rule
  • Codifying the “Look Through” Doctrine
  • Clarifying the Term “Issuer”
  • Investigate Spurious Single-Employer ERISA Plans Arrangements
  • Vigorously Defend the Department of Labor’s Position in the Data Marketing Partnership Lawsuit
  • Ensure Sufficient Oversight of ERISA Plans, Including AHPs and MEWAs
  • Monitor and Collect Data on Large Employer Plans
  • Require Strong Disclosures of Limited Benefits

Recommendations for States:

  • Limit or Consider Prohibiting STLDI Plans
  • Require STLDI Plans to Meet Minimum Standards
  • Increase Transparency and Data Reporting for HCSM
  • Prohibit Sales Through Brokers
  • Maintain or Reestablish Authority Over Farm Bureau Plans
  • Strengthen Licensing Requirements for AHPs
  • Ensure Sufficient Oversight of AHPs and MEWAs
  • Investigate Spurious Single-Employer ERISA Plans Arrangements

This report was compiled on behalf of the following members of the Partnership to Protect Coverage:

  • The AIDS Institute
  • The Alpha-1 Foundation
  • ALS Association
  • American Cancer Society Cancer Action Network
  • American Diabetes Association
  • American Heart Association
  • American Kidney Fund
  • American Liver Foundation
  • American Lung Association
  • Arthritis Foundation
  • Asthma and Allergy Foundation of America
  • Cancer Support Community
  • Chronic Disease Coalition
  • Cystic Fibrosis Foundation
  • Epilepsy Foundation
  • Hemophilia Federation of America
  • JDRF
  • The Leukemia & Lymphoma Society
  • Mended Hearts & Mended Little Hearts
  • Muscular Dystrophy Association
  • National Alliance on Mental Illness
  • National Hemophilia Foundation
  • National Kidney Foundation
  • National Multiple Sclerosis Society
  • National Organization for Rare Disorders
  • National Patient Advocate Foundation
  • Pulmonary Hypertension Association
  • Susan G. Komen
  • United Way Worldwide
  • WomenHeart: The National Coalition for Women with Heart Disease

Full report – 26 pages:
https://www.lls.org…

Comment:

By Don McCanne, M.D.

Those who believe that the Affordable Care Act took care of the deficiencies in health plans and that all we need to do is expand existing coverage need only remind themselves of the non-compliant plans listed in the middle of the excerpts above. The organizations sponsoring this report certainly recognize the deficiencies of the non-compliant plans.

It is interesting to look at the fairly extensive list of recommendations they have for correcting the deficiencies of non-compliance. It seems that it would be more logical to enact and implement single payer Medicare for All than to try to apply patches to a system with a fundamentally flawed financing infrastructure, especially when you consider the multitude of other patches that would be required that would still fall far short of the impossible task of correcting the major deficiencies in affordability, efficiency, universality, and especially equity. We really need Medicare for All to do that.

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