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On public policy and health in the Trump era: A scathing indictment

On public policy and health in the Trump era: A scathing indictment

Interview with Dr. Steffie Woolhandler

February 19, 2021

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One year ago this month, America lost its first life to the coronavirus. Since then, nearly 500,000 Americans have succumbed to the pandemic, and many more have lost their family, their classrooms, and their livelihoods.

No person has been more widely reviled for dooming our response than former President Donald Trump. But a new report published in the British medical journal The Lancet finds that as damaging as were Trump’s actions and his antagonism toward science, they represented merely the extension of a long tradition of harmful policies stretching back decades, which collectively left the United States acutely vulnerable to the pandemic: and resulting in the deaths of 461,000 Americans, in 2018 alone.

This report, published by the Lancet Commission on Public Policy and Health in the Trump Era, offers an unsparing assessment of the many and overlapping failures of the US health care system, as well as of the social mores and policy choices that fueled and have perpetuated those failures over four decades.

Here to discuss their findings, and what they mean for a nation still struggling to move forward, is Dr. Steffie Woolhandler, co-chair of the Lancet Commission and distinguished professor in the CUNY School of Public Health at Hunter College. Dr. Woolhandler is a practicing primary care physician as well as a co-founder and board member of Physicians for a National Health Program, the only national physician organization dedicated to implementing a single-payer health program in the United States — now encompassing more than 20,000 members. She has authored over 150 journal articles, chapters, and books on health policy and continues to guide the national debate as a staunch champion of Medicare for All.

For more about the Lancet Commission, check out:

  • its landing page, with links to the full text as well as graphics and associated editorials
  • the report itself, at 49 pages an excellent weekend read

Follow Dr. Woolhandler on her Twitter page.

And learn more about Civic Rx at civic-rx.org.

https://civic-rx.org…

Why Medicare-for-All is good for our towns

By Jane Katz Field, M.D.
Brattleboro (Vt.) Reformer, February 18, 2021

Town Meeting is coming up, and Putney residents will have a chance to join the groundswell of support for a single-payer national health plan. Article #12 on the Town Meeting warning calls on senators Leahy and Sanders and Representative Welch to work vigorously to enact emergency legislation to ensure everyone gets the care they need during the pandemic, as well as federal legislation that provides universal, comprehensive health care coverage, with no deductibles, copays, or other out-of-pocket costs.

Even before the COVID-19 pandemic, 30 million people in the U.S. had no health insurance, and about 50 million were underinsured. The pandemic has caused millions more to lose coverage because of losing their jobs. Indeed the pandemic has given us perspective on an array of injustices in our health care delivery system — including the lack of an adequate public health infrastructure, the racial disparities in access to care, the rationing of care based on ability to pay, and hospitals’ concentration on lucrative cardiac and orthopedic services rather than mental health and primary care.

The U.S. spends twice as much per capita on health care as other high-income countries that provide universal coverage, and yet our health outcomes are worse. Life expectancy in the U.S. is lower than that in 30 other countries. Our infant mortality is three times higher than it is in economically comparable countries.

This past November, the Vermont Medical Society, representing 2,400 Vermont physicians and physician assistants, became the second state in the nation to formally endorse universal access to high quality health care through a publicly financed, single-payer national health program. This endorsement builds on the growing movement among physicians and other health professionals towards single-payer reform, also known as Medicare-for-All.

In December, the Congressional Budget Office reported that Medicare-for-All would extend coverage to everyone, yet would save $650 billion each year, by 2030. Putney voters can add their town to the more than 50 municipalities which have passed resolutions endorsing Medicare-for-All, including Philadelphia, Detroit, Knoxville and New Orleans. In New Hampshire, voters in Hanover, Grantham, Peterborough and Holderness have passed similar resolutions.

The issue of health care reform has an enormous impact on the town of Putney and its residents. Under a single-payer health care system, all our residents would be covered for medical needs in a comprehensive way, with no out-of-pocket expenses. The health of our community would benefit tremendously under this system, and disparities would be lessened. Moreover, our town would realize tremendous savings; in 2021, the town of Putney will spend $197,000 on health care costs for its 10 employees, but under Medicare-for-All, the town’s cost would drop to about $45,000 — an annual savings of around $150,000. In addition, the 2020 health care costs for Putney Central School employees were $475,000, much of which is paid for by property taxes; under Medicare-for-All, the only expense for health care coverage would be an 8 percent employer-side tax on employees’ salaries, amounting to about $140,000, yielding significantly lower property taxes for residents of Putney.

Getting everyone in the U.S. covered for their health care needs is vital to achieving health, economic and racial justice. The passage of Medicare in 1965 not only provided health insurance for the elderly, it also eliminated segregation in hospitals and helped decrease racial disparities. Only the top executives of the highly profitable insurance and pharmaceutical corporations benefit from the current health care system. But health is not a marketable product; just like education and fire protection, it is a “public good.” Our democracy and our economy are strengthened if everyone is healthy and educated. Medicare-for-All is the only way to control costs, achieve equity and fairness, and improve outcomes. Passing Resolution #12 on the Putney warning is part of the nationwide political momentum to guarantee health care for all, regardless of race, income, or employment status.

Dr. Jane Katz Field is a retired local pediatrician. She is vice president of the Vermont Chapter of the Physicians for a National Health Program.

https://www.reformer.com…

‘Choosing Wisely’ has been disappointing

Trends in Low-Value Health Service Use and Spending in the US Medicare Fee-for-Service Program, 2014-2018

By John N. Mafi, M.D., M.P.H.; Rachel O. Reid, M.D., M.S.; Lesley H. Baseman, B.A.; Scot Hickey, M.S.; Mark Totten, M.S.; Denis Agniel, Ph.D.; A. Mark Fendrick, M.D.; Catherine Sarkisian, M.D., M.S.P.H.; Cheryl L. Damberg, Ph.D.
JAMA Network Open, February 16, 2021

Key Points

Question: Have low-value care use and spending decreased over time with increasing focus on reducing waste in the US health care system?

Findings: In this cross-sectional study of more than 21 million individuals with fee-for-service Medicare, the percentage receiving any of 32 measured low-value services decreased marginally from 2014 to 2018. Claim line–level spending on low-value care per 1000 individuals did not decrease substantially over this period.

Meaning: This study found that among individuals with fee-for-service Medicare receiving any of 32 measured services, low-value care use and spending decreased marginally from 2014 to 2018, despite a national education campaign to address low-value care and increased attention on reducing health care waste.

https://jamanetwork.com…

Comment:

By Don McCanne, M.D.

It is disappointing, but not surprising, that programs such as “Choosing Wisely” have not had much impact on reducing low-value care, but that is the nature of medicine. Only a relatively small percentage of care produces major improvement in outcomes, and much of the rest is of marginal benefit. Some is of no value and may be harmful, but other factors play a role such as in this study showing opioid use for back pain and antibiotic use for upper respiratory viruses actually increased, sometimes to the detriment of the patient.

What do we do about it? Care that is of no value or even detrimental simply should not be covered. Care that is of low-value but not of no value is much more difficult since it may have some value for some individuals. Perhaps low-value care should be paid at rates so low that the benefit of serving the patient would be the primary reward, whereas care that has such a low benefit that it is not worth the time or effort might preferentially be avoided.

The authors suggest ACOs or capitation as possible solutions. Those issues are more complex and other considerations may outweigh those approaches. Under a fee-for-service system low prices or no price seems more appropriate.

Of course, research to identify best practices will provide the continuing guidance that we need for higher value care. If you think back through the decades, medicine has changed and mostly for the better.

What about single payer Medicare for All? It would change the financing from catering to the medical-industrial complex to a system that caters primarily to the patient instead. Just introducing that attitude would give us a great restart in improving our management of low value care.

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Support single-payer Medicare for All

By Jay Brock, M.D.
The (Fredericksburg, Va.) Free Lance-Star, Letters, February 17, 2021

Most Americans are fed up with skyrocketing health care costs. We pay way more than any other advanced nation—and get worse results.

Our bureaucratically bloated health insurance system manages to not only waste $600 billion health care dollars a year just in administrative costs, but also manages to leave one in four Americans with inadequate coverage or none at all. In our system, if you lose your job, you lose your insurance—so it could happen to anyone.

Each year, an estimated 68,000 Americans die because they cannot afford timely medical care. No wonder so many of us feel our health care system is just one big ripoff.

So it was refreshing to hear President Biden pledge in his inauguration speech that he would “make health care secure for all.”

The surest way to do that would be to transition to a single-payer Medicare for All, a health care system that is publicly funded, but in which care is still privately delivered. Hopefully Mr. Biden has finally abandoned the fiction that “building on the Affordable Care Act” would help. It won’t. All it would do is perpetuate a dysfunctional system that for many decades has failed to be affordable or to cover everyone.

I hope Mr. Tim Kaine and Mr. Mark Warner, our two U.S. Senators, join in the effort to ensure that finally “health care is secure for all,” and support real health insurance reform by supporting single-payer Medicare for All.

https://fredericksburg.com…

CBO report on Medicare for All

How CBO Analyzes the Costs of Proposals for Single-Payer Health Care Systems That Are Based on Medicare’s Fee-for-Service Program; Working Paper 2020-08

By CBO’s Single-Payer Health Care Systems Team
Congressional Budget Office, December 2020

Abstract

In this paper, CBO describes the methods it has developed to analyze the federal budgetary costs of proposals for single-payer health care systems that are based on the Medicare fee-for-service program. Five illustrative options show how differences in payment rates, cost sharing, and coverage of long-term services and supports under a single-payer system would affect the federal budget in 2030 and other outcomes. CBO’s projections of national health expenditures under current law are a key basis for the estimates.

CBO projects that federal subsidies for health care in 2030 would increase by amounts ranging from $1.5 trillion to $3.0 trillion under the illustrative single-payer options—compared with federal subsidies in 2030 projected under current law—raising the share of spending on health care financed by the federal government. National health expenditures in 2030 would change by amounts ranging from a decrease of $0.7 trillion to an increase of $0.3 trillion. Lower payment rates for providers and reductions in payers’ administrative spending are the largest factors contributing to the decrease. Increased use of care is the largest factor contributing to the increase.

Health insurance coverage would be nearly universal and out-of-pocket spending on health care would be lower—resulting in increased demand for health care—under the design specifications that CBO analyzed. The supply of health care would increase because of fewer restrictions on patients’ use of health care and on billing, less money and time spent by providers on administrative activities, and providers’ responses to increased demand. The amount of care used would rise, and in that sense, overall access to care would be greater. The increase in demand would exceed the increase in supply, resulting in greater unmet demand than the amount under current law, CBO projects. Those effects on overall access to care and unmet demand would occur simultaneously because people would use more care and would have used even more if it were supplied. The increase in unmet demand would correspond to increased congestion in the health care system—including delays and forgone care—particularly under scenarios with lower cost sharing and lower payment rates.

https://www.cbo.gov…

Congressional Budget Office Scores Medicare-For-All: Universal Coverage For Less Spending

By Adam Gaffney, David Himmelstein, Steffie Woolhandler
Health Affairs Blog, February 16, 2021

For the first time in a quarter century, the Congressional Budget Office (CBO) has undertaken an economic analysis of single-payer health care reform, also known as Medicare for All. The more than 200-page working paper, released last month, includes a rich explanation of methodology together with cost projections for 2030 and will no doubt serve as an important reference for years to come.

The report makes many sound assumptions but also some questionable ones that are overly pessimistic. Yet, overall, its bottom-line estimates should reassure those concerned about the economic feasibility of single payer: The CBO projects that such reform would achieve universal coverage, bolster provider revenues for clinical services, and eliminate almost all copayments and deductibles—even as overall health care spending fell.

We discuss below (see article at link) the CBO’s estimates of single payer’s overall effects on national health spending, the implications of the estimates for providers, and the concerns the analysts raise about worsened “provider congestion” under a single-payer health care system. Throughout, we point out instances where the CBO’s assumptions differ from previous, widely publicized analyses, or from provisions included in the Medicare for All legislation currently in Congress.

The Economics Of Single-Payer Financing: CBO’s Bottom Line

Overall, the CBO report provides one of the most detailed explorations to date of the economics of single-payer financing. As we have noted, it makes many sound assumptions, particularly about payer- and provider-side administrative savings. At the same time, it adopts some unfavorable assumptions about the structure of single-payer reform (including some that conflict with key provisions of the Medicare for All bills in Congress), projects excessive windfalls for some providers, and asserts clinically nescient portrayals of “unmet demand.” Nonetheless, the bottom line of the CBO analysis—that universal coverage can be affordably achieved even as benefits are expanded and cost sharing all but eliminated—should reinvigorate debate over such reform.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

The CBO report discusses the potential impact of various models of a single payer system not only on the federal budget, but also on national health expenditures. In considering these theoretical changes, it is fully expected that assumptions may be made that are not shared by all in the policy community. In their Health Affairs blog, single payer experts Adam Gaffney, David Himmelstein and Steffie Woolhandler explain the deviations from more widely accepted single payer analyses and what impact these revised assumptions would have.

Since we are more interested in an analysis of a preferred model of single payer Medicare for All, the 200 plus page CBO report should be read only in conjunction with the brief Health Affairs article. You will find that single payer is potentially even better than the favorable CBO analysis.

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

Congressional Budget Office Scores Medicare-For-All: Universal Coverage For Less Spending

By Adam Gaffney, M.D., M.P.H.; David Himmelstein, M.D.; and Steffie Woolhandler, M.D., M.P.H.
Health Affairs Blog, February 16, 2021

For the first time in a quarter century, the Congressional Budget Office (CBO) has undertaken an economic analysis of single-payer health care reform, also known as Medicare for All. The more than 200-page working paper, released last month, includes a rich explanation of methodology together with cost projections for 2030 and will no doubt serve as an important reference for years to come.

The report makes many sound assumptions but also some questionable ones that are overly pessimistic. Yet, overall, its bottom-line estimates should reassure those concerned about the economic feasibility of single payer: The CBO projects that such reform would achieve universal coverage, bolster provider revenues for clinical services, and eliminate almost all copayments and deductibles—even as overall health care spending fell.

The CBO models costs under five different variants of single payer. The first four envision universal coverage of all services other than long-term care, while the fifth incorporates a large expansion of long-term services and supports (LTSS) for people with disabilities of all ages. The scenarios vary by patient cost sharing and provider payment level. Low cost-sharing has no copays or deductibles for medical services and minimal cost sharing for prescription drugs; under high cost-sharing, patients with incomes above 150 percent of poverty would bear about 7.5 percent of costs out of pocket. Low payment rates to providers would set rates slightly higher than Medicare’s; high rates would be equivalent to the current average of the rates paid by private insurers and government programs. The five variants (or scenarios) are summarized in exhibit 1.

Exhibit 1: Congressional Budget Office’s five single-payer scenarios

Source: Congressional Budget Office’s (CBO’s) Single-Payer Health Care Systems Team. How CBO analyzes the costs of proposals for single-payer health care systems that are based on Medicare’s fee-for-service program. Washington (DC): CBO; 2020 Dec.

We discuss below the CBO’s estimates of single payer’s overall effects on national health spending, the implications of the estimates for providers, and the concerns the analysts raise about worsened “provider congestion” under a single-payer health care system. Throughout, we point out instances where the CBO’s assumptions differ from previous, widely publicized analyses, or from provisions included in the Medicare for All legislation currently in Congress.

CBO’s Estimates Of Single Payer’s Effects On National Health Expenditures

The CBO projects that variants 1–4 of single-payer reform would reduce national health expenditures (NHE) despite substantial increases in the use of care triggered by expanded and upgraded coverage. If a vast new program covering LTSS for all US residents were included (scenario 5), the CBO estimates that NHE would rise by 4.4 percent above currently projected spending levels. Exhibit 2 summarizes the CBO’s spending estimates for the three low cost-sharing scenarios, which are similar to the Medicare for All bills in Congress.

Exhibit 2: Congressional Budget Office estimates of effect of single payer on health spending in 2030: low cost-sharing scenarios

Source: Authors’ analysis of the Congressional Budget Office’s (CBO’s) Single-Payer Health Care Systems Team. How CBO analyzes the costs of proposals for single-payer health care systems that are based on Medicare’s fee-for-service program. Washington (DC): CBO; 2020 Dec. Note: “Net change in provider payments” reflects combined effect of rate setting and increased use.

How can the use of care rise even as spending falls? Mostly, according to the CBO, through greater administrative simplicity. As the CBO notes, traditional Medicare’s administrative overhead accounts for approximately 2 percent of its total revenue, compared to the 12 percent overhead of private insurers. Under single payer, the CBO projects, administrative spending would fall accordingly; overall overhead for the Medicare for All system is estimated by the CBO at below 2 percent. As shown in exhibit 2, this translates into around $400 billion annually (more than $1,000 per capita) in savings under all of the single-payer variants.

Of note, these evidence-based projections clash with the analyses by the Urban Institute and the RAND Corporation, which perplexingly assumed much higher administrative overhead under a single-payer system than under the current traditional Medicare program or under universal systems abroad.

Implications For Provider Overhead And Revenue

The CBO appropriately projects substantial administrative savings for providers, again unlike many previous analyses. US hospitals and physicians waste money and time contending with multiple payers, each with its own complex and varying coverage rules and payment procedures, formularies, and so forth. The CBO projects that the share of revenues that hospitals spend on administration would fall from 19 percent at present to 12 percent under single payer; that physicians’ administrative overhead would fall from 15 percent to 9 percent; and that the administrative expenses of other medical providers (for example, dentists, home health agencies, and hospices) would fall from 9 percent to 6 percent. In addition, it estimates that physicians and nurses would spend less time on administrative activities, freeing up 4.8 percent of physicians’ work hours and 18.4 percent of nurses’ work time. These assumptions build on a large evidence base showing high administrative overhead among US health care providers relative to other nations.

The CBO assumes that single payer would allow providers to keep these savings on administration and billing, and use the resources freed up to provide more care. Hence, providers’ administrative savings do not appear as savings in exhibit 2. In effect, the CBO interprets these efficiencies as reductions in providers’ costs that would enable them to deliver a greater quantity of services for a given amount of revenue.

Consequently, the “net change in provider payments” shown in exhibit 2 doesn’t fully account for the extra resources made available to hospitals, doctors, and other providers under Medicare for All. In contrast, exhibits 3 and 4 present our estimates of single payer’s financial impacts on physicians and hospitals, incorporating CBO projections of providers’ savings on administrative spending and physicians’ and nurses’ time.

As exhibit 3 demonstrates, payments to clinicians would rise in all five scenarios according to CBO estimates. We estimate this translates into an additional $39,816–$157,412 in revenue per practicing physician. At the same time, physicians’ practice overhead would shrink under single payer, increasing practices’ take-home income. Such a windfall, in our view, may be excessive, at least for some providers. (Disclosure: The authors are all physicians).

Exhibit 3: Modeling Congressional Budget Office’s low-cost sharing scenario: ramifications for physicians

Source: Authors’ analysis of the Congressional Budget Office’s (CBO’s) Single-Payer Health Care Systems Team. How CBO analyzes the costs of proposals for single-payer health care systems that are based on Medicare’s fee-for-service program. Washington (DC): CBO; 2020 Dec. Note: *Based on Association of American Medical Costs estimate of 840,000 practicing physicians in 2030 and the assumption that physician payments account for 77.78 percent of payments in the “Physician and other Clinical Service” category, as they did in 2018 according to the National Health Expenditure Accounts.

For hospitals, the CBO estimates that gross revenue would fall by $187 billion under the “low pay” scenario but rise by $144 billion under the high-payment scenario. Again, these figures do not give the full picture of the impact on hospitals’ bottom lines, given the CBO’s projections that single-payer reform would shrink hospitals’ spending on administration and would also free up substantial amounts of nursing time that is currently devoted to payment-related tasks. The CBO’s estimates suggest that hospitals would save $143 billion to $166 billion on administration and an additional $59 billion on freed-up nursing time, resources that could be redirected to clinical care (exhibit 4). Overall, building on the CBO’s projections, we estimate that hospitals’ clinical funding would change little (rising by $15 billion) under the low-payment scenario or increase substantially, by $369 billion, under the higher-payment one.

Exhibit 4: Modeling Congressional Budget Office’s low cost-sharing scenario: ramifications for hospitals’ revenues and clinical operating budgets

Source: Authors’ analysis of the Congressional Budget Office’s (CBO’s) Single-Payer Health Care Systems Team. How CBO analyzes the costs of proposals for single-payer health care systems that are based on Medicare’s fee-for-service program. Washington (DC): CBO: 2020 Dec. Notes: **Based on the CBO estimate that hospitals’ spending on administration (excluding registered nurse (RN)and licensed practical nurse (LPN) time spent on administration) would be reduced from 19 percent to 12 percent of hospital revenues. ***Based on (1) Bureau of Labor Statistics estimate of number of RNs and LPNs employed in hospitals and average RN and LPN wages in 2019; (2) the assumption that benefit costs equal 20 percent of wages; (3) the assumption that nursing costs would rise at the same rate as overall hospital costs; and (4) CBO’s estimate that RNs and LPNs devote 23 percent of time to administration and that single payer would reduce that time by 80 percent.

The large increase in hospital funding that the CBO projects under the high-payment scenario would, in our view, give an appropriate boost to many struggling rural and safety-net hospitals but would be excessive for hospitals that are currently realizing large annual profits.

Additionally, the fee-for-service hospital financing modeled by the CBO differs from what is envisioned in the Medicare for All bill in the House of Representatives. The House bill proposes paying hospitals, nursing homes, and other institutional providers using “global budgets,” that is, lump sums to cover all of their operating activities. This is the model used by Canada and the US Veterans Health Administration. Global budgeting could allow even greater reductions in administrative spending by eliminating the need for per-patient billing altogether. It would also allow payments to match current operating budgets and facilitate the gradual redistribution of funding among hospitals, directing more resources to communities most in need.

The global budgeting approach, however, would require separate financing of capital expenditures (as in Canada and some European nations), which again is an approach explicitly included in Medicare for All bills in Congress but not in the CBO report. Such regulated capital financing, in turn, could help regulate cost growth in the longer term by avoiding investments in duplicative but profitable high-tech facilities that encourage the delivery of low- or no-value care.

Hence, the CBO’s decision to model a system that used fee-for-service payments for hospitals and other institutional providers rather than global budgets with separate capital financing leads it to underestimate single-payer savings in the short term and to ignore potential longer-term savings and improvements in the distribution of hospital infrastructure. That caveat aside, an important takeaway from the CBO’s analysis is that, overall, providers would see stable or even increased funding for patient care under single payer, even while overall health spending fell.

Provider Congestion?

While the CBO report foresees greatly improved financial access to care under single payer, it raises the specter of “provider congestion,” that is, greater difficulty making appointments or rising waiting times under single payer. Because such reform would newly cover the uninsured and improve coverage for most other people, the CBO projects large increases in the demand for care, and hence use. However, it projects that not all of the demand could be met because of supply constraints, for example, the finite number of doctors, nurses, and hospital beds. Consequently, the report predicts increased “provider congestion” that would cause some foregone care.

This prediction, however, is out of touch with clinical reality, an issue we recently explored in Health Affairs. The CBO’s approach to supply constraints is only half right. There is little question that, as the CBO assumes, a finite supply of health care providers constrain utilization increases after coverage expansions: As we have demonstrated, in nation after nation, universal coverage expansions have led to modest, or even no, societywide increases in use. Increased use by the newly covered has usually been partially or fully offset by small reductions in use among the well-covered or well-off.

Yet, these small reductions appear to be mostly due to the reduced provision of low-value care. Two econometric studies found that offsets after coverage expansion reflect reductions in the amount of wasteful care provided to the already insured. Similarly, studies by the Dartmouth Group indicate that the volume of elective and low-value care increases when the supply of doctors and hospital beds rise—a phenomenon called supplier-induced demand. In other words, faced with an increase in demand for care, providers prioritize their time and services, delivering more high-value care while reducing the provision of low- or no-value services.

Characterizing such offsets as “unmet demand” or “congestion” is hence misleading. It mirrors previous forecasts of “patient pileups” when Medicare was first implemented—forecasts that proved incorrect. In the US today, nearly one-third of all health care delivered is unnecessary or wasteful. Overprovision is common. If coverage expansion leads to some attenuation in supplier-induced demand, all the better.

A Notable Omission

Finally, while the CBO projects reductions in health spending in four out of five single-payer scenarios, as noted, it projects substantial increases in federal spending that would replace all private insurance premiums and nearly all out-of-pocket health care costs. Yet, there are also substantial savings for state and local governments with single-payer reform. The CBO’s brief mention of the savings likely to accrue to these governments (and their taxpayers) omits probable savings from no longer having to bear the costs of public employees’ health insurance (projected to total $318 billion in 2030), as well as about $162 billion in savings on other health programs. These, together with savings on Medicaid (which the CBO does remark on), would bring state and local governments’ total savings from single payer to about $800 billion in 2030 alone, reductions that provide important context for the CBO’s estimates of increased federal government expenditures.

The Economics Of Single-Payer Financing: CBO’s Bottom Line

Overall, the CBO report provides one of the most detailed explorations to date of the economics of single-payer financing. As we have noted, it makes many sound assumptions, particularly about payer- and provider-side administrative savings. At the same time, it adopts some unfavorable assumptions about the structure of single-payer reform (including some that conflict with key provisions of the Medicare for All bills in Congress), projects excessive windfalls for some providers, and asserts clinically nescient portrayals of “unmet demand.” Nonetheless, the bottom line of the CBO analysis—that universal coverage can be affordably achieved even as benefits are expanded and cost sharing all but eliminated—should reinvigorate debate over such reform.

Drs. Gaffney, Himmelstein, and Woolhandler have served as leaders of Physicians for a National Health Program, a nonprofit organization that supports single-payer health care reform.

https://www.healthaffairs.org…

El-Sayed and Johnson: A citizen’s guide to Medicare for All

Medicare for All: A Citizen's Guide

By Abdul El-Sayed, M.D. and Micah Johnson, M.D.

Sample excerpt:

When analyzing how health reform proposals do (or do not) address these problems, it is also helpful to keep in mind the “active ingredients” of Medicare for All described in Chapter 3. To review the six key elements of M4A:

  1. Universal coverage. M4A guarantees health coverage to every American.
  2. Comprehensive coverage. M4A guarantees that Americans’ health coverage is comprehensive in terms of the range of covered benefits, the availability of a wide range of clinicians and hospitals, and minimal or no financial barriers to receiving care.
  3. Pricing power. M4A can wield considerable negotiating leverage to rein in the cost of drugs, hospital stays, and physician services.
  4. Administrative efficiency. M4A eliminates the high overhead costs of private insurance companies and reduces the administrative burden on providers and patients.
  5. Progressive financing. M4A allows healthcare to be financed progressively, replacing the regressive financing of private insurance.
  6. Public accountability. M4A would be accountable to the American public, rather than shareholders.

Oxford University Press:
https://global.oup.com… or https://medicareforallbook.com

Comment:

By Don McCanne, M.D.

Abdul El-Sayed and Micah Johnson have produced an excellent primer on Medicare for All. Since further changes in our health care system are inevitable, it is a book that will be useful to everyone. I’ll mention here how it will be useful particularly to the novice and also to the seasoned health care reform activist.

First of all, it is very basic and highly readable, not getting lost in technical health policy jargon, yet it is still very clear and comprehensive enough to cover the subject well.

For those who do not understand the basics of Medicare for All, and for those who have many questions and need to fill in the blanks, this book will do that. It first provides a diagnosis of health care problems in America and how we got here. It then discusses the fundamentals of Medicare for All policy and how such a program would be designed. It discusses the important point of how to pay for it, and then discusses the alternatives, explaining their deficiencies. The book closes with the politics of reform and how we must organize for it – a section that will be of more interest to the activist, though perhaps somewhat disappointing to some because it does not show us a way to get around the work that needs to be done.

For the seasoned reform activist, not much new in policy is revealed, but, importantly, it does bring policy considerations up to date. It is also very accurate, which is important because even some of us who are very well informed may still be carrying ancient misconceptions about health policy, or be buried in ideology that will keep suppressed important variations in health policy. On the positive side, the simple but informative straightforward rhetoric gives us a common language for communicating the concepts which will help avoid diversions into divisive ideology instead of policy. This is not to say that ideology is not important since the book does address “We the People.”

The timeliness of this book is especially apropos. President Joseph Biden has promised us that he will advance reform by building on the Affordable Care Act and maybe by adding a “public option.” Sadly, this reveals how uninformed our president is. Yes, he was involved in the Obama administration’s reform efforts, but his understanding of policy, based on his public statements, seems to be limited to the Obama model. For instance, he has stated that we cannot afford a single payer Medicare for All model when the opposite is true. His reform will increase costs while failing to repair most of the deficiencies such as those implied in the excerpt above, repairs that automatically improve spending in our health care system.

The president is very busy, and I doubt that we can get him to read the book, as readable as it is. If he did, he would recognize that he is headed down the wrong path. It would be especially helpful if his policy staff did read it, but they are all experts in policy and likely believe that they would not benefit from it, not realizing that the ACA approach is branded in their brains, displacing important policy considerations. That must be the case since they are not adequately addressing the profound waste due to our administrative inefficiency, which must be addressed if we are to have a health care financing system that is fully accountable to the public.

Buy it. Read it. Share it. And then act on it.

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Medicare for All Explained Podcast: Episode 50

Interview with James McGee (Part One)

February 15, 2021

James McGee, recently retired from the Transit Employees’ Health & Welfare Fund, discusses the lofty goals of single-payer reform, and the challenge posed by lesser reforms. “You’re changing the fundamental assumption from health care as a private good to health care as a public good. That is a tricky course to navigate incrementally.”

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

https://medicareforallexplained.podbean.com

Dr. Mary Bassett on “Democracy Now!”

Former NYC Health Commissioner Dr. Mary Bassett appeared on “Democracy Now!” on February 15, 2020. She detailed the findings and recommendations of the Lancet Commission on Public Policy and Health in the Trump Era, and expressed hope that the disastrous response to COVID-19 in the U.S. would spur increased demand for single-payer Medicare for All.

Russell Mokhiber explains why private Medicare Advantage plans are a bad deal

SEIU Aetna Medicare Advantage and the Attack on Traditional Medicare

By Russell Mokhiber
Corporate Crime Reporter, February 13, 2021

Carolyn Adessa worked for fifteen years as an art therapist for the Bronx Lebanon Hospital Center.

When she retired in 2010, she went on traditional Medicare.

But sometime in 2014 or 2015 her union, SEIU 1199, without her consent, switched her out of traditional Medicare.

This came at a time when Adessa was battling stage four lymphoma at Memorial Sloan Kettering Cancer Center in New York City.

“I was treating this cancer at Sloan Kettering when the union, without my knowledge or approval, switched me out of Medicare,” Adessa said. “This resulted in an incredible amount of stress, and hours on the telephone, in an attempt to have my enrollment in basic Medicare restored. I was sick as a dog. I was going to work every day. Apparently they had sent me a letter saying they were going to take me out of traditional Medicare unless I opted out. And I missed the letter. Suddenly, my bills weren’t being paid. I had to contact my Congressman to get it back.”

“I continue to be outraged by the fact that Medicare would allow any entity to disenroll people from the federal Medicare program under any circumstance,” Adessa said.

Then in November 2020, the union came after her again.

“I started getting letters saying that unless we filled in paperwork to opt out of the Aetna Medicare Advantage program we were going to be in this wonderful Advantage plan,” Adessa said. “My mailbox was deluged with material. Everyday my mailbox was stuffed with these letters. I was just so angry.”

“Why does the federal government allow private insurers to use the word Medicare to sell private insurance plans?” Adessa asks. ‘Most seniors don’t understand that when they sign up for — with the Advantage plan they’re effectively signing out of the traditional Medicare insurance program.”

A spokesperson for SEIU 1199 confirmed that in fact all of the more than 56,000 SEIU 1199 retirees are put into the Aetna Medicare Advantage plan unless they affirmatively opt out. Fewer than one percent have opted out. And in order to opt out, the retirees must meet certain conditions.

The union said in a statement that the Aetna plan does allow retirees to apply for a medical waiver to opt out of the Aetna plan but only “under certain circumstances — if the retiree is currently under treatment for a serious or chronic medical condition, if the retiree’s doctor does not participate in the plan and if a change in physician would jeopardize the retiree’s health.”

Does the union get paid by Aetna for doing this?

No.

Then why don’t the retirees get to choose between traditional Medicare and the Aetna Medicare Advantage plan?

The union could not provide an answer.

Does the union support a federal Medicare for All program that would eliminate private health insurance companies and take health insurance off the table when unions negotiate with their employers?

Again, the union could not provide an answer. (Off the Table, a film produced by Unions for Single Payer, shows how Canadian style Medicare could cover everyone in the US without co-pays, deductibles or premiums, and remove one of the biggest obstacles US labor negotiators face in contract negotiations.)

Adessa’s battle to stay on traditional Medicare comes at a time when private insurance companies have launched an all out barrage on seniors to get them to switch over to private Medicare Advantage plans.

Every senior with a mailbox gets flooded with misleading and outright deceptive mailers.

Just today we received a piece of mail that looked like a notice from the IRS.

The flyer is headlined “Medicare Notice.”

“‘Please call to confirm your eligibility.”

For Medicare?

No for a private Medicare Advantage plan.

In tiny print in the lower right hand corner is this:

“Medicare has neither reviewed nor endorsed the information contained in this advertisement.”

In 2020, 39 percent of all Medicare beneficiaries — 24 million out of 62.1 million Medicare eligible seniors — were in Medicare Advantage programs.

Kay Tillow is with Kentuckians for a Single Payer Health Care Law and Unions for Single Payer.

In an article titled Beyond the Medicare Advantage Scam, Tillow writes that under a Medicare Advantage plan “you may be okay for a time and save money monthly – as long as you don’t get sick.”

“Once you need to use the plan, you will discover the problems that come from being in a for-profit plan that makes more when it denies you care,” Tillow said. “Your choice of physicians will be restricted to a list. The specialist you need may not be anywhere near where you live. The hospitals and rehabs centers will be limited. The post-hospitalization facility available to you is likely to be the one with the worst reputation. The drugs you need may now cost a fortune.’

High profile Medicare Advantage pitchmen on television like former quarterback Joe Namath don’t tell you about that.

“When seniors first sign up for a Medicare plan, they are protected by law against discrimination for pre-existing conditions in the purchase of a Medigap plan,” Tillow writes. “But when a person tries to change back to traditional Medicare later, that protection is gone. Only four states have regulations to prohibit such practices.”

Joe Willie Namath doesn’t mention that either.

“Despite the problems of purchasing a Medigap plan, the negative experiences that Medicare Advantage patients encounter once they get sick induce many to return to traditional Medicare,” Tillow writes. “It all works so well for the insurance companies. While the patient is healthy with few expenses, the company rakes in the money. Once the patient becomes ill and needs more care, many patients, facing massive expenses, will return to original Medicare. Now the extra expenses of a sicker patient will fall on the public once again.”

“Not only do these Medicare Advantage Insurance companies profit at the public trough, they use the seniors who are signed up in their plans to lobby Congress to continue with these rip-offs,” Tillow writes. “America’s Health Insurance Plans (AHIP), the organization of health insurance companies, keeps the deceptions going by telling seniors to let their Congressperson know that their Medicare plan is in jeopardy. All legislative efforts to reduce the massive ill-gotten gains of these companies are defeated by AHIP’s shrewd use of the popular ‘protect Medicare’ sentiment to ward off any reform of the Medicare Advantage plans.”

Dr. John Geyman, author of soon to be released book The Mighty Medical Industrial Complex, says that the companies pushing Medicare Advantage on television claim new benefits for less money, but fail to tell listeners of the serious downsides of such “coverage,” including restricted choice of physician and hospital through narrowed networks, the exorbitant costs if one gets sick, and the difficulties of returning to traditional Medicare with a new pre-existing condition.

Dr. Don McCanne of Physicians for a National Health Program says that “traditional Medicare with a comprehensive Medigap supplement works better than Medicare Advantage for the patients when they need health care, though they are deceived by private plan marketing, nominal additional benefits, and are dissuaded by the high premiums charged for the Medigap plans.”

“Medigap plans add greatly to the administrative complexity when it would be far less expensive and less complex to eliminate the Medigap plans and fold the benefits into the traditional Medicare program – claims are processed only once instead of twice and there is no superfluous private insurance bureaucracy to pay for. Then the private Medicare Advantage plans could never compete with the traditional Medicare program.”

https://www.corporatecrimereporter.com…

Comment:

By Don McCanne, M.D.

Medicare beneficiaries are now given a choice of the original government Medicare program or the private Medicare Advantage plans, often administered by for-profit Wall Street corporations. The private plans have been increasing in popularity and now provide services to about two-fifths of Medicare beneficiaries (this is demonstrated in a chart available in the original article at the link above). They are so popular that even unions, such as SEIU 1199, may select them for their retiree health plan, as explained in this article.

What explains this popularity? Many people believe that they are getting a better deal in these plans. They sometimes are receiving additional benefits not offered under traditional Medicare such as limited dental and eye care, or maybe the Silver Sneakers fitness program. More importantly, they receive catastrophic coverage that may limit their potential losses, a benefit not offered under the traditional Medicare program.

They still have the choice of the original program, but it is important that they protect against catastrophic loss. For that reason, individuals in the traditional program often will buy a Medigap plan which provides this protection. The problem is that these plans are quite expensive and look like a bad deal when compared to the private Medicare Advantage plans with their extra included benefits and catastrophic coverage. So an increasing percentage of Medicare beneficiaries are selecting the private Medicare Advantage plans.

Are these private Medicare Advantage plans really a better deal? If you are among the 80 percent of the population that is relatively healthy and do not anticipate needing much care in your declining Medicare years, you may be satisfied with this coverage for the time being. However, if you end up needing more comprehensive, specialized care (and many of you will), you may find that the preferred specialists and hospitals are not covered under the insurer’s provider networks, but would be covered under the traditional Medicare program. Also you will likely find out about the barriers to care such as prior authorization requirements. You may be lucky and get the coverage you want under your plan, but many find out that the barriers are too great, and that is why the Medicare Advantage plans have earned the reputation that “the healthy go in, and the sick come out.”

How well does leaving the plan work? First of all, you have to wait for the special enrollment period which may seem inordinately long and dangerous if you are waiting for cancer treatment. Then, because you may be facing catastrophic losses, you will want to purchase a Medigap plan, only to discover that you can be denied Medigap coverage for a preexisting disorder (guaranteed issue is available only when you first become eligible for Medicare but not in later years). So you may be stuck only because you previously chose a private Medicare Advantage plan, and you want out of it.

Congress has played a very important role in this. They have continued to cater to the private Medicare Advantage insurers while neglecting the traditional Medicare program. Although the private plans must accept all applicants, that does not prevent them from selectively marketing to healthier populations (do the chronically ill really want the Silver Sneakers fitness program?). Even worse, they continue to add incidental diagnoses to their patients to qualify for extra risk bonuses, at taxpayer expense, so they are being paid more than the primary diagnoses warrant. Each year, adjustments are made by Congress and the administration that benefit the private plans but not those in traditional Medicare. As part of the Affordable Care Act, they even removed Medigap Plan F for those who were not grandfathered so you can no longer protect yourself from some out-of-pocket expenses – obviously preventing a marketing advantage for traditional Medicare over the private Medicare Advantage plans, which brings up the question, who receives the advantage from the Medicare Advantage plans? The patient or the private insurer?

It really is time that Congress takes an honest appraisal and corrects the deficiencies in the Medicare program. They should stop catering to the private insurers at the expense of the taxpayers (including misuse of Medicare payroll taxes, Medicare Part B and D premiums, and general revenues for Part A). On the other hand, the traditional Medicare program should be expanded to cover cost sharing barriers to care (deductibles, coinsurance, etc.) and especially catastrophic losses. It is also unfair to allow private plans to include extra benefits while excluding them from the traditional program. If we had an improved traditional Medicare program, then it could be used as the infrastructure for a single payer improved Medicare for All.

And all of this is a matter of fairness. Remember, the mission of private, for-profit Medicare Advantage insurers is to make money, whereas the mission of our traditional Medicare program is to provide health care. We are supporting a program that deferentially caters to the private insurers and their interests when we should be supporting a program that is designed to take care of patients. Those being deceived by the private Medicare Advantage marketing materials really do not realize the bad deal they may be getting until they face the private insurer barriers to needed care. Silver Sneakers won’t take care of that.

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

Beware out-of-network payments in Medicare Advantage

Out-of-network payments in Medicare Advantage

By Austin Frakt and Tynan Friend
The Incidental Economist, February 10, 2021

The complexity of Medicare Advantage (MA) physician networks has been well-documented, but the payment regulations that underlie these plans remain opaque, even to experts. If an MA plan enrollee sees an out-of-network doctor, how much should she expect to pay?

The answer, like much of the American healthcare system, is complicated. We’ve consulted experts and scoured nearly inscrutable government documents to try to find it. In this post we try to explain what we’ve learned in a much more accessible way.

Medicare Advantage Basics

Medicare Advantage is the private insurance alternative to traditional Medicare (TM), comprised largely of HMO and PPO options. One-third of the 60+ million Americans covered by Medicare are enrolled in MA plans. These plans, subsidized by the government, are governed by Medicare rules, but, within certain limits, are able to set their own premiums, deductibles, and service payment schedules each year.

Critically, they also determine their own network extent, choosing which physicians are in- or out-of-network. Apart from cost sharing or deductibles, the cost of care from providers that are in-network is covered by the plan. However, if an enrollee seeks care from a provider who is outside of their plan’s network, what the cost is and who bears it is much more complex.

Provider Types

(Explains participating providers – 97%, non-participating providers – 2%, and opt-out providers – 1%.)

How Out-of-Network Doctors are Paid

So, if an MA beneficiary goes to see an out-of-network doctor, by whom does the doctor get paid and how much? At the most basic level, when a Medicare Advantage HMO member willingly seeks care from an out-of-network provider, the member assumes full liability for payment. That is, neither the HMO plan nor TM will pay for services when an MA member goes out-of-network.

The price that the provider can charge for these services, though, varies, and must be disclosed to the patient before any services are administered. (Complicated – depends on provider type, HMO or PPO, and payment options that the out-of-network provider may select. Read the article for the details.)

There are two major caveats to these payment schemes (with many more nuanced and less-frequent exceptions). (See article for details.)

Conclusion

Outside of the pandemic and emergency situations, knowing how much you’ll need to pay for out-of-network services as a MA enrollee depends on a multitude of factors. Though the vast majority of American physicians contract with Medicare, the intersection of insurer-engineered physician networks and the complex MA payment system could lead to significant unexpected costs to the patient.

https://theincidentaleconomist.com…

Personal communication from Diane Archer

I read the Frakt et al. article this morning. They buried the lead. Plans often pay only 60 percent of Medicare’s approved amount, leaving people with twice as high out of pocket costs as traditional Medicare. Also, plans can retroactively deny coverage for out of network care. While the provider cannot bill the patient for the 60 percent, the provider might not want to provide the care and assume the risk of a denial. The provider can request an advance determination from the MAO, but might not want to go through the hassle, limiting access. Lastly, people in MA PPO have an out-of-pocket cap of $11,300, that’s easily more than three times the cost of Medicare supplemental coverage.

One other point. There is no data on average out-of-pocket costs in MA, in network or out of network, overall, or by plan or type of service.

Comment:

By Don McCanne, M.D.

As the Frakt/Friend article states, “the intersection of insurer-engineered physician networks and the complex MA payment system could lead to significant unexpected costs to the patient.”

Many people believe that they like their private Medicare Advantage plan. It seems to work well for the 80% of people who use only 20% of the care, and the plans make sure that they are marketed primarily to that healthy sector. Other studies have shown that the healthy go into the plans and the sick come out once they find out the truth.

Actually, traditional Medicare with a comprehensive Medigap supplement works better for the patients when they need health care, though they are deceived by private plan marketing, nominal additional benefits, and are dissuaded by the high premiums charged for the Medigap plans. Medigap plans add greatly to the administrative complexity when it would be far less expensive and less complex to eliminate the Medigap plans and fold the benefits into the traditional Medicare program (claims are processed only once instead of twice and there is no superfluous private insurance bureaucracy to pay for) . Then the private Medicare Advantage plans could never compete with the traditional Medicare program.

It’s time that Congress quit catering to the private plans and turned their attention to improving the traditional program – but true improvements and not privatization schemes. (See Gerald Friedman and Travis Campbell, The Hill, “Medicare expansion is a discount compared to ObamaCare“)

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

Our failing healthcare system costs us countless lives. It’s time to adopt Medicare for All

Being a doctor during the pandemic has made clear to me how desperately we need Medicare for All in the US

By Adam Gaffney, M.D., M.P.H.
Salon, February 11, 2021

Over the past year, COVID-19 has inundated the ICU where I work. Death and suffering have become the everyday norm. But I’ve also seen how our broken health care system amplifies the catastrophes caused by the virus.

Last spring, one of my many gravely ill patients who required intubation, and who had to be put in a drug-induced coma while the ventilator breathed for her, turned the corner after many weeks. After the breathing tube was removed, her first words expressed panic – not about the constant din of alarms from cardiac and respiratory monitors or the critical illness that she had narrowly survived — but for fear of ruinous medical bills.

She’s not alone. One in 10 respondents to a Gallup survey in April said they’d avoid treatment if they thought they had COVID-19 because they feared the medical costs. Even before the pandemic, 30 million people were uninsured, 1 in 3 Americans struggled to pay medical bills, and illness and medical bills contributed to more than half a million personal bankruptcies annually.

As our nation recovers from the horrifying second peak of COVID-19, and as it grapples with the most severe economic downturn since the Great Depression, it’s time to eliminate the scourge of inadequate health coverage – forever. It’s time to adopt Medicare for All.

Today, in the medical journal The Lancet, I joined colleagues in providing the first comprehensive assessment of the Trump administration’s impact on health, including in health care financing. We also make recommendations for action.

As we document, health protections dwindled under President Donald Trump. Cuts to the Affordable Care Act’s navigator and outreach programs, the growing red tape in Medicaid, and the administration’s xenophobic “public charge” rule that frightened immigrants away from enrollment in nutrition and health programs caused the number of uninsured to swell by 2.3 million, including 700,000 children – and that’s before the virus struck.

When the pandemic hit, Congress moved to cover the costs of COVID-19 testing, treatment and vaccination for those without coverage. Yet some uninsured patients with COVID-19 have still received large bills. And many – including those with coverage – continue to face financial disaster from deductibles and copayments for non-COVID-19 illness.

Meanwhile, gaps in coverage are growing. Millions of Americans have lost their jobs, and with it, their private health coverage. Many more have suffered income losses that will make copays and deductibles even more onerous.

Make no mistake: Study after study has found that lack of health coverage is often fatal. Each year, tens of thousands of Americans die because they’re uninsured and don’t get vital care.

But it’s not just the uninsured who suffer; cost barriers of any kind are medically hazardous. Deductibles cause women with breast cancer to delay starting chemotherapy by 6 months or more. Insured heart attack victims who fear the costs delay going to the ER – a potentially fatal mistake. For heart attack survivors, copays and deductibles for medications increase the risk of future heart problems. High insulin prices kill young people unable to afford that life-saving medication. And many patients with asthma and emphysema suffer unnecessary exacerbations and hospitalization because they can’t afford routine medications and care.

As we show in our wide-ranging Lancet report, most deficiencies in our health care system predated Trump.  His actions made those deficiencies more acute, however.

It’s therefore not enough to undo Trump’s legacy. We need to go further.

Urgent action to cover health care costs – including copayments and deductibles – for everyone is essential. Legislation introduced last year by Sen. Bernie Sanders (I-Vt.) and Rep. Pramila Jayapal (D-Wash.), the Health Care Emergency Guarantee Act, would cover medical costs for the uninsured, as well as copays and deductibles for those with insurance, for the duration of the pandemic.

But a permanent solution – a Medicare for All reform – is needed in the pandemic’s wake.

Medicare for All would provide all Americans with comprehensive first-dollar coverage. It would improve health and save lives, even as it would save money. A recent analysis from the Congressional Budget Office estimated that such reform could reduce overall health spending by at least $42 billion each year; the $400 billion in annual savings from cutting out private insurer’s waste would more than pay for the costs of expanding and improving coverage.

The COVID-19 pandemic will, fortunately, end. But the ongoing suffering caused by our broken health care financing system will not – unless we take action. Nobody should ever awaken fearing medical bills, much less from a coma. The prescription is clear: Medicare for All.

Dr. Adam Gaffney is the immediate past president of Physicians for a National Health Program. He blogs at theprogressivephysician.org and is on Twitter at @awgaffney.

https://www.salon.com…