PNHP

Even U.S. privileged have worse health outcomes than average for other wealthy nations

Even U.S. privileged have worse health outcomes than average for other wealthy nations

Comparing Health Outcomes of Privileged US Citizens With Those of Average Residents of Other Developed Countries, JAMA Internal Medicine, March, 2021;181:339-44, by Ezekiel J. Emanuel et al.

From the Abstract:

Objective: To assess whether the health outcomes of White US citizens living in the 1% and 5% richest counties (hereafter referred to as privileged White US citizens) are better than the health outcomes of average residents in other developed countries…

Conclusions and Relevance: This study suggests that privileged White US citizens have better health outcomes than average US citizens for 6 health outcomes but often fare worse than the mean measure of health outcomes of 12 other developed countries. These findings imply that even if all US citizens experienced the same health outcomes enjoyed by privileged White US citizens, US health indicators would still lag behind those in many other countries.

Comment:

By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

US society and medical care are bad for almost everyone’s health. While Black and Native Americans, and the poor, suffer the most, even white residents of the wealthiest 1% of counties have worse health outcomes on many measures than the average of other wealthy nations.

This terrible indictment of our society indicates the need for fundamental changes in medical care and beyond. A society that values corporations’ drive for profit above all else is bad for everyone’s health.

http://healthjusticemonitor.org…

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How Would Medicare for All Affect Physician Revenue?

By Christopher Cai, M.D.
Journal of General Internal Medicine, Viewpoint, July 8, 2021

Organized medicine in the USA is shifting its position toward single-payer reform, one version of which, “Medicare for All,” has gained substantial support in Congress. The American Medical Association recently left the Partnership for America’s Healthcare Future, a lobbying group that spent more than one hundred million dollars annually opposing both a public option and Medicare for All in federal election campaigns. In 2020, the American College of Physicians and the Society of General Internal Medicine went a step further, endorsing both public option and single-payer reforms.

Yet, physician opinion on Medicare for All remains split, with most doctors concerned that such reform might decrease their income. While physicians are highly paid, these concerns are understandable given the burden of student debt, the length of medical training, and Medicare’s lower fees relative to private insurers’.

Are such concerns supported by evidence? The nonpartisan Congressional Budget Office (CBO) recently estimated payments to physicians in 2030 under current policies and five options for Medicare for All. It projects that without reform the weighted average of public and private payments to physicians will increase to 116% of the 2019 weighted average, versus between 108% and 117% under the various Medicare for All options analyzed.1 But because the CBO expects Medicare for All to increase society-wide utilization of care, it also predicts that providers’ total revenues would increase, even if fee levels were to decline.

More specifically, the CBO projects that in 2030 providers’ total outpatient revenues would be between 5 and 9% higher under Medicare for All than without reform; physician services currently account for 78% of such revenue.1,2 These estimates assume that Medicare for All would not significantly alter the supply of physicians, which is currently limited by the supply of residency and medical school spots.1

Some scholars project even larger boosts to physicians’ take-home pay because the CBO estimates may understate practices’ savings from streamlined billing. If, as studies suggest, Medicare for All would free up roughly 5% of doctors’ work hours currently spent on billing, allowing them to increase patient care, per-physician revenue could rise by between $39,816 and $157,412 annually.2 While those figures may be an overestimate, since some providers might choose to spend the freed-up time on leisure activities rather than increased patient care, they may underestimate revenue changes, as fee-for-service providers have, in the past, responded to decreased Medicare reimbursement rates by increasing volume of services.1 The latter won’t apply to salaried providers, such as those working in capitated healthcare systems, but these providers are still likely to feel the benefits of administrative streamlining.

Other prominent economic analyses of Medicare for All have also projected net increases in physicians’ revenue, even if current Medicare payment rates do not increase.3 Yet despite projecting increases in physicians’ revenues, almost all estimates of the overall costs of single-payer reform project savings, due to savings from administrative simplification.3 Hence, it appears possible to design a single-payer reform that would offer universal coverage without cost sharing, while increasing net revenue to providers and decreasing national health expenditures.3

History offers hopeful messages about the likely effect of single-payer reform on doctors’ incomes. When Canada transitioned to single-payer in the mid-20th century, physician income increased, and physicians remained the highest paid professionals in the nation.4 Since then, physician income in Canada has grown faster than the incomes of other workers. Yet, caution is warranted in interpreting these trends, which may not be duplicated in a reform initiated five decades or more after Canada’s system was fully implemented in 1971. Medicare’s history offers mixed lessons. Limitation on increases in Medicare’s payments to physicians (known as the sustainable growth rate or SGR) included in the 1997 Balanced Budget Act threatened sharp cuts in Medicare’s fee schedule. Yet Congress annually overrode the threatened cuts, and eventually repealed the SGR formula.

How would increases in revenue projected by the CBO be distributed among various physician specialties? Since both Congressional Medicare for All bills provide comprehensive benefits with little or no cost sharing (copayments or deductibles), individuals who currently cannot get medical care because of cost would increase their utilization of care. As a result, doctors who serve patients who are undertreated at present may experience the greatest increases in demand for their services, and in their revenues. Primary care providers are likely to fall into this category, given the degree to which hypertension, diabetes, hyperlipidemia, and other chronic conditions are currently undertreated. Anticipating this, the Congressional legislation would set aside funding to establish an Office of Primary Care, charged with developing policies to increase the number of primary care practitioners.

Although primary care doctors might get the biggest income boosts under single payer, specialists would continue to be high earners. The 1966 implementation of Medicaid/Medicare resulted in an increase in per-capita surgical procedures among the elderly.5 In Canada, the specialist:primary care income ratio has remained quite high; in 2019, gross clinical payments to thoracic surgeons averaged $588,000 (Canadian dollars) compared to $280,000 for family medicine physicians. Malpractice insurance costs, currently the highest for proceduralists, would likely fall as they did in Canada, since patients would no longer have to sue to cover future medical costs. And in many doctors’ practices, the case mix is likely to change for the better. As patients with unmet medical needs increase their utilization, the limited supply of hospital beds and physicians would likely cause a modest decrease in the delivery of low-value services.5 In essence, doctors could shift their efforts to address the greatest needs, without fear of losing income. To prevent waitlists, an increase in residency training programs may be necessary.

Medicare for All may also decrease inequities in physician pay. Increased demand and federal funding for primary care may modestly mitigate the racial and gender pay gaps in medicine, as nonwhite and non-male physicians are more likely to specialize in primary care fields.6 In addition, using a funding scheme called “global budgeting,” Medicare for All would likely increase revenue for underfunded safety net hospitals and clinics, which disproportionately employ physicians of color.7 However, the root causes of such pay disparities are racism and sexism, and thus, even with Medicare for All, additional anti-racist and anti-sexist reforms will be needed in the workplace.

Proposals for a Medicare “public option” or “Medicare Advantage for All” would sacrifice most of the administrative savings that Medicare for All could garner, making universal first dollar coverage unaffordable, minimizing increases in the utilization of care, and hence physicians’ practice revenues. Additionally, current fee schedules would likely persist under a public option reform, preserving the status quo that offers outsized rewards for performing procedures and caring for privately insured patients.

In sum, the available evidence—including the CBO’s authoritative estimate—suggests that physicians would prosper under single-payer reform. By supporting Medicare for All, physicians—and organized medicine—can get a twofer: acting in physicians’ self-interest while advancing legislation that would be enormously beneficial to patients.

Contributors: I am grateful for the feedback of Dr. Steffie Woolhandler, Dr. David Himmelstein, Dr. Samuel Dickman, Dr. Iris Borowsky, and Dr. Steve Borowsky on previous versions of this manuscript.

Author Affiliations: Department of Medicine, Internal Medicine Residency Program at Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

Disclosures: Dr. Cai has previously worked as a paid summer health policy fellow for US Representative Pramila Jayapal, the lead cosponsor of the Medicare for All Act of 2021, as a paid summer researcher for Physicians for a National Health Program (PNHP), a nonprofit which favors single-payer health reform, and as an unpaid board member of Students for a National Health Program (SNaHP) and PNHP.

https://link.springer.com…

References

  1. 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 [Internet]. Congressional Budget Office; [cited 2021 Jan 30]. Available from: https://www.cbo.gov…
  2. Gaffney A, Woolhandler S, Himmelstein D. Congressional Budget Office Scores Medicare-for-All: Universal Coverage for Less Spending [Internet]. Health Affairs Blog. February 16 2021. Available from: https://www.healthaffairs.org…
  3. Cai C, Runte J, Ostrer I, Berry K, Ponce N, Rodriguez M, et al. Projected costs of single-payer healthcare financing in the United States: a systematic review of economic analyses. PLoS Med 2020;17(1):e1003013. Article  Google Scholar
  4. Duffin J. The impact of single-payer health care on physician income in Canada, 1850-2005. Am J Public Health 2011;101(7):1198–208. Article  Google Scholar
  5. Gaffney A, McCormick D, Bor D, Woolhandler S, Himmelstein D. Coverage Expansions and utilization of physician care: evidence from the 2014 Affordable Care Act and 1966 Medicare/Medicaid Expansions. Am J Public Health 2019;109(12):1694–701. Article  Google Scholar
  6. Medscape 2020 Physicians’ Compensation Report [Internet]. [cited 2021 Feb 5]. Available from: https://www.medscape.com…
  7. Cai C, Kahn J. Medicare for All Would Improve Hospital Financing [Internet]. Health Affairs Blog 2019. Available from: https://www.healthaffairs.org…

New rules are nice, but a new program would be better

By Ken Lefkowitz
The Washington Post, Letters, July 8, 2021

Regarding the July 2 Politics & the Nation article “New rules are issued to protect patients from surprise medical billing”:

The new Biden administration rules to protect patients against “surprise billing” for out-of-network services is commendable, but their impact on medical costs will most certainly be diluted. Health insurers’ networks are negotiated so the insurer can save costs in our free-market, for-profit health-care system. We can expect that to counter the savings lost by insurers under the new rules, health-care providers will turn to another avenue to make up for the reduced profits, such as increasing premiums for coverage.

It is time to stop tweaking our for-profit system and implement Medicare-for-all, a cost-effective single-payer approach. It will cover all residents with no networks, premiums, deductibles or co-pays. It has proved to be less costly in other countries. It will wring out the duplicative and wasteful administrative costs of the free marketplace and provide negotiating leverage to stabilize doctors, hospitals and pharmacy costs. Three major studies — one by the University of Massachusetts, one published in the Lancet and another appearing in the Annals of Medicine — have estimated annual savings on health-care spending between $500 billion and $600 billion per year if Medicare-for-all were adopted.

The writer is a member of the New Jersey Universal Healthcare Coalition and Physicians for a National Health Program.

https://www.washingtonpost.com…

Insurers issue defective & deceptive provider directories

San Diego sues Molina, HealthNet, Kaiser, Modern Healthcare, June 25, 2021, by Nona Tepper

The city of San Diego sued three health insurers on Friday, alleging Kaiser Permanente, HealthNet and Molina Healthcare all advertised false networks of providers in an attempt to get consumers to sign up for their plans.

“Consumers should be able to trust their health insurers when seeking medical attention,” San Diego City Attorney Mara Elliot said in a statement. “Error-filled directories create dangerous barriers to healthcare services, with patients struggling to find a directory-listed doctor who will accept their insurance.” California law requires health insurers to update their printed provider directories quarterly and online listings weekly, the complaint said. These payers knew they were advertising false networks.

The complaints allege that up to 35% of the providers in Kaiser Permanente and HealthNet’s directories were listed inaccurately, and 80% of clinicians in Molina Healthcare’s directory were falsely listed as in-network.

Insurers’ error-riddled provider directories allowed them to attract more prospective enrollees and command higher prices, according to the suit. Falsely inflating their network size also made it harder for competitors to compete in the marketplace, the complaint said.

Each complaint said that insurers’ inaccurate listings disproportionately impacted low-income enrollees — who were more likely to be Black or Hispanic, according to the lawsuit — individuals with disabilities, people seeking mental healthcare, seniors lacking digital literacy, and women.

Each complaint noted that this was not the first warning insurers received.

Comment:

By Don McCanne, M.D.

The dishonesty of these insurers in maintaining deceptive provider directories not only represents an unfair business practice, but it is also a violation of law that results in financial harm to patients, the very population that they should be serving.

If we had a single payer Medicare for All program, there would be no need for provider lists because all legal health care professionals and institutions would be automatically covered under one system. Further, we would not need to pay hundreds of billions of dollars to these superfluous intermediaries. (But think of a future for integrated systems such as Kaiser Permanente strictly as health care delivery systems and not as risk-bearing insurers.)

For those who say that we have a moral obligation to support the insurers, think again. Our moral obligation is to the patients, and we need to terminate the burden that the insurers are placing on them, and, incidentally, the burden that they are placing on the health care delivery system itself.

http://healthjusticemonitor.org…

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Yet Another Medicare Advantage Cheating Scheme

Medicare Advantage Chart Reviews Are Associated With Billions in Additional Payments for Some Plans, Medical Care, February, 2021, by David J. Meyers and Amal Trivedi

From the Abstract:

Background: In the Medicare Advantage (MA) program, private plans receive capitated payments that are adjusted based on their enrollees’ number and type of clinical conditions. Plans have the ability to review charts to identify additional conditions that are not present in claims data, thereby increasing risk-adjusted payments.. . .

Results: Chart reviews were associated with a $2.3 billion increase in payments to plans, a 3.7% increase in Medicare spending to MA plans. Just 10% of plans accounted for 42% of the $2.3 billion in additional spending attributed to chart review. Among these plans, the relative increase in risk score from chart review was 17.2%. For-profit plans engaged in chart reviews substantially more frequently than nonprofit plans.

Comment:

By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

It’s long been known that Medicare Advantage (MA) plans selectively recruit low-cost Medicare enrollees and evict the expensively-ill, such as those who require nursing home care. As a result, Medicare pays MA plans 4% more than it would cost to care for their patients in the traditional Medicare program.

In response, CMS has tried to risk adjust MA plan premiums based on patients’ diagnoses. MA plans have counter-attacked by pressing clinicians to more assiduously code every diagnosis that might raise the risk score. That’s entirely legal. But this study shows that they’ve  gone even further than that, combing through patients’ medical records for possible indicators of diagnoses that physicians never entered as actual diagnoses. So if, for instance, a doctor never mentioned renal failure, but noted a slightly high creatinine level on one blood test (which might have come down on a subsequent test), that might trigger an MA plan to claim the extra payment for renal failure.

After 40 years of unsuccessful attempts to rein-in MA plans’ profit-driven efforts to cheat the taxpayers, it’s time to end the MA program and return to fully public Medicare.

http://healthjusticemonitor.org…

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Voting Rights Are Health Care Rights

When politicians are no longer accountable to voters, they serve their most powerful and deep-pocketed donors, such as for-profit hospitals and the commercial health insurance and pharmaceutical industries.

By Susan Rogers, M.D.
Common Dreams, July 6, 2021

Republican lawmakers in 43 states have introduced proposals that will severely limit Americans’ ability to vote, both in person and by mail. And last week’s Supreme Court ruling on Arizona’s voting rules opened the door for states to impose even more restrictions on voting. As a result, our most vulnerable neighbors—primarily low-income and people of color—will not be able to freely and fully exercise their constitutional right to vote.

As a physician who spent my career treating underserved communities, I know that when my patients lose their right to vote, they lose their right to the health care they need and deserve.

What do voting rights have to do with health care? In a free and functioning democracy, elected officials would implement health policies that are both popular and proven to best serve the needs of their constituents. But when politicians are no longer accountable to voters, they serve their most powerful and deep-pocketed donors, such as for-profit hospitals and the commercial health insurance and pharmaceutical industries.

When it comes to health care, the stakes couldn’t be higher. The U.S. spends $4 trillion per year on health care, almost twice as much as any other industrialized country, but we suffer from the worst performance on nearly every measurable health outcome, from life expectancy to maternal mortality. Thirty million Americans are uninsured, and an additional 40 million are underinsured. Nearly every family has a health care horror story: surprise bills, insurance company denials, medical bankruptcy, and—as I have seen much too frequently in my own practice—patients who delay treatment until it is too late.

Meanwhile, the industries that profit from our fractured health system are thriving: UnitedHealth Group, the nation’s largest insurer, reported 2020 profits of $15.4 billion; Cigna’s 2020 profits of $8.5 billion marked a staggering 66% increase over 2019.

Not surprisingly, Americans are outraged, and a majority of voters now support Medicare for All, which would improve Medicare’s benefits to also include necessary health services such as dental, vision, mental health, and reproductive care, and then expand coverage to everyone in the nation. Many studies, including a recent report from the Congressional Budget Office, show that Medicare for All could vastly improve our nation’s health outcomes while also decreasing overall health care costs.

If most voters want Medicare for All reform, why are we still trapped on the sinking ship of our fractured health system? Members of Congress (like all elected officials) respond to power, and political power comes in two forms: money and votes.

When it comes to money, the hospital, pharma, and insurance industries will always have ordinary people beat.

How can the average American compete, since these same industries have caused so much financial harm? Almost half of U.S. adults have skipped paying for essential items and bills so they could afford their medications, and nearly one in five skipped treatment for a health problem in the last year because of cost. The pandemic has pushed millions more Americans—particularly people of color—into poverty.

But, the one thing that every American should have, regardless of our income, zip code, or the color of our skin, is our vote. In an era of unprecedented corporate influence (the lobbying group America’s Health Insurance Plans spent nearly $4 million on lobbying so far this year), our vote is increasingly our only voice in the health care debate; our vote is the firewall that keeps health care from being entirely shaped by those that seek to profit from it.

Any attempt to restrict Americans’ ability to vote, particularly in communities of color, will result in worse health care and worse health outcomes for the most vulnerable.

My patients are desperate for equitable and universal coverage that can only be achieved with Medicare for All. But we won’t get real health care reform until we elect representatives that actually represent us. Health care will never be a right unless voting is a right—for all.

Dr. Susan Rogers is recently retired from Stroger Hospital of Cook County in Chicago, but continues as a volunteer attending hospitalist and internist there. While at Stroger Hospital, she was co-director of medical student programs for the Department of Medicine and received numerous teaching awards from medical students and residents. She is an Assistant Professor of Medicine at Rush University, where she continues to be an active member of the Committee of Admissions. Dr. Rogers currently serves as president of Physicians for a National Health Program, a nonprofit research and education organization whose more than 23,000 members support single-payer Medicare for All reform.

https://www.commondreams.org…

Democracy and Single Payer

Comment:

By Jim Kahn, M.D., M.P.H.

On the 4th of July, my thoughts turn to our system of governance, as it relates to health reform.

Our democracy is under siege. First, the President who lost his re-election bid tried to retain power by claiming he won and fomenting a coup. Crisis averted, barely. The vast majority of GOP officials still support this “big lie” about the election. Then, in June, a Democratic Senator – Joe Manchin of W. Virginia – published an op-ed declaring his fealty to the filibuster (anti-majority) and bipartisanship (a myth) over voting rights. This would allow GOP-controlled swing states to selectively disenfranchise Democrats, especially poor people of color living in big cities. Subsequently, Manchin expressed support for a scaled-back but still strong voting rights bill. Encouraging. Last week, the U.S. Supreme Court upheld state laws that manipulate voting rules in ways that will likely selectively disenfranchise blacks, relying on a 6-3 conservative majority enabled by Mitch McConnell’s abandonment of long-standing norms regarding Supreme Court appointments. Worrisome. The future of voting bills and rights – with implications for 2022 Congressional midterms and Biden’s ability to govern – will play out later this month. These events are thoroughly and thoughtfully chronicled by Heather Cox Richardson in Letters from an American. I also recommend Paul Krugman’s forceful take-down of the GOP’s thorough abandonment of reality in favor of ideology and self-interest. Dire challenges loom for democracy.

So what does this have to do with single payer financing of health care?

A lot, actually. The parallels are numerous. For today’s blog, I offer a list. If you care to suggest others, please reply to the email or add comments on the website. In future posts, I’ll delve into specific issues.

Democracy and single payer …

  • Both honor human rights, highlighting human dignity – the ability to participate in collective decisions, and the right to healthcare and health.
  • Both foster equality – everyone is treated the same. No preferential voice, no preferential care. Nobody excluded.
  • Both reflect and strengthen community values – society working collectively to address important decisions and solutions.
  • Both honor majority rule – fair voting to maximize the right and ability to cast ballots, and adoption of a health care financing approach favored by most Americans.
  • Both use simplicity to achieve performance & efficiency – one straightforward, unconvoluted set of rules for everyone, simplifying and maximizing access.
  • Both reduce manipulation of the system for gain by those in control – by requiring neutral voting rules and eliminating exorbitant profits from the provision of health.
  • Both recognize that some societal functions are most efficiently and effectively accomplished by government agencies –e.g., fairly designed and enforced voting, and financing for essential services like health care.

I think I always knew intuitively that single payer is profoundly democratic. Now I’m beginning to understand the details.

Finally, the day-to-day struggles for both causes are linked:

Empowering the maximum number of people with the vote will bolster the prospects for single payer. Because voters – especially those the GOP is trying to exclude – support single payer. And achieving single payer will build commitment to progressive, democratic values, and showcase the advantages of a benevolent government. Linking the battles may prove synergistically enabling, helping achieve both worthy causes.

Enjoy the holiday weekend, and next week let’s all dig in again to fight for justice in democracy and health care.

http://healthjusticemonitor.org…

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High deductibles can kill patients, especially if they’re poor

Impact of High-Deductible Health Plans on Emergency Department Patients With Nonspecific Chest Pain and Their Subsequent Care, Circulation, June 2021, by Shih-Chuan Chou et al.

Methods: Using a commercial and Medicare Advantage claims database, we identified members 19 to 63 years old whose employers exclusively offered low-deductible (≤$500) plans in 1 year, then, at an index date, mandated enrollment in HDHPs (≥$1000) for a subsequent year. We matched them with contemporaneous members whose employers only offered low- deductible plans. Primary outcomes included population rates of index ED visits with a principal diagnosis of nonspecific chest pain, admission during index ED visits, and index ED visits followed by noninvasive cardiac testing within 3 and 30 days, coronary revascularization, and acute myocardial infarction hospitalization within 30 days. Members from higher-poverty neighborhoods were a subgroup of interest.

From Discussion: The contrasting findings between members from neighborhoods of different poverty levels merit particular attention. After HDHP switches, members from lower-poverty neighborhoods reduced invasive procedures after nonspecific chest pain ED visits without changes in ED visits for nonspecific chest pain, hospitalizations, non-invasive testing, or AMI admissions. However, members living in higher-poverty neighborhoods reduced non-specific chest pain ED visits, disproportionately reduced hospitalizations from index ED visits, and significantly increased AMI hospitalization in 30 days after index ED visits. Our findings support that, although HDHPs can reduce potentially low-value acute care among those with higher socioeconomic status, the disproportionate financial pressure from high out-of-pocket costs on lower-income populations appears to lead to unintended consequences with potentially negative health implications.

There is growing evidence that exposing low socioeconomic status populations to high cost-sharing leads to the deferral of appropriate care.

What Is New? High deductible health plan enrollment was associated with increased 30-day acute myocardial infarction rate after emergency department visits for nonspecific chest pain among patients living in neighborhoods with higher poverty rates.

Comment:

By Don McCanne, M.D.

Keep in mind that high deductibles are a tool used by private insurers to discourage patients from obtaining health care that the insurer might have to pay for. It is a profit-motivated business tool and not a tool to provide assistance to a patient in obtaining beneficial health care. It especially negatively impacts those with greater financial needs. Of note, this study evaluated private commercial and Medicare Advantage plans and not patients in the public Medicare program which avoids high deductibles (though even modest deductibles may be a hardship for those of limited financial means).

In this study of emergency department patients presenting with chest pain, it was found that those with low socioeconomic status who had high deductibles “reduced non-specific chest pain ED visits” and “significantly increased acute myocardial infarction hospitalization in 30 days after index ED visits.” They conclude, “the disproportionate financial pressure from high out-of-pocket costs on lower-income populations appears to lead to unintended consequences with potentially negative health implications.”

We can conclude that “potentially negative health implications” from deferred diagnosis of acute myocardial infarctions includes the potential for death. Since the delays were due to high deductibles, we can further conclude that high deductibles used by private health plans kill people.

We don’t need high deductibles, and we certainly don’t need expensive private insurers who use them to create more wealth for themselves at a cost of providing optimal patient service. After many decades, their profit-maximizing behavior only grows worse. Time to replace them with a single payer improved Medicare for All – no profits, just patient service.

http://healthjusticemonitor.org…

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Medicare for All Explained Podcast: Episode 59

Interview with Traci Gleason

July 1, 2021

Missouri Budget Project vice president Traci Gleason urges the state legislature to respect the will of voters and expand Medicaid. She says fears that the program would be too costly are overblown since “no state that has expanded Medicaid has had to come back and raise taxes in order to pay for it.”

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

https://medicareforallexplained.podbean.com

Medicare for All Would Guarantee Health Care for the Undocumented

Desperate for Covid Care, Undocumented Immigrants Resort to Unproven Drugs, New York Times, June 20, 2021, by Amy Maxmen

“It’s disappointing but not surprising” that people living below the poverty line have spent large sums of money for unproven treatments for Covid-19, said Rais Vohra, the interim head of Fresno County’s health department. “People are desperate and bombarded with misinformation and may not have the skills, time or context to interpret medical evidence.” …

During the pandemic, many immigrants shut out of mainstream health care have turned to such markets for Covid-19 treatments. About 20 percent of Hispanic people in the United States lack health insurance, and the proportion is far higher among undocumented immigrants.

What’s more, some immigrants mistrust doctors who don’t speak their language or who treat them curtly — and those concerns have been amplified by harsh political rhetoric directed at Mexicans and Central Americans. …

“My community fears that the government might be trying to get rid of us,” said Oralia Maceda Méndez, an advocate at a Fresno-based community group for Indigenous people from Oaxaca, Mexico. She has heard many stories from immigrants in her community who treat themselves for Covid-19 with penicillin, other antibiotics or a mix of vitamins and herbal therapies bought from shops or travelers selling medications bought in Mexico.

“I am not surprised that people are taken advantage of,” she said. “We don’t have the care we need.”

Comment:

By Eagan Kemp

Barring undocumented immigrants and workers from getting health care is cruel and inhumane. As the cited NYT article notes, the COVID-19 crisis has further exacerbated the costs and dangers of lacking health insurance in America. This is particularly severe for undocumented workers in frontline industries where they are unable to social distance. Even before the pandemic, almost half of undocument immigrants were uninsured, placing them at risk for financial ruin if they got sick.

It may also be suicidal — lack of regular medical care will prevent many from getting the COVID-19 vaccine. We must protect everyone from even more dangerous COVID-19 variants through inoculating a sufficient percentage of people in the U.S. and around the world.

And while undocumented immigrants make up only around 3 percent of the U.S. population and 4.4 percent of the workforce, they are make up a large share in certain industries, including some deemed essential during the COVID-19 crisis.

For example, more than half of all agricultural workers are undocumented, many of whom were deemed essential during the COVID-19 crisis, placing them at increased risk for the virus. Similarly, around 40 percent of workers in meatpacking plants in the U.S. are reported to be undocumented, with many unable to effectively social distance or fight for better worker protections.

Of the policy reforms under consideration by Congress, only Medicare for All would guarantee all necessary health care to all undocumented immigrants, by finally treating health care as a human right instead of as a means for profit.

No one in the U.S. should be forced to go without health care, especially the COVID-19 vaccine. And leaving immigrants to fend off the medical vultures seeking to exploit them and take their money is no solution at all. We need reform now.

http://healthjusticemonitor.org…

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The Financialization of US Health Care Is Responsible for the EHR Burden on Clinicians

Assessment of Electronic Health Record Use Between US and Non-US Health Systems, JAMA Internal Medicine 2021; 181(2):251-259, February 1, 2021, by A. Jay Holmgren et al.

From the Abstract: Design, Setting, and Participants: This cross-sectional study analyzed the deidentified metadata of ambulatory care health systems in the US, Canada, Northern Europe, Western Europe, the Middle East, and Oceania from January 1, 2019, to August 31, 2019. All of these organizations used the EHR software from Epic Systems and represented most of Epic Systems’s ambulatory customer base.

Results: US clinicians spent more time per day actively using the EHR compared with non-US clinicians (mean time, 90.2 minutes vs 59.1 minutes; P < .001). In addition, US clinicians vs non-US clinicians spent significantly more time performing 4 clinical activities: notes (40.7 minutes vs 30.7 minutes; P < .001), orders (19.5 minutes vs 8.75 minutes; P < .001), in-basket messages (12.5 minutes vs 4.80 minutes; P < .001), and clinical review (17.6 minutes vs 14.8 minutes; P = .01). Clinicians in the US composed more automated note text than their non-US counterparts (77.5% vs 60.8% of note text; P < .001) . . . . The median US clinician spent as much time actively using the EHR per day (90.1 minutes) as a non-US clinician in the 99th percentile of active EHR use time per day (90.7 minutes) in the sample. These results persisted after controlling for organizational characteristics, including structure, type, size, and daily patient volume.

Comment:

By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

US clinicians complain bitterly about their documentation burden and unwieldy EHRs that sap the joy of patient care, and these burdens are a main cause of the widespread and growing burnout problem. This study makes clear that the US payment system inflicts much of this burden. In other nations, clinicians using EPIC – the most widely used EHR in the US – spend far less of their time staring at computer screens and checking the endless boxes needed to assure payment. A single payer reform that simplifies payment would greatly improve clinicians’ work lives.

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Proper funding for home-based long-term care is essential

Time to Rethink Nursing Homes, The JAMA Forum, April 13, 2021, by Stuart M. Butler

“Hundreds of thousands of people who are older and disabled live in nursing homes not because they need specialized care or want to live in those facilities, but because Medicaid payment rules make that the only housing with daily living care they can afford.

Nursing homes serve two quite different populations. One requires short-term postacute care services. The other is long-stay residents who mostly need only basic daily living care, many of whom would prefer to be living in their own communities and among friends.”

Comment:

By Allison K. Hoffman, J.D.

The COVID pandemic led many to question the safety and wisdom of long-term care in nursing homes, where the virus spread dramatically and tragically. In response, nursing homes and their regulation are under scrutiny, and some people are advocating for their end.

However, moving long-term care into personal homes is not easy and not always the right option, even if older people might prefer to “be living in their own communities and among friends.” Historically, Medicaid had a distinct institutional bias, funding long-term care in institutional settings as a mandatory benefit and in home-based settings as an optional benefit. Over the past few decades, however, funding for Medicaid long-term services and supports has shifted dramatically from paying for care in institutions toward home- and community-based services (HCBS) – a process called “rebalancing.” Now, over half of Medicaid dollars fund care in home-based settings.

When long-term care happens in homes, however, much of the cost of that care is incurred by family members who serve as informal caregivers. Elsewhere, I’ve called these sizeable costs the “invisible copayment” of long-term care. Some scholars like Butler suggest that we’ll save money by moving care out of institutions and into homes.

But this move does not truly save costs; it shifts and hides them. Family members incur costs invisibly and behind closed doors in the form of lost wages, leisure time, and benefits and retirement savings, as well as poor health. My colleague Norma Coe and co-authors estimate that the median and indirect cost of caring for an older parent over two years are equal to the cost of full-time institutional care. Any response to nursing home problems that increases the already strong trends of relying on family caregiving will exacerbate these costs.

We’re far from a solution that will fully pay for home-based care, whether provided by formal caregivers or by family. President Biden proposed an additional $400B over the next 10 years to help fund home and community-based as part of the Americans Jobs Plan. Even if this full amount were to be enacted into law (a big if!), it barely scratches the surface of what it would take to fund the demand for long-term care at home. Already, states’ waiting lists for HCBS are long and formal caregivers are grossly underpaid, causing workforce shortages.

To meet the need for long-term care and to pay for it at a living wage, whether provided by formal caregivers or by family members, will take a much more dedicated effort. This is an essential topic in the single payer discussion.

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