PNHP

“Exploring Single-Payer Alternatives for Health Care Reform”

“Exploring Single-Payer Alternatives for Health Care Reform”

RAND 2016

Title: Exploring Single-Payer Alternatives for Health Care Reform
Year: 2016
Authors: Jodi L. Liu
Institution: Pardee RAND graduate school
Funding Source: N/A
Plan Analyzed: S. 1782 / H.R. 1200
Percent Change in National Health Expenditure under M4A (1-year): -5% (2017)
Percent Change in National Health Expenditure under M4A (10-year): NS
Increase in Federal health expenditures: $446 billion (2017)

Read Study:

Exploring Single-Payer Alternatives for Health Care Reform

Study Abstract:

The Affordable Care Act (ACA) has reduced the number of uninsured and established new cost containment initiatives. However, interest in more comprehensive health care reform such as a single-payer system has persisted. Definitions of single-payer systems are heterogeneous, and estimates of the effects on spending vary. The objectives of this dissertation were to understand single-payer proposals and to estimate health care spending under single-payer alternatives in the United States. Single-payer proposals are wide-ranging reform efforts spanning financing and delivery, but vary in the provisions. I modeled two sets of national scenarios – one labeled comprehensive and the other catastrophic – and compared insurance coverage and spending relative to the ACA in 2017. First, I estimated the effects of utilization and financing changes, and then I added the effects of “other savings and costs” relating to administration, drug and provider prices, and implementation. Due to coverage of all legal residents and low cost sharing, and prior to adjusting for other savings and costs, the comprehensive scenario increased national health care expenditures by $435 billion and federal expenditures by $1 trillion relative to the ACA. The range of the net effect of the other savings and costs in the literature was $1.5 trillion in savings to $140 billion in costs, with a mean estimate of $556 billion in savings. If this mean estimate was applied to the comprehensive scenario, national expenditures would be $121 billion lower but federal expenditures would still be $446 billion higher relative to the ACA. The catastrophic scenario also covered all legal residents but increased overall cost sharing, resulting in a reduction in national expenditures by $211 billion and federal expenditures by $40 billion even before adjusting for other savings and costs. Average household spending on health care in both sets of scenarios could be more progressive by income than spending under the ACA. I also developed an interactive, web-based cost tool that allows the savings and cost assumptions to be adjusted by any user. As the debate on how to finance health care for all Americans continues, this study provides increased transparency about economic evaluations of health care reform.

Overview:

  • This comprehensive 2016 paper served as Jodi Liu’s dissertation, which utilizes a microsimulation model to account for costs/savings and individual level variation
  • The paper contains four main chapters:
    • Chapter 1: A review of types of health care systems, single-payer systems worldwide, and brief overview of single-payer health care reform in the United States
    • Chapter 2: Definitions of single-payer health care systems and a survey of single-payer proposals
    • Chapter 3: Estimates of health insurance coverage and spending under single-payer scenarios
      • Liu looks at 2 policy scenarios: Comprehensive (comprehensive benefits without cost-sharing) and Catastrophic (coverage only against large financial loss)
      • Comp-Base Scenario – Single-payer bill as written: 98% Actuarial value (2% OOP for individuals)
      • Comp-Low AV Scenario – a 78% AV plan (22% OOP for individuals)
      • Comp-High Tax Scenario – 98% AV, but income tax adjusted upward to match federal expenditure under ACA
    • Chapter 4: Description of a cost tool that could be used to understand assumptions (not available)

Wharton Professor Robert Hughes advocates for universal health care

Does the U.S. Need Universal Health Care?

Interview of Robert Hughes, professor of business ethics and legal studies at Wharton
The Wharton School of the University of Pennsylvania, Knowledge@Wharton, December 8, 2020

Nothing quite exposes the inequalities that exist in American society more than the health care system. It’s a complex combination of private insurance, public programs and politics that drives up costs, creating significant barriers to lifesaving medical treatment for large segments of the population. In America, access to quality health care often depends on income, employment and status.

Robert Hughes, professor of business ethics and legal studies at Wharton, is an advocate for universal health care coverage. Drawing deeply on his research in philosophy, Hughes believes that equal access to medical care is beneficial for both liberty and social stability. Health, he says, should not be tied to wealth.

“I think it’s very disturbing that people have to go to GoFundMe in order to get their medical treatments paid for. It creates a power imbalance,” he said, referring to the crowdsourcing platform used to help raise money for patient bills. “That’s why I say that truly universal health care would be good for people’s liberty. Because you’re not really free if you’re depending on charity, especially discretionary charity like the kind you see on GoFundMe, for a basic need like health care.”

The ACA, commonly referred to as Obamacare, brought the U.S. closer to providing universal health care through subsidized private health insurance, but Hughes said there’s still a wide gap. He believes policymakers should ensure that everyone has coverage and access to the same needed treatments.

The professor argued the case for universal health care in a paper titled “Egalitarian Provision of Necessary Medical Treatment,” which was published last year in the Journal of Ethics. (The author-accepted version is here.) He examined the health care systems of the U.K., Australia and Canada, concluding that Canada’s single-payer system is the most advantageous for the U.S.

“I don’t understand why there’s so much resistance to the idea of truly universal health insurance in the United States, given that this is something that other industrial countries just do,” Hughes said.

He acknowledged that the U.S. doesn’t have the “political will” to change a system that’s been entrenched since the end of World War II, when employers began offering health insurance to their workers instead of higher wages.

Link includes 12 minute podcast:
https://knowledge.wharton.upenn.edu…

Egalitarian Provision of Necessary Medical Treatment

By Robert C. Hughes
The Journal of Ethics, October 31, 2019

Abstract

Considerations of autonomy and independence, properly understood, support strictly egalitarian provision of necessary medical treatment. If the financially better-off can purchase access to necessary medical treatments that the financially less well-off cannot purchase without help, then their discretionary power to give or to withhold monetary gifts indirectly gives them the power to make life-and-death or sickness-and-health decisions for others. To prevent private citizens from having this objectionable form of power, government must ensure that citizens’ finances do not affect their access to medical treatments that significantly prolong life, relieve suffering, or cure or mitigate disabilities. Government should ensure this even if doing so involves leveling down and even if it is unclear whether egalitarian provision of necessary treatment would provide better care to the poor than a less egalitarian health care system would.

The Journal of Ethics: Abstract
https://link.springer.com…

Author’s pre-copyedit version of the full article:
http://robertchughes.com…

Comment:

By Don McCanne, M.D.

Robert Hughes’ position on universal health care is one that is certainly familiar to supporters of single payer Medicare for All. What is unique here is that Hughes is a professor of business ethics and legal studies at the University of Pennsylvania’s Wharton School, which some believe is a center of conservative thought at an otherwise liberal university.

His views on egalitarian provision of necessary medical treatment should provoke thought. Does care need to be egalitarian (equal for all), or can it ethically be equitable (merely fair for all)? Should “leveling down” be applied to services for the affluent so that they do not exceed services for the poor? If leveling down is applied only to unnecessary services then can’t a wealthy nation like the United States afford to provide all necessary services for everyone? If so, then would it be ethical to avoid leveling down unnecessary health services that might be desired by the affluent as long as they were not financed by the government? But then how would you silo unnecessary services?

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

“The Costs of a National Single-Payer Healthcare System”

Mercatus Center 2018

Title: The Costs of a National Single-Payer Healthcare System
Year: 2018
Authors: Charles Blahaus
Institution: Mercatus Center
Funding Source: Koch
Plan Analyzed: S. 1804 Medicare for All Act of 2017
Percent Change in National Health Expenditure under M4A (1-year): -2.03% (2022)
Percent Change in National Health Expenditure under M4A (10-year): -3.44% (2022-31)
Increase in Federal health expenditures: $5.838 trillion (2017-26)

Read Study:

The Costs of a National Single-Payer Healthcare System

Study Abstract:

The leading current bill to establish single-payer health insurance, the Medicare for All Act (M4A), would, under conservative estimates, increase federal budget commitments by approximately $32.6 trillion during its first 10 years of full implementation (2022–2031), assuming enactment in 2018. This projected increase in federal health care commitments would equal approximately 10.7 percent of GDP in 2022, rising to nearly 12.7 percent of GDP in 2031 and further thereafter. Doubling all currently projected federal individual and corporate income tax collections would be insufficient to finance the added federal costs of the plan. It is likely that the actual cost of M4A would be substantially greater than these estimates, which assume significant administrative and drug cost savings under the plan, and also assume that health care providers operating under M4A will be reimbursed at rates more than 40 percent lower than those currently paid by private health insurance.

Overview:

  • The Mercatus Report focuses on national health expenditures (NHE), but places particular emphasis on federal health expenditures.
  • The Report focuses on:
    • An overview of the findings and rationale for why Blahaus believes his estimate is an “underestimate”
    • Detail Increased Demand and Utilization assumptions and Long Term Services and Supports (LTSS)
    • Savings from Provider Payment Reductions, Drug Costs, Administrative Savings. Blahaus underscores that all of these savings will likely not be achieved because his estimates require a perfect transition from policy to practice. (Administrative Tasks, Prescription Drug Negotiation, etc) operate their optimal capacity/efficiency
    • Effects on NHE and the Federal Budget, expressing skepticism about financing plans despite not laying out any particular financing plans
    • Appendix with Financial Effects of different scenarios under Medicare for All

PNHP Response:

PNHP co-founders Drs. David Himmelstein and Steffie Woolhandler critique the Mercatus reports as “ideology masquerading as health economics.”

Further Reading:

  • “SinglePayerGate” misses the point: (Vox)
  • Blahous Rebuttal: (e21)

“Economic Analysis of Medicare for All”

Political Economy Research Institute (PERI) 2018

Title: Economic Analysis of Medicare for All
Year: 2018
Author: Robert Pollin, James Heintz, Peter Arno, Jeannette Wicks-Lim, and Michael Ash
Institution: Political Economy Research Institute (PERI) U-Mass Amherst
Funding Source: California Nurses Association/National Nurses United
Plan Analyzed: S. 1804 Medicare for All Act of 2017
Percent Change in National Health Expenditure under M4A (1-year): -9.6% (2017)
Percent Change in National Health Expenditure under M4A (10-year): -11.9% (2017-26)
Increase in Federal health expenditures: $1.35 trillion (2017-26)

Read Study:

PERI – Economic Analysis of Medicare for All

Study Abstract:

This study by PERI researchers Robert Pollin, James Heintz, Peter Arno, Jeannette Wicks-Lim and Michael Ash presents a comprehensive analysis of the prospects for a Medicare-for-All health care system in the United States. The most fundamental goals of Medicare for All are to significantly improve health care outcomes for everyone living in the United States while also establishing effective cost controls throughout the health care system. These two purposes are both achievable. As of 2017, the U.S. was spending about $3.24 trillion on personal health care—about 17 percent of total U.S. GDP. Meanwhile, 9 percent of U.S. residents had no insurance and 26 percent were underinsured—they were unable to access needed care because of prohibitively high costs. Other high-income countries spend an average of about 40 percent less per person and produce better health outcomes. Medicare for All could reduce total health care spending in the U.S. by nearly 10 percent, to $2.93 trillion, while creating stable access to good care for all U.S. residents.

Overview:

  • The PERI study is a lengthy and comprehensive cost-analysis study. The authors explain their assumptions and counterfactuals at length and show their calculations in a very easy-to-follow format.
  • The Report contains 7 sections:
    • Chapter 1: Underscores why affordable health care can improve health outcomes
    • Chapters 2-3: Identifies sources of costs and savings
    • Chapter 4: Financing Plans for Medicare For All
    • Chapter 5: Effects of financing plans on families (based on income) and businesses (small, medium, and large)
    • Chapter 6: Considers the logistics and the costs of transitioning from our current system to a single-payer system (“Just Transition”)
    • Chapter 7: Estimates the effects of Medicare for All on health care spending as a share of US GDP, and other macroeconomic impacts

PNHP Response:

PNHP co-founders Drs. Steffie Woolhandler and David Himmelstein, and PNHP president Dr. Adam Gaffney, submitted a reviewer assessment of the PERI study. They note that the PERI analysis may understate administrative savings, but overall find it to be a “highly credible economic analysis.”

Further Reading:

Facing job loss with Just Transition (KHN)

“From Incremental to Comprehensive Health Insurance Reform: How Various Reform Options Compare on Coverage and Costs”

The Urban Institute 2019

Title: From Incremental to Comprehensive Health Insurance Reform: How Various Reform Options Compare on Coverage and Costs
Year: 2019
Author: Linda J. Blumberg, John Holahan, Matthew Buettgens, Anuj Gangopadhyaya, Bowen Garrett, Adele Shartzer, Michael Simpson, Robin Wang, Melissa M. Favreault, and Diane Arnos
Institution: Urban Institute
Funding Source: The Commonwealth Fund
Plan Analyzed: “Reform 8”
Percent Change in National Health Expenditure under M4A (1-year): 20.6% (2020)
Percent Change in National Health Expenditure under M4A (10-year): NS
Increases in federal health expenditures: $33.988 trillion (2020-29)

Read Study:

From Incremental to Comprehensive Health Insurance Reform: How Various Reform Options Compare on Coverage and Costs

Abstract:

Policymakers, including candidates in the 2020 presidential campaign and members of Congress, have proposed a variety of options to address the shortcomings of the current health care system. These range from improvements to the Affordable Care Act to robust single-payer reform.

There are numerous challenging trade-offs when choosing an approach to health care reform, including covering the uninsured, improving the affordability of health care, and raising the government funding required to implement them. The public and policymakers alike need more information about the potential effects of various health reform proposals.

This study, funded by the Commonwealth Fund, analyzes eight health care reforms and their potential effects on health insurance coverage and spending. Each of the analyzed reform proposals makes health insurance considerably more affordable by reducing people’s premiums and cost sharing. Some reforms also reduce US health care costs, and all require additional federal dollars.

Overview:

  • This study is unique in that it outlines 8 potential health care policy reform options, and then outlines impacts on national health expenditures, federal health expenditure, and insurance rates. It utilizes the same microsimulation approach that the Urban institute utilized in its 2016 paper.
  • Reforms considered by this paper include those that:
    • Build on the ACA
      • Reform 1: Enhanced financial assistance
      • Reform 2: Federal individual mandate and STLD prohibitions
      • Reform 3: Filling the Medicaid eligibility gap
      • Reform 4: Public option and/or capped provider payment rates
      • Reform 5: CARE, no ESI firewall
      • Reform 6: Further enhanced financial assistance
    • Replace the ACA
      • Reform 7: Single-payer lite
      • Reform 8: Single-payer enhanced

PNHP Response:

PNHP co-founders Drs. David Himmelstein and Steffie Woolhandler found that “the Urban Institute analysis grossly underestimates the administrative savings under single payer, and projects increases in the number of doctor visits and hospitalizations that far exceed the capacity of doctors and hospitals to provide this added care.” Their full critique here, and a QOTD response from Dr. Don McCanne, including comments from PNHP president Dr. Adam Gaffney, here.

Further Reading:

Comparing Health Insurance Reform Options: From “Building on the ACA” to Single Payer

“National Health Spending Estimates Under Medicare for All”

RAND 2019

Title: National Health Spending Estimates Under Medicare for All
Year: 2019
Authors: Jodi L. Liu and Christine Eibner
Institution: RAND
Funding Source: Modeled after H.R. 1384
Plan Analyzed: S. 1782 / H.R. 1200
Percent Change in National Health Expenditure under M4A (1-year): +1.75% (2019)
Percent Change in National Health Expenditure under M4A (10-year): NS
Increases in federal health expenditures: $2.4 trillion (2019)

Read Study:

National Health Spending Estimates Under Medicare for All

Study Abstract:

We estimate that total health expenditures under a Medicare-for-All plan that provides comprehensive coverage and long-term care benefits would be $3.89 trillion in 2019 (assuming such a plan was in place for all of the year), or a 1.8 percent increase relative to expenditures under current law. This estimate accounts for a variety of factors including increased demand for health services, changes in payment and prices, and lower administrative costs. We also include a supply constraint that results in unmet demand equal to 50 percent of the new demand. If there were no supply constraint, we estimate that total health expenditures would increase by 9.8 percent to $4.20 trillion.

While the 1.8 percent increase is a relatively small change in national spending, the federal government’s health care spending would increase substantially, rising from $1.09 trillion to $3.50 trillion, an increase of 221 percent.

Overview:

  • An update done by extrapolating projections from the microsimulation modelling in the 2016 RAND study. No new modelling was undertaken for this analysis.
  • This study considers:
    • Increased demand for medical services and long-term care services and supports (LTSS)
    • Savings from all-payer rates for services, prices for drugs and devices, administrative costs
    • Supply-side constraints for services
    • Level of financing needed for Medicare For All

PNHP Response:

Regarding increased utilization, we would highlight three studies from 2019 that found large-scale coverage expansions in the United States (Medicare/Medicaid in the late 1960s and the ACA in the early 2010s) did not lead to a society-wide increase in hospitalizations or doctor visits, and that large-scale expansions in other nations also did not cause a spike in utilization. (See “Utilization of health care services after large coverage expansions.”)

“Yes, We Can Have Improved Medicare for All”

Hopbrook Institute 2019

Title: Yes, We Can Have Improved Medicare for All
Year: 2019
Author: Gerald Friedman
Institution: University of Massachusetts at Amherst
Funding Source: Hopbrook Institute
Plan Analyzed: H.R. 676
Percent Change in National Health Expenditure under M4A (1-year): -20.0% (2019)
Percent Change in National Health Expenditure under M4A (10-year): -20.6% (2019-28)

Read Study:

Yes, We Can Have Improved Medicare for All

Abstract:

Growing public support for universal health coverage through a public program has provoked increasing attention to the question of how to finance such a program. There should not be any controversy about our ability to pay for universal health care. Given the nearly universal agreement that the current health-care system involves administrative waste and monopoly pricing, a system that would be more efficient and would reduce both should certainly be affordable. Studies finding higher costs for universal coverage programs have reached their conclusions by acknowledging efficiency savings but dismissing them by emphasizing, even exaggerating, the higher costs of providing better access to health care.  Such studies provide a poor guide to the possibilities for an overhaul of our health-care finance system. In this paper, I discuss the financing of a universal health-care program, beginning with a discussion of current projected spending and the savings to be achieved through administrative efficiency and reducing monopoly pricing. Next, I outline increased spending associated with universal coverage through covering the uninsured and reducing barriers to access. I consider the net cost of universal coverage, after taking account of savings and the cost of extending and improving coverage, under various scenarios with alternative immediate savings and savings over time. Finally, I discuss sources of funding for such a program, beginning with public funds already committed and including possible additional sources of revenue. I develop funding plans under a variety of assumptions regarding the course of the single-payer system, and under alternative assumptions regarding revenue sources. This work shows that compared with the current system of health-care finance, a program of Improved Medicare for All could save Americans over $1 trillion in the first year, and savings could increase over time. Because some of the savings would be returned to health care through programs of universal coverage and improved access, net savings could be over $700 billion in the first year, rising over the next decade. Depending on the assumptions made and the program details, total financial savings, after taking account of program improvements, would come to $10 trillion or more over the next decade, on top of gains in quality of life and reduced mortality through universal access. A variety of models are compared, with varying assumptions of the magnitude of administrative savings and savings through reduced monopoly rents, as well as savings from bending the cost curve and maintaining some cost-sharing. Overall, the ten-year national savings on health-care expenditures range from a low of over $6 trillion to a high of over $13 trillion.  In every model tested, Improved Medicare for All is cheaper than the current system even while providing improved health care.

Overview:

Comprehensive cost analysis conducted by Gerald Friedman updating his previous work on the subject with similar considerations for financing options.

  • Section 1: Current spending and waste
    • Administrative savings in provider offices
    • Savings from pricing at Medicare negotiated rates
      • Drugs and medical devices
      • Hospital and physician practices
  • Section 2: Additional spending with universal coverage
    • Medicare premiums
    • Cost of universal coverage
    • Cost of eliminating barriers to access
  • Section 3: Total Spending with Medicare for All
  • Section 4: Paying for Medicare for All
    • Available revenues
    • New revenues
  • Conclusion: We can afford Improved Medicare for All

“Improving the Prognosis of Health Care in the USA”

Yale School of Public Health 2020

Title: Improving the prognosis of health care in the USA
Year: 2020
Authors: Alison P. Galvani, Alyssa S. Parpia, Eric M. Foster, Burton H. Singer, Meagan C. Fitzpatrick
Institution: Yale School of Public Health
Funding Source: N/A
Plan Analyzed: S. 1804 Medicare for All Act of 2017
Percent Change in National Health Expenditure under M4A (1-year): -13.1% (2017)
Percent Change in National Health Expenditure under M4A (10-year): NS
Increase in Federal health expenditures: $773 billion (2017)

Read Study:

Improving the prognosis of health care in the USA

Study Abstract:

Although health care expenditure per capita is higher in the USA than in any other country, more than 37 million Americans do not have health insurance, and 41 million more have inadequate access to care. Efforts are ongoing to repeal the Affordable Care Act which would exacerbate health care inequities. By contrast, a universal system, such as that proposed in the Medicare for All Act, has the potential to transform the availability and efficiency of American health care services. Taking into account both the costs of coverage expansion, and the savings that would be achieved through the Medicare for All Act, we calculate that a single-payer, universal health care system is likely to lead to a 13% savings in national health-care expenditure, equivalent to more than US$450 billion annually (based on the value of the US$ in 2017). The entire system could be funded with less financial outlay than is incurred by employers and households paying for health care premiums combined with existing government allocations. This shift to single-payer health care would provide the greatest relief to lower-income households. Furthermore, we estimate that ensuring health care access for all Americans would save more than 68,000 lives and 1.73 million life-years every year compared with the status quo.

Overview:

  • In early 2020, Alison Galvani published a cost-analysis of the Senate Medicare for All bill, S. 1804. Of note, Galvani served as an “informal unpaid adviser” to the writers of this particular bill.
  • The Yale study focuses on:
    • Savings from reduced fees for hospital and clinical services, unified system for billing and administration, pharmaceutical price negotiation
    • The cost of expansion of coverage and services
    • Financing plan effects on employers and households
    • Public health approach to estimate “life-years” saved by Medicare for All
    • Positive spillovers from emphasizing preventive services
    • Creation of a Tool that can model costs/savings as well as revenue generation

Further Reading:

SHIFT Tool allowing users to modify inputs and assumptions

United States once again in 11th place out of 11

Income-Related Inequalities in Affordability and Access to Primary Care in Eleven High-Income Countries

By Michelle M. Doty, Roosa Tikkanen, Molly FitzGerald, Katharine Fields, and Reginald D. Williams II
The Commonwealth Fund, December 9, 2020

The Issue

As COVID-19 continues to ravage the globe, the United States faces renewed scrutiny for the stark disparities in health and economic impacts experienced by people with lower incomes and by Black and Latino communities. In other countries, the crisis has highlighted the need for greater resiliency of national health systems to ensure access to care.

To compare the health experiences of adults with lower income during the pandemic and the effect of income-related disparities, the Commonwealth Fund surveyed adults across 11 high-income countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the U.S. The results of the survey, conducted during the early part of the pandemic between February and May 2020, were published in the December 2020 issue of Health Affairs (Abstract below).

What the Study Found

  • In nearly all countries, adults with lower income were significantly more likely than those with higher income to have multiple chronic health conditions. However, on nearly every measure the study used, income-related disparities were greatest in the U.S.:
    • More than one-third (36%) of U.S. adults with lower income have two or more chronic conditions — significantly more than in other countries.
    • Approximately one-third of adults with lower income in the U.S. (36%), Australia (36%), and Canada (34%) reported having anxiety or depression, the highest rates in the survey. Their counterparts in Germany (14%) and Switzerland (15%) were the least likely to report anxiety or depression.
    • More than one-quarter (28%) of U.S. adults with lower income said that, in the past year, they worried about being able to afford basic necessities such as food or housing, a significantly greater proportion than seen in other countries, where 6 percent to 22 percent reported this.
  • Half of U.S. adults with lower income don’t get needed care because it’s too costly. In the survey, 50 percent reported skipping doctor visits, recommended tests, treatments or follow-up care, or prescription medications in the past year because of the cost. In contrast, just 12 percent to 15 percent of adults with lower income in Germany, the U.K., Norway, and France reported doing the same.
  • Difficulty in paying medical bills is mostly a U.S. phenomenon, with 36 percent of U.S. adults with lower income reporting this problem, compared to 7 percent to 16 percent in the other countries.
  • In most countries, virtually all adults with lower incomes reported having a regular doctor or place of care. Rates in the U.S., Canada, and Sweden, meanwhile, ranged from 85 percent to 89 percent.
    • Same-day and next-day appointments: About four in 10 adults with lower income in the U.S., Canada, New Zealand, and Norway were able to get a same- or next-day appointment to see a doctor or nurse when they were sick. In contrast, 74 percent of those in Germany and 63 percent those in the Netherlands were able to get this care.
    • After-hours care: The Netherlands stands out, with only 35 percent reporting difficulty getting after-hours care without going to the emergency department (ED). In all other countries, between 43 percent and 64 percent of lower-income adults reported this problem (58% in the U.S.).
    • Emergency care: Forty-five percent of U.S. adults with lower income reported using the emergency department in the past two years to get care that could have been delivered by their regular doctor had it been available. That is a significantly higher rate than in Australia, France, Sweden, and the U.K.

The Big Picture

Achieving greater health equity in the U.S. will likely require policies that extend insurance coverage, make health care easier to afford, and strengthen primary care. The study authors also say that greater investments are needed to address the social determinants of health — factors beyond traditional health care, such as housing, education, and nutrition, that also affect people’s health. The U.S. in particular, they say, has much to gain from examining the experience of countries where universal health coverage ensures people have access to affordable health care.

The Bottom Line

Income-related health disparities exist in all high-income countries but are far worse in the United States. And they may be undermining U.S. efforts to respond to the pandemic, including prospects for effective vaccination of the U.S. population.

https://www.commonwealthfund.org…

Income-Related Inequality In Affordability And Access To Primary Care In Eleven High-Income Countries

By Michelle M. Doty, Roosa S. Tikkanen, Molly FitzGerald, Katharine Fields, and Reginald D. Williams
Health Affairs, December 9, 2020

Abstract

A high-performing health care system strives to achieve universal access, affordability, high-quality care, and equity, aiming to reduce inequality in outcomes and access. Using data from the 2020 Commonwealth Fund International Health Policy Survey, we report on health status, socioeconomic risk factors, affordability, and access to primary care among US adults compared with ten other high-income countries. We highlight health experiences among lower-income adults and compare income-related disparities between lower- and higher-income adults across countries. Results indicate that among adults with lower incomes, those in the US fare relatively worse on affordability and access to primary care than those in other countries, and income-related disparities across domains are relatively greater throughout. The presence of these disparities should strengthen the resolve to find solutions to eliminate income-related inequality in affordability and primary care access.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

The results of another in the series of studies by The Commonwealth Fund on the health care systems of eleven wealthy nations should surprise no one who has followed the prior studies. The United States is last again, this time in income-related inequality in affordability and access to primary care.

The Health Affairs study: “Results indicate that among adults with lower incomes, those in the US fare relatively worse on affordability and access to primary care than those in other countries, and income-related disparities across domains are relatively greater throughout.”

The Commonwealth Fund report (same authors): “Achieving greater health equity in the U.S. will likely require policies that extend insurance coverage, make health care easier to afford, and strengthen primary care. The study authors also say that greater investments are needed to address the social determinants of health — factors beyond traditional health care, such as housing, education, and nutrition, that also affect people’s health. The U.S. in particular, they say, has much to gain from examining the experience of countries where universal health coverage ensures people have access to affordable health care.”

When we are already spending more than enough to fix our health care system, far more than any other nation, how much longer are we going to stand in shame and embarrassment before other wealthy nations that obtain much better results with far less per capita spending than we have in the U.S.?

For starters, we should enact and implement single payer Medicare for All. That will take care of health care for everyone without costing us any more than we are already spending. Then tending to other socioeconomic needs should move us up to first place, or close to it.

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

Been there. PNHP’s Dr. Susan Rogers on racism in U.S. medicine.

By Brenda Gazzar
Code Wack Podcast, December 14, 2020

Featuring Dr. Susan Rogers, new president of Physicians for a National Health Program. Dr. Rogers is recently retired from Stroger Hospital of Cook County, Illinois, but continues as a volunteer attending hospitalist and internist there. She is an Assistant Professor of Medicine at Rush University, where she is an active member of the Committee of Admissions. She is a Fellow of the American College of Physicians and a member of the National Medical Association.

What was it like growing up Black in America during the Civil Rights struggles of the 1960’s? What was the experience of systemic racism faced by students of color – especially Black women – in medical school during that era? With host Brenda Gazzar, Dr. Susan Rogers, new president of Physicians for a National Health Program, describes the life experiences that helped shape her commitment to social justice and healthcare equity.

Transcript

(10-second Talk back music)

Welcome to Code WACK!, your podcast on America’s broken healthcare system and how Medicare for All could help. I’m your host, Brenda Gazzar. 

Dr. Susan Rogers is at the forefront of the fight for single-payer health care — and healthcare equity — in America. She’s the new president of Physicians for a National Health Program. She was a young Black student in Chicago during the Civil Rights Movement and the Vietnam War protests. Those historic events helped shape her into the physician and patient advocate that she is today.

(5-second stinger music)

Dr. Susan Rogers grew up in Chicago’s Hyde Park community in the 1950s and 60s. It was near the University of Chicago and one of the only truly integrated neighborhoods in the city back then.

Rogers: I grew up with white friends, Asian friends, everybody. You know, there weren’t that many Latinos in the area, but it was totally integrated. And even though I would hear about things in the news, that was normal for me to grow up with people like that and I’m still friends with many of those that I grew up with from different races and so my perspective of the world was a little bit different in the sense that this was my normal.

When she was in the 7th or 8th grade, her mother took her and her siblings downtown to march with Dr. Martin Luther King, Jr.  The civil rights icon had come to Chicago to fight neighborhood segregation. He found it to be just as segregated, she said, as the South.

(Backdrop of protests sounds)

Rogers: And so we went down to that march, and I was just amazed. It was you know, at this time, there were boycotts at the school. The superintendent of schools at that time did not want to integrate the schools. So even though our school was integrated, he put up what they called these mobile classrooms. So, even though there were schools that were overcrowded,  he didn’t want Black students to go elsewhere or white students to go. So he put these mobile classrooms in the parking lots of these schools so that he could maintain segregated education and his last name was Willis, Ben Willis, and we all called them the Willis Wagons.

Sen. Bernie Sanders was once arrested after protesting the installation of these classroom trailers as a University of Chicago student.

Rogers: My mother was very active in a lot of the social justice issues of the neighborhood. And so I grew up thinking, this is the norm. This is what you do.

Dr. Rogers went to Kenwood High School in Hyde Park, where her class of 1971 was also very politically active.

Rogers: We walked out against the gang problem. We walked out against the Vietnam War. So it was a socially active group, even at that time, in terms of being involved in civil unrest and against the police.

After high school, Dr. Rogers went to a small liberal arts college in Colorado, which she had heard about from a friend back home. But she wasn’t prepared for that experience.

Rogers: It was like going to a foreign country. I had never met white people who had never physically seen a Black person. There was so much wealth at that school. I mean their idea of a summer job was taking care of their neighbor’s horse.

The school’s Black students congregated at a home that became the center of their social life. But they didn’t feel welcomed at the school.

Rogers: And I remember at the time, my second year, we rallied to get Black faculty because there really wasn’t any Black faculty on the campus. And so who they came up with, was a tennis coach.

(Sound of tennis ball volleying)

That was how they were going to integrate the faculty. It was a reflection really of how this country was. It was very separate, there wasn’t much interaction.

It was interesting because there was a white guy there, who I had grown up with, he was the one who told me about the school. He was a year ahead of me. And we never really talked while we were there. The separateness, even though we both grew up in a very integrated neighborhood, we both became separate because that was the culture at the school.

Dr. Rogers was also the only Black biology major at the school. That left her feeling somewhat isolated.

Rogers: The whole idea that I even mentioned being a doctor was “are you sure you want…?” I mean, I wasn’t encouraged. It was different…I’m glad I left, because I don’t think I would have gone to medical school, if I had stayed there.

I did have support at home but at the time, I was very angry. The Black Panthers were very active. The whole Vietnam War and all the subtle racism there at the school, that you become angry, and you lose sight of what you should do or what’s the right thing to do because … this anger. And so that’s why I’m glad I left, because then I could focus on what it was that I  wanted to do and what was the right thing to do, the good thing to do, what I was able to do versus being, you know, consumed by this anger.

So after two years, Dr. Rogers left Colorado College and went to a historically Black college, Hampton Institute, in Virginia. She ultimately graduated from Roosevelt University in downtown Chicago in order to be at home with her ill mother. 

Dr. Rogers says she was fortunate that her father was a dentist and the family was well off at the time. That enabled her to have choices.

And I realized that a lot of people have no choices. And as I’ve gotten older and read more about the history of this country and how atrocious it is, and all of that, most people don’t have choices in their lives.

It’s like, if you look at what’s happening today. Look at essential workers. They don’t have a choice. What is their choice? They can either go to work and risk COVID, and bring it home, or they cannot go to work and risk being homeless and hungry. Those aren’t choices. You end up doing what you need to do to survive to the next day.

When she went to the University of Illinois Medical school in 1975, U.S. hospitals had been integrated for less than a decade. She said the older white attending physicians who were training her didn’t believe she should be there.

Rogers: They had grown up in this totally segregated healthcare community and it was a struggle to prove that you were smart enough to do that. And I look back at some of the evaluations and they were totally unfair, totally unfair.

Her first medical school rotation was OB GYN.

(Sound of baby crying) 

It was eight weeks on rotation, three weeks off and then they had to take a big board exam.

And I read and read and I knew that I knew what I was talking about. I learned so much. but my evaluation says, although I wasn’t smart, I worked hard, so he passed me. And I knew that that was totally wrong…I felt awful. I cried. I mean how could this be?  And I was not a student who struggled.

I went to the dean, and the dean took me up there, and it was an older white guy, who was known for his racism. He said, “well, if you don’t believe me, you can talk to the residents” and I wish I had called his bluff but even then, I don’t know if the residents would have supported me versus supporting him, you know.

I look at where I am now and the fact that I was personally able to see that that wasn’t fair and that I didn’t let it convince me that I shouldn’t be there. And it’s still a struggle today. I mean that hasn’t changed — just being professionals, you know. The sense of entitlement in this country, regardless of what anyone else has done. Why should I have to continue to prove myself?

Dr. Rogers trained at a county hospital in Chicago because that was close to her heart.

I went into medical school telling myself, “I’m going to medical school to take care of Black people.” That was my goal and that was why I trained at Cook County and that’s why I retired from Cook County.

I did leave and did some other things in public health institutions, with the (Department of Veteran’s Affairs)  with community health centers and all. So I still stayed taking care of that population but I ended up coming back to (Cook) County Hospital.

And I did what I wanted to do. I took care of the people who I wanted to take care of.

Next time on Code WACK!, we’ll hear about Dr. Susan Roger’s experience treating patients at Cook County Hospital — now Stroger Hospital of Cook County —  in Chicago.

Find more Code WACK! episodes on ProgressiveVoices.com and on the PV app. You can also subscribe to Code WACK! wherever you find your podcasts. This podcast is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country.

https://heal-ca.org…

If you chose your health plan, you may well have the wrong one

It’s Not Just You: Picking a Health Insurance Plan Is Really Hard

Most Americans make poor choices. So do most professional insurance brokers, a new study finds.

By Margot Sanger-Katz
The New York Times, December 11, 2020

When Paul Krugman, the Nobel-winning economist and a New York Times columnist, started a teaching job at the City University of New York, he had a choice between one union health plan at The Times and an array of university options, “which I found incomprehensible,” he said in an email.

“I asked H.R. at CUNY if they could explain the differences; they said no. So I went with The Times, precisely because it didn’t require that I make a choice!”

For most Americans, with or without a Ph.D in economics, right now is the time to pick your health insurance. Medicare beneficiaries can choose a Medicare Advantage plan or a Part D prescription drug plan. People with coverage at work can choose from the options their employers offer. People who buy their own insurance can make a choice on the Obamacare marketplace in their state.

The range of choice is generally heralded as a good thing: Not everyone wants the same plan, the thinking goes, so offering multiple options helps people shop for the one that is best for them. That logic drove the creation of Medicare Advantage, with legislation passed by Republicans, and drove the design of Obamacare, with legislation passed by Democrats.

But it turns out in real life most people are terrible at picking the health plan that is right for them. Health insurance is a complicated financial product, and study after study has shown that people routinely pick bad plans, even choosing options that leave them worse off financially in every possible scenario. And, because people are so bad at choosing good plans, the market often sends weird signals to insurance companies, encouraging them to offer more of the wrong plans instead of the right ones.

People struggle to make good choices when it comes to all kinds of financial products, but health insurance is especially confusing, with its mix of technical benefits and fees. Many Americans don’t understand terms like “deductible” or “coinsurance” very well. And few are good at predicting what sort of health care needs they will have in the coming year. Picking an ideal health plan requires combining all of these features — knowing what you might use, what it might cost you, and how those expenses combine with the plan’s monthly premium.

The people most likely to make bad choices appear to be those least able to afford it. A recent study in the Netherlands, which offers insurance to everyone through an Obamacare-like marketplace, found that only 5 percent of Dutch customers did a better job at choosing an ideal plan than they would have by choosing a plan at random.

But even highly educated Dutch professionals struggled. People who worked in the insurance industry and had advanced degrees made a good choice about 30 percent of the time. And only about 40 percent of trained statisticians — the group with the best performance — chose good plans for their needs.

In the United States, a working paper has found that many professionals who help people select health insurance are also bad at picking plans, performing substantially worse than a computer algorithm.

Brigitte Madrian, the dean of the Marriott School of Business at Brigham Young University, has also studied health insurance, but said picking a plan for her family when she arrived in Utah was a heavy lift. She set aside an entire Saturday for the task, scouring websites and constructing spreadsheets. Ultimately, she asked her fellow health economists what they had chosen.

“If I’m having a hard time, what is the rest of the population doing?” she said she wondered. “They must be throwing darts.”

Reader response:

By Don McCanne, M.D., San Juan Capistrano, CA

The traditional Medicare program gives patients almost unlimited choices in their health care professionals and hospitals which are the choices they really want, not choices of confusing health plans.

But deductibles, coinsurance and potential catastrophic losses in Medicare may be a problem for some. If we were to fold Medigap-type benefits into Medicare then it becomes the one size that really does fit all that we truly want – a comprehensive program that works for everyone (i.e., an improved Medicare for All). There would be no need to have to choose between plans that limit your choices to provider networks, with a high risk of turning out to have been the wrong plan choice, as Margot Sanger-Katz’s article shows us.

The administrative efficiency would save hundreds of billions of dollars which would be more than enough to pay for the improved benefits of Medicare for All.

By Charles Pack, Redbank

Why do we do this to people, especially old folks like me? Insurance should be pooling everyone into one pool and sharing the “risk”. Asking everyone to choose a plan (and pay for it) assigns the risk to each individual. This is wrong and unnecessary. Single payer systems like Medicare for All is the only way to go.

https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

Americans make poor choices when offered a variety of plans through their employer, through an insurance broker, through the ACA exchanges, through Medicare Advantage, through Medicare Part D, or whatever. If you want more proof then you might check the three reports available through the “study after study” links in the article by Margot Sanger-Katz. Or do your own Internet search.

Suppose the government took away your choice of these confusing plans that often provide unpleasant surprises when you need to use them, like your own doctor isn’t covered, or your community hospital isn’t covered, or the deductibles and the surprise bills are unaffordable, or the insurer refuses to authorize the care your doctor recommended, or, well, the list goes on. Not such great choices.

Suppose instead the government limited you to only one plan – one that covered you from conception to death, one that provided you the freedom to choose your health care professionals and institutions, one that provided all essential health care benefits, one that made health care affordable based on your ability to pay regardless of the extent of your health care needs, one that covered you wherever you happen to be, one that eliminated the expensive and burdensome administrative excesses generated by the private insurance industry, and one that could do this in an efficient system that included your family, friends, associates and everyone else in the country. Would you really object to the fact that this means that you would bow out of a system in which the odds are you would make a poor choice in selecting a health plan – a plan that didn’t serve you very well?

Many of the reader responses to the New York Times article expressed a sentiment like that of Charles Pack of Redbank (above). Single payer Medicare for All is the one choice that most people really want. Many have had it with private health plans; President Biden doesn’t need to guarantee us any more of that!

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

Medicare for All Explained Podcast: Episode 47

Interview with Dr. James G. Kahn

December 14, 2020

Public health expert Dr. James G. Kahn notes that “COVID-19 revealed a lot of vulnerabilities in our health care financing system. These are not new revelations, but [the pandemic] really exposed them in stark contrast.” He also reminds us that, while U.S. patients have suffered terribly, commercial health insurers have seen their profits double (or more).

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

https://medicareforallexplained.podbean.com