CMS.gov, October 15, 2020

Today, the Centers for Medicare & Medicaid Services (CMS), under the leadership of President Trump, announced action it has taken to advance an innovative package of state-led reforms that were crafted in response to the guidance and unprecedented flexibility offered by the Trump Administration.

Specifically, CMS announced the approval of Georgia’s new Medicaid section 1115 demonstration called “Pathways to Coverage.” The demonstration is designed to create a pathway for working-age Georgia adults who are ineligible for Medicaid to opt into Medicaid coverage by participating in qualifying activities like work and education, as well as meeting premium and income requirements.

Georgia’s Medicaid section 1115 demonstration “Pathways to Coverage” applies to individuals who are between the age of 19 through 64, with income up to and including 100 percent of the federal poverty level (FPL) and is effective today through September 30, 2025, with implementation beginning July 1, 2021. Those who already qualify for Medicaid today will not be directly affected, and it is estimated that over 30,000 individuals will receive Medicaid coverage during the first year of the demonstration and nearly 65,000 Georgians will enroll in Medicaid or receive Medicaid premium assistance for coverage through Employer Sponsored Insurance (ESI) over the five-year demonstration.

In order to qualify for this program, individuals must comply with specific requirements, including participating in 80 hours a month of work or other qualifying activities. Most individuals with income between 50 and 100 percent of the FPL will be required to make initial and ongoing monthly premium payments. Applicants and beneficiaries with disabilities requiring reasonable accommodation will have options available to complete and report their qualifying activities and hours. The state is providing support to those not already working to encourage and enable those beneficiaries to obtain employment and take part in other education and job-supporting activities.

Georgia is also pursuing complementary reforms of its individual health insurance market through a section 1332 State Relief and Empowerment Waiver, also referred to as a section 1332 waiver. This waiver is designed to put Georgia on a path to change the systemic issues with the state’s individual health insurance market—with the goal of reducing premiums, providing greater access and promoting a more competitive private insurance marketplace.

Under the Georgia Access Model, consumers will shop for and compare available plans through private sector partners, including web brokers, health insurance companies, and traditional agents and brokers.

https://www.cms.gov…

CMS details of “Georgia Pathways to Coverage” (51 pages):
https://www.medicaid.gov…

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Comment:

By Don McCanne, M.D.

CMS administrator Seema Verma worked with Vice President Mike Pence when he was governor of Indiana to attempt to convert their Medicaid program into a consumer-directed program with phony health savings accounts. She brought with her to CMS her ideology aimed at privatizing the government health programs.

Under a section 1115 waiver, she has granted Georgia changes that will allow qualified individuals with incomes between 50 and 100 percent of the federal poverty level to enroll in Medicaid providing they meet an 80 hour per month work/education requirement and “pay” a premium for their Medicaid coverage (a complicated process described in the 51 page CMS document – link above). Failure to meet the requirements can result in expulsion from the program.

They are also in the process of privatizing the ACA exchange function by allowing private insurance brokers to provide that function.

Seema Verma says, “I’m thrilled to support this comprehensive state-led reform that will help thousands of working adults in Georgia gain access to coverage for the first time in a way that addresses both their health and socio-economic needs.” “Socio-economic needs” means finding and holding jobs in a depressed economy that has caused many to lose their employment.

These people have incomes below the federal poverty level. How can Verma expect them to function on a socio-economic level comparable to individuals with average incomes?

We have tremendous problems – many of them being due to ever widening income and wealth inequality. These problems cry out for public solutions. In health care, the solution is easy – simply enact and implement a well designed, single payer model of an improved Medicare for All. Each person can meet their individual responsibility that Verma demands by paying their equitable share of progressive taxes that would fund the system (though solidarity-based responsibility is not what Verma has in mind).

In a couple of months there should be new management at HHS/CMS. Let’s just hope that they do not put in charge more neoliberals who would maintain a dominant role for the private insurers that keep shifting responsibility (risk) to patients. We can get this right if we all join together and work on it.

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By David M. Cutler
Health Affairs Blog, October 2, 2020

This post explores the possibility of saving money by reducing the administrative costs of health care.

Reducing administrative costs is attractive for several reasons. Administrative costs are high, perhaps a quarter of health spending, so reductions in administrative costs could yield a good deal of savings. Further, the goal of medical care is clinical care, so reducing administrative staff likely has a smaller effect on quantity and quality of care than would reductions in clinical staff. Finally, excess administrative hassles adversely affect peoples’ ability to receive care, so reducing administrative hassles could improve the timeliness of care received.

Employment data show the magnitude of administrative expense in health care. Clinical occupations account for two-thirds of health care employment; administrative occupations account for 22 percent; the remainder is a small amount of other occupations, including cooks and security guards. There are nearly four administrative workers for every physician and dentist. Even the 22 percent estimate is an understatement of the administrative burden, as physicians and nurses spend part of their time doing administrative work. The vast bulk of people employed in insurance companies are administrative workers.

Most of the administrative costs in health care are in billing and insurance related services (BIR). Every time a patient wants to see a provider, the patient’s insurance eligibility needs to be checked, the appropriate co-pay or co-insurance needs to be determined, and prior authorizations need to be adjudicated. After the visit, the service needs to be correctly coded, the coding must be reviewed by both the provider and the payer, and payment must be made. All this requires people. Other areas requiring significant administrative time include regulatory compliance and measuring and reporting quality metrics. In Medicare alone, there are over 2,000 quality metrics.

What Could Be Saved?

The natural question is how much could be saved by undertaking administrative restructuring. An exact answer is hard to determine, but some outlines can be estimated. Single-payer systems involve the least administrative expense, perhaps two-thirds below the US level. Many single-payer systems involve very little documentation. Of course, single payer involves many other tradeoffs that may not be appealing.

There seems to be a very good economic case for a significant and sustained campaign to reduce the administrative cost of US health care, and it is an especially fruitful and timely pursuit during the COVID-19 pandemic.

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Health Affairs Comment:

By Don McCanne, M.D.

“Of course, single payer involves many other tradeoffs that may not be appealing.”

Single payer trades the uninsured for universal coverage.

Single payer trades underinsurance through excessive cost sharing for elimination of financial barriers to care.

Single payer trades inequitable premiums and cost sharing for equitable progressive taxation that makes health care affordable for each of us.

Single payer trades inefficient, costly, excessive administration caused primarily by a fragmented financing system heavily dependent on private insurers for a highly efficient, single publicly-administered system.

Single payer trades market-based infrastructure expansion based on enhancing the medical-industrial complex (business model) for central planning of infrastructure expansion based on regional health care needs (patient service model).

Single payer trades unsustainable growth in global costs due to dependence on markets for single payer economic tools of cost containment that bend the cost curve to sustainable levels.

Where are the tradeoffs that are so unappealing that they largely offset these clear single payer advantages?

https://www.healthaffairs.org…

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Additional Comment:

By Don McCanne, M.D.

Many highly respected members of the academic health policy community, such as Harvard’s David Cutler, seem to acknowledge the efficiency of the single payer model of health care financing in that it would greatly reduce the profoundly wasteful administrative excesses uniquely characteristic of the U.S. health care financing system. But then the model is usually dismissed, often with unintentionally glib comments such as “single payer involves many other tradeoffs that may not be appealing.” The standard policy approach today is to reflexly dismiss single payer Medicare for All as soon as it is mentioned.

Cutler rightly explains that the “paper tiger” in health care needs to be tamed. But what are the tradeoffs that he seems to feel are so lacking in appeal that the single payer model can be dismissed outright? In my response to his Health Affairs article I list several tradeoffs, but they should be exceptionally appealing since they make the health care system work well for all of us as patients. I really can’t think of other tradeoffs that are so unappealing that they would even begin to offset the positive tradeoffs listed.

We need to work on the policy community to get them to reject the knee-jerk reaction of dismissing single payer Medicare for All at its mere mention. It is their rejection that we need to reject so that we can all have an honest dialogue on the clear advantages of Medicare for All.

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By Harris Meyer
Health Affairs Blog, October 13, 2020

Last month’s Rand Corporation report on the prices paid for inpatient and outpatient services to more than 3,000 US hospitals in 49 states is the latest salvo in an escalating battle to reduce health care spending through transparent pricing and greater market competition.

But stakeholders, including employers, workers, and state and federal policy makers, have a daunting task ahead to squeeze down hospital and physician prices, by far the highest in the world, in the face of fierce resistance to price transparency from both providers and insurers.

“The actors charging these prices are doing everything they can to keep prices secret,” said James Gelfand, senior vice president for health policy at the ERISA Industry Committee, which represents large self-insured employers. “That crazy, outrageous pricing persists because of the lack of information.”

Despite industry opposition, the secret-pricing system has to change, particularly if policy makers insist on preserving a market-based health care system rather than shifting to a government-run model with regulated prices such as Medicare for All or public-option health plans. The continued failure of the market model to hold down costs gives ammunition to Joe Biden and the Democrats, if they win the November elections, to establish a price regulation system.

A Legislative Approach

Ultimately, Congress has to get involved to make transparency happen because more than 100 million non-elderly Americans are covered by health plans that can only be regulated by the federal government. Lawmakers should backstop the Trump administration’s court-endangered transparency rules by passing legislation requiring hospitals and health plans to publish their negotiated prices.

Legislation also should limit providers’ monopoly pricing power by capping hospitals’ and physicians’ out-of-network charges at a reasonable percentage of Medicare rates, perhaps 125 percent. That would weaken providers’ negotiating trump card of threatening to stay out of an insurer’s network.

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Health Affairs Comment:

By Don McCanne, M.D.

The emphasis on price transparency stems from the belief that the health care consumer can control spending through price shopping. It’s as if we’ve forgotten Kenneth Arrow’s classic lesson on how markets do not work in health care. Price shopping is effective only for marginal services and can have very little impact on our total national health expenditures.

Our health care financing system should be designed to assist patients in obtaining the care that they need. Yet our insurance innovations erect financial barriers to care through high deductibles and other cost sharing and by preventing coverage of out-of-network providers. Even the Trump administration’s expansion of short term plans exposes patients with health care needs to higher costs because of a reduction in covered benefits. And health savings accounts are strictly a tax gimmick for higher income individuals and not a ticket to health care.

Having medical problems is a burden enough without the additional burden of assessing greater financial penalties for accessing health care (out-of-pocket cost sharing and payment for services not covered).

Other wealthy nations cover nearly everyone at an average per capita cost of about half of what we spend while we leave tens of millions with inadequate health coverage and tens of millions more with no coverage at all. We already have more consumer-directed health care than most other nations, and our very high spending is proof that it is a flawed concept.

Rather than relying on patient-consumer shopping we should rely on government administered pricing since that has been effective in many other nations. Through a single payer, improved Medicare for All that uses negotiated prices, bulk purchasing, global budgets for institutions such as hospitals, separate budgeting of capital improvements based on need, and a dramatic reduction in wasteful administrative services, we can control excess spending while ensuring adequate capacity in the system. Everyone is included in an equitably financed system that is affordable for each of us. Price transparency can’t do that, not even close.

Wasting time and more excessive administrative services on price transparency will only further delay the comprehensive reform that we desperately need.

https://www.healthaffairs.org…

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Additional Comment:

By Don McCanne, M.D.

In advocating for using price transparency to enable price shopping in the marketplace, the author also recommends “capping hospitals’ and physicians’ out-of-network charges at a reasonable percentage of Medicare rates, perhaps 125 percent.” This is an obvious concession that Medicare has been far more effective in controlling prices than has the marketplace. Further, why should we limit government price controls to the current Medicare program plus health care spending outside of private insurer provider networks? Why shouldn’t we all receive the benefit of government administered pricing?

Price increases have been far greater under the private insurers than they have through Medicare. Some of that has been due to excessive administrative waste of the insurers themselves and from the costly administrative burden they place on the health care delivery system. Much of that administrative waste could be recovered by using single payer economic tools as listed in my comment posted to the Health Affairs article above.

For those who have Medicare, when you review your explanation of benefits, were you aware of the listed prices before you received the services, or were you aware of the amount of the allowed charges and the adjustments for which neither you nor the government would be responsible? Of course not. Price transparency plays no role in determining Medicare payments. Government administered pricing is far more effective than price transparency in the health care marketplace could ever be.

We do need to improve Medicare so that we can get pricing right. Payments need to be adequate to cover legitimate expenses of the health care delivery system plus provide a fair margin for those delivering health care (profit, salary, or whatever is appropriate for the financial structure under which the health care services are being provided). Yet judicious use of our public funds would also require that price gouging be prevented. Other countries do that well. We can too.

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By Robert King
Fierce Healthcare, October 13, 2020

Seema Verma, the head of the Centers for Medicare & Medicaid Services (CMS), said that some value-based care payment models did not generate enough savings and quality outcomes.

Her remarks Tuesday during HLTH’s virtual conference come a few weeks after other Trump administration officials reported mixed results for bundled payment models in producing savings. Verma did tout models that required providers to take on financial risk at a faster pace, potentially alluding to the direction CMS wants to steer value-based care models.

“I think the issue we have in value-based care is that many of our models unfortunately are not working the way we would like them to,” she said. “They are not producing the types of savings the taxpayers deserve.”

It has been a “very poor return in investment,” Verma added.

Verma also gave praise to CMS’ Pathways to Success model that overhauled the program managing accountable care organizations (ACOs).

Pathways required ACOs to take on financial risk at a shorter period than the Medicare Shared Savings Program created under the Obama administration. This meant that ACOs had to pay back Medicare if it did not meet certain savings targets.

“We are already seeing significant savings and increases in quality,” Verma said of Pathways, which started in 2019.

Verma said that CMS isn’t shying away from value-based care, but she hinted at what direction the next wave of payment models could entail.

“I think it is important for providers to have skin in the game,” she said. “Just having upside risk doesn’t really produce the type of savings and quality measures that we want to see.”

https://www.fiercehealthcare.com…

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Comment:

By Don McCanne, M.D.

The policy community still seems to be fixated on the rhetoric of paying for value instead of volume, as they continue to support value-based models such as ACOs. CMS administrator Seema Verma now concedes that value-based models have provided a “very poor return in investment.”

Verma, who is driven more by ideology than by health policy that is designed to serve patients first, is not exactly giving up on value-based care, but rather she is focusing on a model design “for providers to have skin in the game.” She wants value-based models that are designed for providers “to take on financial risk at a faster pace.” Instead of emphasizing upside risk that rewards providers with Medicare dollars, she is now emphasizing downside risk that penalizes providers who then have to return money to Medicare.

Verma has long supported consumer-driven health care that requires patients to assume greater risk when accessing health care, but now she also wants to transfer even more risk from the government to the providers of health care. Forget patient care; it really is about the money.

Lack of affordability is one of the greatest problems in health care today. Making health care even less affordable by transferring more risk to the patient, such as with increased deductibles and not paying for out-of-network providers, is the opposite of the direction in which we should be headed. Government programs are noted for their parsimonious payment policies, often paying less than costs of care, and thus shifting more risk to the providers can threaten especially the safety-net system – again, the wrong direction on policy.

Many decades ago Nobel laureate Kenneth Arrow explained why markets do not work in health care, and yet the wish-they-would-work ideologues keep pushing their concepts on us. Our insistence on using markets in health care, such as our heavy reliance on private health plans, has resulted in the most expensive health care system yet one of the poorest performing when considering the tens of millions with inadequate insurance or no insurance at all. Our very high spending with poor performance is proof that, in health care, the markets are not bringing us high quality at low cost.

If we had a single payer Medicare for All system, we wouldn’t have to rely on the marketplace to manage costs since the government would use patient-friendly and provider-friendly administered pricing. Those who still contend that the government can’t do it right have to recognize that all other wealthy nations are providing health care for essentially everyone at an average per capita cost of half of what we spend.

More “skin in the game” punishes those who already are suffering the burden of having medical disorders. Our health care financing system should be designed to help relive those burdens, not cause more.

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Centers for Medicare and Medicaid Services, October 9, 2020

Introduction

This report provides data on enrollment trends for people who purchased on- and off-Exchange individual market health insurance plans, both with and without federal advanced premium tax credit (APTC) subsidies. These data are based on an analysis of individual market plans that participated in the risk adjustment program established under section 1343 of the Patient Protection and Affordable Care Act (PPACA) and Health Insurance Exchange effectuated enrollment data. The data provided in this report include state-specific, average monthly enrollment covering plan years 2014 to 2019. Over that period, average monthly enrollment in the individual market—including both subsidized and unsubsidized enrollment—peaked in 2016, reaching 14.5 million. Enrollment then declined by 10 percent in 2017, 7 percent in 2018, and 3 percent in 2019. Enrollment among the unsubsidized, who do not receive APTC subsidies, saw a considerable decline of 9 percent from 2018 to 2019, compared to a decrease of 1 percent in APTC subsidized enrollment. From its peak in 2016, unsubsidized enrollment declined by 2.8 million people by 2019, a 45 percent drop nationwide. From 2016 to 2019, unsubsidized enrollment declined by more than 70 percent in Arizona, Georgia, Iowa, Missouri, Nebraska, New Hampshire, Oklahoma, Tennessee, and West Virginia.

Key Findings

This report provides data on individual health insurance market enrollment trends for people who purchase health insurance with (subsidized) and without (unsubsidized) advanced premium tax credits (APTC).

• From plan years 2016 to 2019, unsubsidized enrollment declined by 2.8 million people, representing a 45 percent drop nationally. At the state level, the percentage change in unsubsidized enrollment over this period ranged from a 4 percent drop in Rhode Island to a 90 percent drop in Iowa.
• The most recent year of enrollment data shows that average monthly enrollment across the individual market nationally decreased by 3 percent between 2018 and 2019.
• Eighty percent of the decrease in enrollment between 2018 and 2019 occurred among people who did not receive APTC subsidies. Unsubsidized enrollment declined by 9 percent, compared to only a 1 percent decrease in subsidized enrollment, from 2018 to 2019.
• Though unsubsidized enrollment continued to decline in 2019, the rate of decline was substantially lower than the 24 percent drop in 2018 and the 20 percent drop in 2017. This lower rate of decline occurred as premium rates leveled off in 2019, after increasing by double-digits in 2017 and 2018.
• Looking at state-level enrollment trends between 2016 and 2019 also shows the link between enrollment and premium trends. States with larger declines in unsubsidized enrollment tended to experience a larger increase in average premiums.
• Review of state-level data also shows that trends in declining enrollment began from 2015 to 2016 for 10 states. Declining enrollment occurred in 44 states from 2016 to 2017, 43 states from 2017 to 2018, and 39 states from 2018 to 2019.
• Average monthly enrollment in the subsidized portion of the market grew substantially in comparison to the unsubsidized market. The subsidized portion of the market was 140 percent larger than the unsubsidized portion in 2019, up from 122 percent larger in 2018 and 61 percent in 2017.

https://www.cms.gov…

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Comment:

By Don McCanne, M.D.

To no surprise, as premiums increased in the plans offered through the ACA exchanges, the enrollment by individuals who received no subsidies (advanced premium tax credits) declined by 45%. They found the premiums to be simply unaffordable.

In contrast, the percentage of enrollees who received subsidies increased dramatically (though the actual numbers enrolled didn’t increase much – see Figure 3 at link above). In 2015, the subsidized enrollment was 24% larger than the unsubsidized enrollment, whereas, by 2019, the subsidized enrollment had grown to 140% larger.

When it was decided to reject a universal public insurance program and instead enact an exchange (market) of private insurance plans to help fill the void in coverage, the authors of the legislation rejected the efficiency and effectiveness that had already been demonstrated in our Medicare program and instead relied on the fragmented and highly dysfunctional private insurance model – a model that has not served us well.

It is understandable why people would accept private insurance when the government is providing generous subsidies for its purchase. Likewise, it is also certainly understandable why the private plans would be rejected when the enrollees were required to pay the full unaffordable premiums. Why would they want to pay hard-earned money for a private plan that had unaffordable deductibles, limited provider networks, and wasteful, costly administrative excesses? A more pertinent question is why would Congress insist on offering such a defective model of health care financing when we could have an efficient, equitable, affordable, single payer Medicare for All program that includes everyone?

The near future looks grim. Both presidential candidates have rejected the single payer model, and the likely victor has suggested more of the same, with perhaps an increase in subsidies and the addition of a private-style option which has been mislabeled as Medicare.

Our clearly dysfunctional system is working poorly for too many of us and not at all for far too many more. Why would we simply want to throw more subsidies at it when all of us could have a far better deal through a single payer program of Medicare for All?

Joe Biden keeps saying to us, “Here’s the deal.”

It’s time for us to say, “No! Here’s the deal we demand.”

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By Joan Alker, Alexandra Corcoran
Georgetown University, Health Policy Institute, Center for Children and Families, October 8, 2020

Introduction

For many years, the United States was on a positive trajectory in reducing the number and rate of uninsured children; in 2016, the nation attained a historic low of 3.6 million uninsured children. This progress occurred as a result of expansions of public coverage—primarily Medicaid and the Children’s Health Insurance Program (CHIP)—and was accelerated by the implementation of the Affordable Care Act’s (ACA) major coverage expansions in 2014. As employer-sponsored insurance became increasingly unaffordable for dependents, public coverage ameliorated the impacts of private coverage losses for children. However, the number of uninsured children began to increase in 2017 as Medicaid enrollment began to decline and reached 4.4 million in 2019. This represents an increase of 726,000 children during this three-year period. The rate of uninsured children rose a full percentage point from 4.7 percent to 5.7 percent. Much of the gain in coverage that children made as a consequence of the ACA’s major coverage expansions has now been eliminated. Moreover, the most recent year of data (2018 to 2019) shows the biggest one-year loss in children’s coverage during this time period, with 320,000 more children becoming uninsured. These coverage losses occurred in a healthy economy with the lowest unemployment rate in decades prior to the economic shocks and job loss associated with the COVID-19 pandemic.

Key Findings

• After reaching a historic low of 4.7 percent in 2016, the child uninsured rate began to increase in 2017, and as of 2019 jumped back up to 5.7 percent. This increase of a full percentage point translates to approximately 726,000 more children without health insurance since the beginning of the Trump Administration when the number of uninsured children began to rise. Much of the gain in coverage that children made as a consequence of the Affordable Care Act’s major coverage expansions implemented in 2014 has now been eliminated.
• The number of uninsured children increased every year during the Trump Administration. The largest increase was observed between 2018 and 2019 when, despite a continued strong economy, the number of children without health insurance rose by 320,000. This increase in the number of uninsured children was the largest annual jump seen in more than a decade. Moreover, since this data was collected prior to the pandemic, the number of uninsured children is likely considerably higher in 2020, as families have lost their jobs and employer-sponsored insurance, though it is impossible to know yet by precisely how much.
• One-third of the total increase in the number of uninsured children from 2016 to 2019 live in Texas. The state saw by far the greatest coverage loss over the period with an estimated 243,000 more children living without health coverage. Florida has the next biggest loss, adding about 55,000 children to the uninsured count over the three-year period. As a consequence, 41 percent of children’s coverage losses during the Trump Administration occurred in Texas and Florida. Twenty-nine states experienced an adverse change for children from 2016 to 2019. The only state that bucked national trends and significantly reduced its number of uninsured children during this three-year time period was New York.
• These coverage losses were widespread across income, age, and race/ethnicity, but were largest among White and especially Latino children (who can be of any race).

https://ccf.georgetown.edu…

Full report:
https://ccf.georgetown.edu…

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Comment:

By Don McCanne, M.D.

There is a special place for children in the hearts of Americans. For the last half century an extra effort has been made to provide health care coverage for children, especially through the Medicaid and CHIP programs, but also through private plans through the ACA exchanges and employer-sponsored plans that also cover dependents.

However, the reluctance to support a universal national health program inevitably left many children without coverage. American style of health care reform – incremental patches – did have some effect in reducing but not eliminating the number of children uninsured, but this has changed during the last three years – not coincidentally the years of the Trump administration. An additional 726,000 children are now without health insurance (totaling 4.4 million in 2019), and that does not include more recent losses in coverage due to job loss during the Covid pandemic, due to the threat of the public charge rule against immigrants who are here legally, and due to increased administrative barriers to enrollment in the public programs. Apparently not all Americans hold in esteem children who represent the future of our nation. But it really is disconcerting to see some of our public stewards struggle to take health care away from children.

Think again about a single payer system of improved Medicare for All… health care… for everyone… for life… health care that is affordable for each of us. Imagine an America where each year we wouldn’t find ourselves compelled to count up the number of children uninsured due to the failure of our politicians to ensure health care for everyone who needs it. Yes, the uninsured children… think of them and what that represents, and then extrapolate that to the rest of us.

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The vaccine partnership would help ensure equitable access to a COVID-19 vaccine—including in the United States—but Trump won’t participate.

By Eric A. Friedman, Lawrence O. Gostin, Matthew M. Kavanaugh, John T. Monahan, Harold Hongju Koh
Foreign Policy, September 15, 2020

In one of its latest strikes against global solidarity in the midst of the COVID-19 pandemic, the administration of U.S. President Donald Trump has declared that it will not participate in the COVID-19 Vaccine Global Access (COVAX) Facility, a global partnership that aims to support the development of a vaccine and share access to it. Trump apparently prefers, instead, a go-it-alone approach that could undermine Americans’ access to an eventual vaccine and disrupt efforts to ensure equity in its global distribution.

This move is one of a string of administration actions that have undermined the now distant-seeming tradition of U.S. global health leadership. The same week as its COVAX announcement, the Trump administration also said that it would withhold $62 million that the United States owes to the World Health Organization (WHO) for its annual dues. The administration plans to redirect the funding to other United Nations health programs. Congress had already appropriated the WHO funding, making Trump’s move the latest among his strikes against the rule of law; he has no authority to redirect funds that Congress has already allocated.

The administration’s effort to undermine WHO reached a climax in July when the United States began the yearlong process of withdrawing from the organization.

The administration has virtually invented “vaccine nationalism,” making exclusive deals with several vaccine manufacturers to ensure a supply of their vaccines for Americans, the consequences for the rest of the world being of no concern.

And now, as the world anxiously awaits a safe and effective vaccine for COVID-19, the administration announced that it will not participate in COVAX. The decision stands to undermine the most consequential area of global cooperation around COVID-19, a crisis otherwise marked by a stunning lack of global solidarity. And by denying Americans the benefits that all countries participating in COVAX will receive, the decision poses a direct health and economic threat to Americans.

The U.S. is shunning COVAX because of its link to the WHO, which the administration wrongheadedly views as being controlled by China. The vast majority of countries, 172, have joined COVAX, which is co-led by WHO, the Coalition for Epidemic Preparedness Innovations (CEPI), and Gavi, the Vaccine Alliance.

https://foreignpolicy.com…

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Foreign Ministry Spokesperson Hua Chunying’s Remarks on China Joining COVAX

Ministry of Foreign Affairs, the People’s Republic of China, October 9, 2020

On October 8, China and Gavi, the Vaccine Alliance, signed an agreement, officially joining COVAX. This is an important step China has taken to uphold the concept of a shared community of health for all and to honor its commitment to turn COVID-19 vaccines into a global public good.

Currently, the COVID-19 pandemic still poses a severe threat to the safety and health of people in all countries. China continues to focus on ensuring that developing countries have equal access to appropriate, safe and effective vaccines. To that end, we have solemnly pledged to make vaccines developed and deployed by China a global public good, which will be provided to developing countries as a priority. Therefore, China has maintained close communication with COVAX with a positive attitude towards joining it. Even when China is leading the world with several vaccines in advanced stages of R&D and with ample production capacity, it still decided to join COVAX. We are taking this concrete step to ensure equitable distribution of vaccines, especially to developing countries, and hope more capable countries will also join and support COVAX. China will also strengthen vaccine cooperation with relevant countries through the COVAX network.

China will continue to work together with COVAX partners and contribute its share to the global fight against the pandemic to safeguard all human beings’ safety and health.

https://www.fmprc.gov.cn…

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Johns Hopkins, Coronavirus Resource Center

Accessed October 9, 2020

United States

• 7,605,873 Confirmed cases
• 212,762 Deaths
• 2.8% Case-Fatality
• 65.03 Deaths/100K Pop.

China

• 90,728 Confirmed cases
• 4,739 Deaths
• 5.2% Case-Fatality
• 0.34 Deaths/100K Pop.

https://coronavirus.jhu.edu…

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Comment:

By Don McCanne, M.D.

Today’s Quote of the Day resources are really troubling. President Trump has repeatedly condemned China for the problems that we have with the Covid-19 pandemic. Yet the United States has far more cases and deaths from the coronavirus than does China. We have almost 200 times the number of deaths per 100,000 population than does China.

This tragic pandemic cries out for world cooperation in bringing it under control and in preventing similar pandemics in the future. The World Health Organization, with the cooperation of other agencies, has brought 172 nations together in COVAX – a global partnership that aims to support the development of a vaccine and share access to it. Yet President Trump has refused to allow the United States to participate, partly because he “wrongheadedly” views WHO as being controlled by China. According to Foreign Policy, “Trump apparently prefers, instead, a go-it-alone approach that could undermine Americans’ access to an eventual vaccine and disrupt efforts to ensure equity in its global distribution.” Considering the Trump administration’s attitudes on trade, it is not unreasonable to suspect that he would like to capture the international market for Covid vaccine and knock China out of the competition.

Contrast that with the release from China’s Ministry of Foreign Affairs. “China will continue to work together with COVAX partners and contribute its share to the global fight against the pandemic to safeguard all human beings’ safety and health.” In taking this step, they express their desire “to uphold the concept of a shared community of health for all and to honor its commitment to turn COVID-19 vaccines into a global public good.”

Do we no longer believe in a shared community committed to a global public good? As I said, today’s message is really troubling.

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By The Editors
The New England Journal of Medicine, October 8, 2020

Covid-19 has created a crisis throughout the world. This crisis has produced a test of leadership. With no good options to combat a novel pathogen, countries were forced to make hard choices about how to respond. Here in the United States, our leaders have failed that test. They have taken a crisis and turned it into a tragedy.

The magnitude of this failure is astonishing. According to the Johns Hopkins Center for Systems Science and Engineering, the United States leads the world in Covid-19 cases and in deaths due to the disease, far exceeding the numbers in much larger countries, such as China. The death rate in this country is more than double that of Canada, exceeds that of Japan, a country with a vulnerable and elderly population, by a factor of almost 50, and even dwarfs the rates in lower-middle-income countries, such as Vietnam, by a factor of almost 2000. Covid-19 is an overwhelming challenge, and many factors contribute to its severity. But the one we can control is how we behave. And in the United States we have consistently behaved poorly.

We know that we could have done better. China, faced with the first outbreak, chose strict quarantine and isolation after an initial delay. These measures were severe but effective, essentially eliminating transmission at the point where the outbreak began and reducing the death rate to a reported 3 per million, as compared with more than 500 per million in the United States. Countries that had far more exchange with China, such as Singapore and South Korea, began intensive testing early, along with aggressive contact tracing and appropriate isolation, and have had relatively small outbreaks. And New Zealand has used these same measures, together with its geographic advantages, to come close to eliminating the disease, something that has allowed that country to limit the time of closure and to largely reopen society to a prepandemic level. In general, not only have many democracies done better than the United States, but they have also outperformed us by orders of magnitude.

Why has the United States handled this pandemic so badly? We have failed at almost every step. We had ample warning, but when the disease first arrived, we were incapable of testing effectively and couldn’t provide even the most basic personal protective equipment to health care workers and the general public. And we continue to be way behind the curve in testing. While the absolute numbers of tests have increased substantially, the more useful metric is the number of tests performed per infected person, a rate that puts us far down the international list, below such places as Kazakhstan, Zimbabwe, and Ethiopia, countries that cannot boast the biomedical infrastructure or the manufacturing capacity that we have. Moreover, a lack of emphasis on developing capacity has meant that U.S. test results are often long delayed, rendering the results useless for disease control.

Although we tend to focus on technology, most of the interventions that have large effects are not complicated. The United States instituted quarantine and isolation measures late and inconsistently, often without any effort to enforce them, after the disease had spread substantially in many communities. Our rules on social distancing have in many places been lackadaisical at best, with loosening of restrictions long before adequate disease control had been achieved. And in much of the country, people simply don’t wear masks, largely because our leaders have stated outright that masks are political tools rather than effective infection control measures. The government has appropriately invested heavily in vaccine development, but its rhetoric has politicized the development process and led to growing public distrust.

The United States came into this crisis with enormous advantages. Along with tremendous manufacturing capacity, we have a biomedical research system that is the envy of the world. We have enormous expertise in public health, health policy, and basic biology and have consistently been able to turn that expertise into new therapies and preventive measures. And much of that national expertise resides in government institutions. Yet our leaders have largely chosen to ignore and even denigrate experts.

The response of our nation’s leaders has been consistently inadequate. The federal government has largely abandoned disease control to the states. Governors have varied in their responses, not so much by party as by competence. But whatever their competence, governors do not have the tools that Washington controls. Instead of using those tools, the federal government has undermined them. The Centers for Disease Control and Prevention, which was the world’s leading disease response organization, has been eviscerated and has suffered dramatic testing and policy failures. The National Institutes of Health have played a key role in vaccine development but have been excluded from much crucial government decision making. And the Food and Drug Administration has been shamefully politicized, appearing to respond to pressure from the administration rather than scientific evidence. Our current leaders have undercut trust in science and in government, causing damage that will certainly outlast them. Instead of relying on expertise, the administration has turned to uninformed “opinion leaders” and charlatans who obscure the truth and facilitate the promulgation of outright lies.

Let’s be clear about the cost of not taking even simple measures. An outbreak that has disproportionately affected communities of color has exacerbated the tensions associated with inequality. Many of our children are missing school at critical times in their social and intellectual development. The hard work of health care professionals, who have put their lives on the line, has not been used wisely. Our current leadership takes pride in the economy, but while most of the world has opened up to some extent, the United States still suffers from disease rates that have prevented many businesses from reopening, with a resultant loss of hundreds of billions of dollars and millions of jobs. And more than 200,000 Americans have died. Some deaths from Covid-19 were unavoidable. But, although it is impossible to project the precise number of additional American lives lost because of weak and inappropriate government policies, it is at least in the tens of thousands in a pandemic that has already killed more Americans than any conflict since World War II.

Anyone else who recklessly squandered lives and money in this way would be suffering legal consequences. Our leaders have largely claimed immunity for their actions. But this election gives us the power to render judgment. Reasonable people will certainly disagree about the many political positions taken by candidates. But truth is neither liberal nor conservative. When it comes to the response to the largest public health crisis of our time, our current political leaders have demonstrated that they are dangerously incompetent. We should not abet them and enable the deaths of thousands more Americans by allowing them to keep their jobs.

https://www.nejm.org…

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Comment:

By Don McCanne, M.D.

This great tragedy resulting in loss of life, physical suffering from illness, loss of employment, financial hardship from damage to our economy, and day in and day out angst for all of us could have and should have been partially or largely ameliorated had our government been competent and attentive. It was not. This was a massive political failure. The blame lies heavily with the president and his administration, but also with the legislators – especially those controlling the Senate – and their inadequate response, and ultimately much of the blame lies with the voters who elected and continue to support a political hierarchy that has failed us so miserably.

This incompetence is not new. For many decades we have tolerated an expensive health care system that has left tens of millions of us without any health care coverage, and tens of millions more with inadequate coverage that leaves them having to cope with financial barriers to care. We have allowed hundreds of billions of health care dollars to be redirected to extremely wasteful administrative excesses, benefiting passive investors at the cost of impaired patient access to care. This too is a political failure.

The policy science is straightforward. We know how to design a system that would provide essential health care services for absolutely everyone at a cost that each of us could afford – single payer, improved Medicare for All. The policy is easy, but we have to get the politics right. The Covid-19 pandemic and the political response to it should give us all of the lessons we need. Let’s apply them now.

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Congress of the United States, Congressional Budget Office, October 2020

In this report, CBO describes the key features—specifically, the enrollment process, premiums, cost sharing and benefits, and the role of private insurance, public programs, and employment-based insurance—of four general approaches that could achieve near-universal coverage by using premium subsidies and different forms of automatic coverage through a default plan. Those approaches are as follows:

• Approach 1. A multipayer system that retains existing sources of coverage while expanding eligibility for premium subsidies and providing partially subsidized default coverage through a private plan or a new public option.
• Approach 2. A multipayer system that retains employment-based coverage and replaces the current nongroup market and the acute care portions of Medicaid and the Children’s Health Insurance Program (CHIP) with a new public program that allows people to choose between partially subsidized private plans and a publicly administered plan that provides default coverage.
• Approach 3. A multipayer system that provides full subsidies for all people to purchase a private plan of their choice, with a default plan that provides automatic coverage to people who do not enroll in a plan on their own.
• Approach 4. A single-payer system that acts as a default plan for all people.

(For the first three approaches, see the full report at the link below.)

Approach 4: A Single-Payer System

Under a single-payer system, everyone in the defined population would receive health insurance coverage from the same public plan, and there generally would be no role for private insurance. There would be no premiums, and to achieve deficit neutrality, such a system would need to be financed through broad-based tax revenues; that is, new mechanisms of financing also would be required. This approach would involve the most significant departure from the current health care system, and it would be an enormously complex undertaking. Under current law, people receive coverage through various public and private sources, as described earlier in this report. Under a single-payer system, there generally would be no role for employment-based insurance, and the role of other public programs, such as Medicaid and Medicare, would be greatly reduced or eliminated.

Enrollment Process. Under a single-payer system, the government would strive to enroll all people in the defined population in the public plan. People also could be automatically enrolled at the time they were issued Social Security numbers, newborns could be enrolled in hospitals, and other eligible people could be enrolled at the time they sought medical care. Some people seeking medical care would not be eligible for enrollment—because they were visiting from another country, for instance—and the enrollment system would need to confirm that they were not eligible. Because people would need to provide information to the enrollment system and some would not do so, coverage would not be completely universal.

Premiums. There would be no premiums under a single-payer system. To achieve deficit neutrality, such a system would need to be financed through broad-based tax revenues.

Cost Sharing and Benefits. A single-payer system would have lower cost sharing than the average under current law. Such a system could include no cost sharing for most services. If the single-payer system included cost sharing, there could be exceptions for certain populations, such as people with low income, children, and the disabled.

The single-payer system would provide comprehensive major medical coverage, but certain items and services, such as over-the-counter medications and cosmetic procedures, could be excluded from coverage. Existing proposals cover a more comprehensive set of benefits than many current sources of coverage, including dental, vision, hearing, and long-term services and supports, but a single-payer system could be designed without those additional benefits.

Role of Private Plans. There generally would be no role, or a very limited role, for private insurance. If private insurance was allowed, it could be limited to services not covered by the public plan. However, private insurance also could be offered as an alternative source of coverage if enrollees and providers were allowed to opt out of the single-payer system. Alternatively, private insurance could provide benefit enhancements, such as faster access to care or private rooms instead of semiprivate rooms for inpatient stays, or it could be used to access providers that opt out of the single-payer system or to seek care abroad.

Role of Employment-Based Insurance. Employment-based insurance probably would no longer exist under a single-payer health system, or its role would be greatly reduced. For instance, it might provide supplemental coverage for services not covered by the public plan or reduce cost-sharing amounts, if any.

Role of Public Programs. Most public programs, such as Medicaid, CHIP, and Medicare probably would have a limited role or be eliminated under a single-payer system. Some components of those programs could continue to operate separately and provide benefits for services not covered by the single-payer health plan. For example, Medicaid and CHIP could continue to provide long-term services and support benefits only to low-income populations, but the Medicare program would no longer exist.

Examples of This Approach. The two versions of the Medicare for All Act of 2019 include many of the features described in this approach, including no premiums, comprehensive major medical coverage, limited to no cost sharing, and no private insurance that would duplicate the benefits of the single-payer system. (See the Medicare for All Act of 2019, H.R. 1384 and S. 1129, 116th Cong.)

https://www.cbo.gov…

Yarmuth letter requesting CBO study:
https://budget.house.gov…

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Hall v. Sebelius

Opinion written by Circuit Judge Brett Kavanaugh
667 F.3d 1293 (D.C.Cir.2012), No. 11–5076, February 7, 2012

This is not your typical lawsuit against the Government. Plaintiffs here have sued because they don’t want government benefits. They seek to disclaim their legal entitlement to Medicare Part A benefits for hospitalization costs. Plaintiffs want to disclaim their legal entitlement to Medicare Part A benefits because their private insurers limit coverage for patients who are entitled to Medicare Part A benefits. And plaintiffs would prefer to receive coverage from their private insurers rather than from the Government.

Plaintiffs’ lawsuit faces an insurmountable problem: Citizens who receive Social Security benefits and are 65 or older are automatically entitled under federal law to Medicare Part A benefits. To be sure, no one has to take the Medicare Part A benefits. But the benefits are available if you want them. There is no statutory avenue for those who are 65 or older and receiving Social Security benefits to disclaim their legal entitlement to Medicare Part A benefits. For that reason, the District Court granted summary judgment for the Government. We understand plaintiffs’ frustration with their insurance situation and appreciate their desire for better private insurance coverage. But based on the law, we affirm the judgment of the District Court.

https://casetext.com…

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Comment:

By Don McCanne, M.D.

House Budget Committee Chairman John Yarmuth and colleagues requested this CBO study on different policy approaches for achieving universal coverage, including “how each approach could provide coverage to individuals who do not otherwise actively enroll in private or public health coverage.”

Of the four approaches in the report, the first three are not discussed here for the following reasons: 1) Although they would expand coverage, none of them reach truly universal coverage, 2) All of them are multi-payer systems that include private insurance plans which have been the source of many of the dysfunctions in our current health care financing system, 3) All of them involve profound administrative complexity which has been a source of much of the waste in our current system, not to mention the grief that these excesses have caused, and 4) All of them would significantly increase the level of per capita spending on health care when we are already spending twice the average of other wealthy nations.

The fourth model should be familiar to advocates of single payer Medicare for All since it is based on the Medicare for All Act of 2019 sponsored by Bernie Sanders in the Senate and Pramila Jayapal in the House. It is summarized above, and more details can be found at the website of Physicians for a National Health Program at www.pnhp.org.

The CBO report says that, under this model, coverage would not be completely universal “because people would need to provide information to the enrollment system and some would not do so.” However, the program is designed to automatically include everyone for life. In fact, there is legal precedent for prohibiting individuals from disclaiming their legal entitlement to Medicare Part A. D.C. Circuit Court Judge Brett Kavanaugh wrote in an opinion that although individuals did not have to accept Medicare Part A benefits, they could not disclaim their legal entitlement to those benefits. So the government can require that everyone is covered.

At any rate, this report is important since the highly credible CBO has objectively described a single payer system in terms that make it clear that it is still the only model currently under consideration that would provide truly affordable health care coverage for absolutely everyone.

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