Achieving Universal, Affordable, Quality Health Care (Pages 28-37)

(Excerpts)

We are going to at last build the health care system the American people have always deserved: One that finally provides universal health care coverage; reduces prescription drug prices, premiums, and out-of-pocket costs; reins in overall health care expenses; and tackles the deep-seated inequities in our health care system. We will build a health care system that is driven by the needs of patients and the people who care for them, instead of the profit motives of big corporations.

Democrats will always fight to save Americans’ lives by making it easier and more affordable to go to the doctor, get prescription medicines, and access preventive testing and treatments. Our policy agenda is designed to produce real results for the American people—not hollow platitudes. As Democrats, we fundamentally believe health care is a right for all, not a privilege for the few.

Responding to the Coronavirus Pandemic

We must start by making COVID-19 testing widely available, convenient, and free to everyone. That includes expanding programs to proactively extend testing services to populations we know are especially vulnerable, including the homeless and those living in nursing homes and long-term care facilities. We must also expand funding so state and local public health departments can hire sufficient staff to adequately conduct contact tracing for everyone who tests positive for the novel coronavirus. Only through testing, tracing, and targeted quarantining can we hope to fully understand the scope of the pandemic, contain it, and stop it.

In a public health crisis, we all have to rely on each other. That’s why Democrats support making COVID-19 testing, treatment, and any eventual vaccines free to everyone, regardless of their wealth or their immigration status.

In the midst of this pandemic, we will provide direct, increased support to states to enroll eligible adults in Medicaid, have the federal government cover a higher percentage of the bill, and add incentives for states which have not yet expanded Medicaid to do so.

For people who risk losing their insurance coverage if they lose their jobs in this pandemic, Democrats believe the federal government should pick up 100 percent of the tab for COBRA insurance, which keeps people on their employer-sponsored plans. For those who are still unemployed or do not have access to employer-sponsored health care when their COBRA eligibility period expires and are eligible for premium-free coverage, we will take action to automatically roll them over to other coverage options, so they do not experience any gap in health care. We will also re-open the Affordable Care Act marketplaces, even outside of the normal open enrollment season, and expand subsidies to make it easier for people to buy coverage.

Democrats will also make available on the marketplace a platinum-level, federally administered health insurance option with low fees and no deductibles, so that everyone will have access to this high-quality, low-cost plan. Low-income Americans will be automatically enrolled in this federally-administered option at zero cost to them.

We will keep these emergency measures in place until the pandemic ends and unemployment falls significantly.

Democrats will direct the federal government to work with private-sector manufacturers to dramatically scale up the United States’ domestic manufacturing capacity for both personal protective equipment and essential medicines.

Reinvesting in Public Health

Democrats will act swiftly to stand up a comprehensive, national public health surveillance program for COVID-19 and future infectious diseases, including recruiting 100,000 contact tracers to help state and local health departments identify people at risk of contracting or spreading the coronavirus.

We will substantially increase funding for the Centers for Disease Control and Prevention and for state and local public health departments, many of which suffered deep budget cuts during the Great Recession. And we will restore American leadership on global public health by working with our allies and partners around the world, including through the World Health Organization.

Securing Universal Health Care Through a Public Option

We will give all Americans the choice to select a high-quality, affordable public option through the Affordable Care Act marketplace. The public option will provide at least one plan choice without deductibles, will be administered by the traditional Medicare program, not private companies, and will cover all primary care without any co- payments and control costs for other treatments by negotiating prices with doctors and hospitals, just like Medicare does on behalf of older people. The lowest-income Americans not eligible for Medicaid will be automatically enrolled in the public option at no cost to them, although they may choose to opt out at any time. Everyone will be eligible to choose the public option or another Affordable Care Act marketplace plan, even those who currently get insurance through their employers, because Democrats believe working people shouldn’t be locked in to expensive or insufficient health care plans when better options are available.

For the 4.8 million adults who should be eligible for Medicaid, but who live in states where Republican governors have refused to expand the program, Democrats will make the public option available without premiums. And we will enable millions of older workers to choose between their employer-provided plans, the public option, or enrolling in Medicare when they turn 60, instead of having to wait until they are 65.

Democrats will also empower the states, as laboratories of democracy, to use Affordable Care Act innovation waivers to develop locally tailored approaches to health coverage, including by removing barriers to states that seek to experiment with statewide universal health care approaches.

We also know that finally covering every American through the public and private insurance system alone is not enough to guarantee universal access. That is why Democrats support doubling investments in community health centers and rural health clinics, including increased support for dental care, mental health care, and substance use services like medication-assisted treatment. We will expand the National Health Service Corps to address critical shortages of health care providers in rural areas, including primary care nurses, dental professionals, and mental health and substance use counselors.

Bringing Down Drug Prices and Taking on the Pharmaceutical Industry

Democrats will take aggressive action to ensure that Americans do not pay more for prescription drugs than people in other advanced economies. We will empower Medicare to at last be able to negotiate prescription drug prices for all public and private purchasers—for families and businesses, as well as older Americans—no matter where they get their coverage. We will also ensure and enforce that the price of brand-name and outlier generic drugs cannot rise faster than the inflation rate. We will cap out-of-pocket drug costs for seniors, and ensure that effective treatments for chronic health conditions are available at little or no cost.

Reducing Health Care Costs and Improving Health Care Quality

We will make it easier for working families to afford high-quality insurance in the Affordable Care Act marketplaces by ensuring that no one pays more than 8.5 percent of their income in premiums and eliminating the cap on subsidies.

We will work to increase price transparency in the health care system across all payers, and reduce paperwork through uniform medical billing.

Democrats will support policies that increase the number of primary care practitioners, registered nurses, dentists, and dental therapists, especially in rural and low-income metropolitan areas, so it’s easier for every American to access preventive and primary health care.

Expanding Access to Mental Health and Substance Use Treatment

Democrats will aggressively enforce the federal mental health parity law and ensure that health insurers adequately cover mental health and substance use treatment.

Expanding Long-Term Care Services and Supports

Democrats support measures to eliminate state waiting lists for home and community based care, including through a significant expansion of the home care workforce, and will work to develop a broader approach to eliminate the institutional bias within Medicaid.

Eliminate Racial, Gender, and Geographic Health Inequities

Democrats are committed to eliminating health disparities by race, ethnicity, gender, and geography. We recognize it is not enough to have a commitment: We must have a plan. That is why Democrats will launch a sustained, government-wide effort, with leadership at the highest levels, to eliminate racial, ethnic, gender, and geographic gaps in insurance rates, access to quality care, and health outcomes. That includes tackling the social, economic, and environmental inequities—the social determinants of health like poor housing, hunger, inadequate transportation, mass incarceration, air and water pollution, and gun violence—that contribute to worse health outcomes for low-income Americans and communities of color.

(More on Black people and Latinos, pollution, maternal mortality, data collection to understand disparities, Indian Health Service, reproductive health care services, sexual assault and domestic abuse, LGBTQ+ discrimination, and HIV/AIDS treatment and prevention.)

We will expand access to health care for people living and working across the United States by extending Affordable Care Act coverage to Dreamers, and working with Congress to lift the five-year waiting period for Medicaid and Children’s Health Insurance Program eligibility for low-income, lawfully present immigrants.

Democrats believe that gun violence is a public health crisis. We believe that expanding access to mental health care is key to confronting the epidemic of suicides-by-firearm, including among veterans. Democrats will ensure the Centers for Disease Control and Prevention have sufficient resources to study gun violence as a public health issue and support evidence-based programs for preventing gun violence.

Strengthening and Supporting the Health Care Workforce

We will invest in community health worker care-forces around the nation proven to prevent, manage and better treat chronic illness now burdening tens of millions of Americans, and empower first-time mothers with nurse home visiting. We will close provider gaps and increase diversity in the health care profession by creating a robust pipeline of talent with career ladders for work advancement. And we will also increase opportunities for community health workers to come from the communities they serve.

Investing in Health Science and Research

We will support increased and sustainable funding for federal health and medical research across agencies, including at the National Cancer Institute and other components of the National Institutes of Health, the Centers for Disease Control and Prevention, and the Agency for Health Care Research and Quality. We will increase the federal investment in research and development for new medications through the National Institutes of Health, and make sure that there is a return on that investment for taxpayers.

Democrats also support increasing funding for research into health disparities by race, gender, age, geographic area, and socioeconomic status, with a particular focus on how the social determinants of health contribute to differences in health outcomes.

Rep. Pramila Jayapal, Co-chair
Vivek Murthy, Co-chair
Donald Berwick
Abdul El-Sayed
Sherry Glied
Mary Kay Henry
Chris Jennings
Rep. Robin Kelly

https://joebiden.com…

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Comment:

By Don McCanne, M.D.

When the neoliberals commandeered the Democratic primary process and bumped Bernie Sanders out of the running, it was recognized that Joe Biden would have to do something to reunite the Democrats since the flame of the popular progressive revolution had been extinguished, and the Democrats were left with a candidate basically representing the status quo. Perhaps the greatest disappointment was that single payer Medicare for All had been removed from the agenda.

The report of the recommendations of the Biden-Sanders Unity Task Force(s) is 110 pages long and covers many areas of policy. The ten page section on health care basically perpetuates the current health policies, led by the Affordable Care Act, while adding a public option and reducing Medicare eligibility age to 60. The most glaring feature is invisible – the total lack of any mention of single payer Medicare for All.

Single payer Medicare for All is not simply an expansion of Medicare to cover everyone. It is a comprehensive revision of the financing of health care making it universal, comprehensive, efficient, effective, equitable, accessible, and affordable for everyone, for life. The Biden-Sanders Unity Task Force proposal meets none of those criteria.

Biden has said that we cannot afford single payer Medicare for All, yet his model perpetuates much of the excessive spending in health care, failing to recover hundreds of billions of dollars in administrative waste. For administrative efficiency he suggests reducing paperwork through uniform medical billing, but we already have that in Form 1500. He also suggests price transparency as if Nobel laureate Kenneth Arrow never explained why health care markets don’t work. Biden’s proposals would significantly add to our health care spending, and thus would be much more expensive than an efficient single payer Medicare for All.

The goal of the Unity Task Force is to bring disappointed progressives back into the fold. It is likely that President Trump is going to orchestrate his own defeat, and Joe Biden will be elected by default. Regardless, it is important that progressives not give up on single payer. Assuming Biden is elected, it is imperative that we continue to educate everyone on the virtues of the single payer model. If President Biden truly understood the single payer model (and he doesn’t), he would certainly sign legislation enacting it.

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

We need a health system where the distribution of infrastructure and resources is not left to the dictates of the market, but rationally planned according to the needs of communities—and the certainty of future disasters.

By Adam Gaffney, M.D., M.P.H.
Dissent, Summer 2020

When the COVID-19 pandemic hit, my life as a critical care physician in a Boston-area hospital changed quickly. Massachusetts weathered the third biggest outbreak, in total cases, in the nation. Patients who had contracted the novel coronavirus filled our intensive care units. Their lungs failed; our days started early and ran late. To expand capacity, we acquired more ventilators and brought in new staff. Our surgical recovery room was converted into an open-ward ICU exclusively for critically ill COVID-19 patients.

Another change: we began to cooperate with other hospitals in a novel way.

The ICU capacity at our region’s mid-sized hospitals could evaporate overnight with a surge of admissions of patients in respiratory failure. Much larger institutions nearby had more space and some specialized technologies, like extracorporeal membrane oxygenation (ECMO)—a sort of external artificial lung that pushes oxygen into the bloodstream and sucks out the carbon dioxide, which can help some of those with refractory lung failure. When I wasn’t treating patients, I joined daily phone meetings with physicians working throughout the greater Boston area. We shared data and learned where we could send critically ill patients when we ran out of beds. Something similar played out in New York, where the crisis, by necessity, spurred unprecedented cooperation among the state’s hospitals.

Pandemics lay bare the need for cooperation in health services. But cooperation, and planning, will be equally important after the pandemic is over, and must go well beyond meetings. We need to envision a health system where the distribution of infrastructure and resources is not left to the dictates of the market, but rationally planned according to the needs of communities—and the certainty of future disasters.

Planning has been a dirty word in healthcare for decades. Competition is today’s idol. But it was not always so: in the postwar era, though the United States failed to achieve European-style reform, a “health planning” movement emerged. The Hill−Burton Act of 1946 provided billions of federal dollars to expand existing hospitals and build new ones, particularly in underserved regions. In the 1960s and 1970s, state and later federal legislation—culminating in the 1974 National Health Planning and Resources Development Act—created planning bodies tasked with assessing local community health needs, approving new capital projects, and ensuring an adequate distribution of health infrastructure. But in the absence of universal healthcare financing for patients, à la Medicare for All, the movement was only marginally effective—and the rise of a new capitalist healthcare paradigm in the Reagan era easily brushed it aside.

The consequence has been simultaneous excess and deficit in health infrastructure. Today, market forces dictate the life and death of American hospitals. The epidemic of rural hospital closures, for instance, is not the consequence of a lack of rural health needs, but of the cold reality that serving those needs is unprofitable. A large academic hospital closed in Philadelphia last year not because its disproportionately low-income and minority patients no longer needed its services, but because those patients did not generate sufficient revenue. One Journal of the American Medical Association study found that, per capita, Manhattan has the most hospital beds among the five boroughs but had the fewest COVID-19 hospitalizations. Little wonder, then, that the virus battered outer boroughs’ hospitals with such ferocity.

The lack of planning is evident not only in the mismatch of hospitals and patients but in the distribution of basic supplies. “California’s Coronavirus Testing Still A Frustrating Patchwork Of Haves And Have-Nots” ran the headline of an NPR story that described glaring geographic disparities in access to testing months into the pandemic. The logic of competition that informs our national approach to healthcare has also meant chaotic and wasteful bidding wars for testing supplies and personal protective equipment (PPE) among hospitals and state and local governments.

The Medicare for All bills in Congress, if enacted, would do much to advance planning: they mandate dedicated funding streams for healthcare capital expenditures. Adequate investment in stockpiles of PPE and other equipment—and the capacity to rapidly distribute it—could also be undertaken by such a system. But we need to think of other ways that planning could prepare us for the pandemics of the future.

Maintaining a large, unused, yet readily deployable ICU “surge capacity,” for instance, is illogical in market terms: it costs money but delivers no revenue outside of plague years. But that unused reserve capacity benefits society. We need to rethink hospital design, with areas that can be used in times of emergencies but otherwise be idled. Israel’s Ramban Health Care Campus—which has a large underground parking garage that can be converted into a 2,000-bed hospital within hours—offers one example. Similar innovations could be envisioned for the inevitable calamities of our future—and be made available to everyone on a truly equal basis.

That necessitates, of course, abandoning the market ethos that currently drives the expansion and contraction of healthcare infrastructure. It requires discarding the false promise of anarchical medical competition as the salve of our healthcare cost crisis. It does not mean returning to the last era of health planning, but instead reinventing planning for the post-COVID age.

Adam Gaffney is a pulmonary and critical care physician, a public health researcher, and an Instructor in Medicine at Harvard Medical School. He serves as president of Physicians for a National Health Program and is the author of To Heal Humankind: The Right to Health in History.

https://www.dissentmagazine.org…

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Comment:

By Don McCanne, M.D.

In a 2011 Quote of the Day, I wrote, “One fundamental concept that has appeared repeatedly on the pages of Physicians for a National Health Program (PNHP) is that excellence is a product of cooperation, not competition. It is not choice between private for-profit and public systems, but rather it is equity within public systems that facilitates excellence.”

Imagine all participants in the health care system working together to improve the efficiency and effectiveness of health care delivery. Obviously health planning is fundamental to this concept,

Instead, in the United States, we rely on markets and competition which shred coordinated planning and cooperation. That is not only very expensive, it creates many of the inefficiencies, deficiencies, and dysfunctions in health care delivery.

The current pandemic has been very instructive in this regard. Instead of providing leadership in a cooperative effort, the federal government has passed much of the responsibility to the states that have had to rely on competitive bidding in the markets for limited supplies, which has driven prices up, not down. When the research community needs to cooperate in developing drugs and vaccines, the United States has gone so far as to withdraw from the World Health Organization – the entity in which nations cooperate in such goals that would improve health throughout the world. The Trump administration has even promoted agreements in which they hope American firms will gain control of the world markets for these new drugs and vaccines, wherein business success trumps public health, at a cost to those on the losing end (competition creates winners and losers, whereas, with cooperation, everyone wins). They also intend to punish our colleges and universities that follow certain recommended public health standards aimed at reducing transmission of the coronavirus, by revoking the visas of international students, an important source of revenue for these institutions. Not only is this not cooperation, it is not even competition. It is simply madness.

Imagine. Working together. For the benefit of patients. Instead of competition and markets, we need cooperation and public service – features characteristic of the single payer model of Medicare for All. Planning together. We have the money. We simply need an infusion of social solidarity.

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

By Sharon Begley
STAT, July 7, 2020

You won’t find the usual suspects like Massachusetts General Hospital or the Mayo Clinic at the top of a new ranking of U.S. hospitals. That’s because the rating system relies not just on traditional quality measures, but also on a hospital’s community-minded policies and avoidance of unnecessary care.

The rankings show that those hospitals with good clinical outcomes tend to score poorly in addressing inequities that affect the health of their communities. And even when hospitals perform many low-value procedures — those that research has shown to be of limited or no benefit — their patients generally have a low risk of dying both in the hospital and after being discharged, as well as a low risk of having to be readmitted.

No previous hospital rankings use “civic leadership,” which includes community-minded policies such as charity care, financial aid, and paying all staffers a living wage, or “value of care,” meaning whether a hospital avoids 13 procedures of questionable or clearly absent clinical benefit. The Lown Institute, a nonprofit think tank in Brookline, Mass., incorporated both measures into its rankings of 3,282 hospitals because “it is time for hospitals to rethink what it means to be great,” said Lown’s president, physician Vikas Saini.

Civic leadership matters because the health of the people in a hospital’s community “reflect things outside the four walls of a hospital,” he said. “If one patient is going back to a community without a lot of resources, where health equity is low, and another is going back to a wealthier community, their [long-term] health will be very different even if the quality of care in the hospital was identical. Hospitals have an obligation to improve the health of the outside community.”

A number of hospitals renowned for their quality of care got A+ or A for patient outcomes but a D for civic leadership, including Massachusetts General Hospital, the Cleveland Clinic, the Mayo Clinic, and the University of Washington in Seattle. Teaching hospitals such as these do pretty well on supporting their communities, but pay equity — multimillion-dollar salaries for top executives — sinks them in Lown’s calculation of civic leadership. Not a single hospital in the top 100 for patient outcomes was in the top 100 for civic leadership, and vice versa.

Many hospitals perform high numbers of low-quality procedures, which tend to be lucrative (and waste an estimated $100 billion per year in health care spending). “The right thing to do financially isn’t necessarily the right thing to do for patients,” said Leah Binder, president and CEO of the Leapfrog Group, a nonprofit backed by large employers that aims to identify and promote high-quality, high-value health care and whose hospital ratings emphasize patient safety.

She called Lown’s decision to downgrade a hospital for performing many low-quality procedures “a breakthrough” in hospital ratings. “We know inappropriate care is an extremely significant problem for the health care system,” Binder said. “It’s also a terrible tragedy for individual patients to go through an unnecessary procedure.”

Few patients are likely to reject a hospital based on how much it pays its CEO relative to its custodians. But Binder called civic leadership an important metric. “If there is anything you want out of a hospital, it’s ethics,” she said. Charity care, community support, and pay equity “are informative about a hospital’s culture.”

The American Hospital Association, however, said in a statement that the report offers consumers no “accurate and useful information,” instead offering “a hodgepodge of composite score, ranking, star ratings, and letter grades that will, at best, confuse consumers and likely mislead them.”

https://www.statnews.com…

Lown Institute – Hospitals Index:
https://lownhospitalsindex.org

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Comment:

By Don McCanne, M.D.

Some hospitals are great at pleasing the principal players in the medical-industrial complex. To no surprise, many of these hospitals score high on current arbitrary measures of hospital performance, not to mention that they also have impressive financial statements. But Vikas Saini and his colleagues at the Lown Institute have studied extensively problems with the health care delivery system, and they identify another crucial factor that contributes to high performance of hospitals, and that is “civic leadership.”

Civic leadership includes community-minded policies such as charity care, financial aid, and paying all staffers a living wage, or “value of care,” meaning whether a hospital avoids 13 procedures of questionable or clearly absent clinical benefit. As Leah Binder of the Leapfrog Group stated, “If there is anything you want out of a hospital, it’s ethics.”

When you look at the features of single payer Medicare for All, you see that its infrastructure represents the epitome of ethics or civic leadership that stands in contrast to the mere business foundation of the medical-industrial complex. Single payer is universal, equitable, affordable for everyone, allocated efficiently, and always there when needed – ethical features that are simply not innate in a system controlled exclusively by the medical-industrial complex.

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

The United States is the only developed nation unable to balance cost, efficacy and social good in setting prices.

By Elisabeth Rosenthal
The New York Times, July 6, 2020

The last vaccine to quell a global viral scourge was the polio inoculation, which ended outbreaks that killed thousands and paralyzed tens of thousands each year in the United States. The March of Dimes Foundation covered the nominal drug cost for a free national vaccination program, estimated at $50,000.

It came in the mid-1950s, before health insurance for outpatient care was common, before new drugs were protected by multiple patents, before medical research was regarded as a way to become rich. It was not patented because it was not considered patentable under the standards at the time.

Now we are looking for viral deliverance when drug development is one of the world’s most lucrative businesses, ownership of drug patents is disputed in endless court battles, and monopoly power often lets manufacturers set any price, no matter how extraordinary. A new cancer treatment can cost a half-million dollars and old staples like insulin have risen manifold in price to thousands of dollars annually.

And the American government has no effective way to fight back.

If a Covid-19 vaccine yields a price of, say, $500 a course, vaccinating the entire population would bring a company over $150 billion, almost all of it profit.

Kevin Schulman, a physician-economist at Stanford Business School, called that amount “staggering.” But Katherine Baicker, dean of the University of Chicago Harris School of Public Policy, said that from society’s perspective “$150 billion might not be an unreasonable sum” to pay to tame an epidemic that has left millions unemployed and cost the economy trillions.

Every other developed country has evolved schemes to set or negotiate prices, while balancing cost, efficacy and social good. The United States instead has let business calculations drive drug price tags, forcing us to accept and absorb ever higher costs. That feels particularly galling for treatments and vaccines against Covid-19, whose development and production is being subsidized and incentivized with billions in federal investment.

Manufacturers have traditionally claimed that only the lure of windfall profits would encourage them to take the necessary risks, since drug development is expensive and there’s no way of knowing whether they’re putting their money on a horse that will finish first, or scratch.

More recently they have justified high prices by comparing them to the costs they would prevent. Expensive hepatitis C drugs, they say, avoid the need for a $1 million liver transplant. No matter that the comparison being made is to the highly inflated costs of treating disease in American hospitals.

Such logic would be disastrous if it were applied to a successful Covid vaccine. Covid-19 has shut down countless businesses, creating record-high unemployment. And the medical consequences of severe Covid-19 mean weeks of highly expensive intensive care.

There is no simple, direct mechanism for regulators or legislators to control pricing. Our laws, in fact, favor business: Medicare is not allowed to engage in price negotiations for medicines covered by its part D drug plan. The Food and Drug Administration, which will have to approve the manufacturer’s vaccine for use as ‘safe and effective,’ is not allowed to consider proposed cost.

Other countries, such as Britain, take a more head on approach: a national body does a cost-benefit analysis regarding the price at which a new drug is worth being made available to its citizens. Health authorities then use that information to negotiate with a drug maker on price and to develop a national reimbursement scheme.

The federal government could, for example, invoke a never-before-used power called “march-in rights,” through which it can override a patent holder’s rights if it doesn’t make its medicines “available to the public on reasonable terms.”

We could, alternatively, allow Medicare to negotiate drug prices — a proposal that has been raised by politicians and beaten back by industry again and again.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Perhaps the most appalling measure of the gall of the private pharmaceutical industry is that they believe that they should be able to claim ownership of the financial value of beneficial results from their drug products.

If a drug that is given to 10,000 patients can prevent 100 people from having a $200,000 hospitalization, then, by this reasoning, that $20,000,000 savings belongs to the drug company. It would be collected in the form of a $2,000 marginal price increase from each of the 10,000 patients who receive the drug. This is not theoretical since such reasoning has already been implemented in driving up drug prices, at least indirectly, and has even been under consideration in international trade agreements under pricing of drugs based on “value.”

And the policy community? Katherine Baicker, dean of the University of Chicago Harris School of Public Policy seems to think that “$150 billion might not be an unreasonable sum” to pay for Covid-19 vaccine based on value (though consider that the national polio vaccine program cost $50,000, and, no, inflation does not explain most of the difference). Baicker, as a director of Eli Lilly, is also not likely bothered by the outrageous increases in insulin prices.

Considering the rigid resistance of the industry to establishing fair drug prices, we really should consider beginning the process of nationalizing the pharmaceutical industry. Perhaps then industry leaders would consider changing their tune, but I doubt it. They are truly driven by greed, as this “value pricing” scheme indicates.

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

Kaiser Health News/Associated Press, July 1, 2020

Local and state public health departments across the country work to ensure that people in their communities have healthy water to drink, their restaurants don’t serve contaminated food and outbreaks of infectious diseases don’t spread. Those departments now find themselves at the forefront of fighting the coronavirus pandemic.

But years of budget and staffing cuts have left them unprepared to face the worst health crisis in a century.

KHN and The Associated Press sought to understand the scale of the cuts and how the decades-long starvation of public health departments by federal, state and local governments has affected the system meant to protect the nation’s health.

Here are six key takeaways from the KHN-AP investigation:

• Since 2010, spending for state public health departments has dropped by 16% per capita, and for local health departments by 18%. Local public health spending varies widely by county or town, even within the same state.
• At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeletal workforce in what was once viewed as one of the world’s top public health systems.
• Nearly two-thirds of Americans live in counties that spend more than twice as much on policing as they spend on non-hospital health care, which includes public health.
• More than three-quarters of Americans live in states that spend less than $100 per person annually on public health. Spending ranges from $32 in Louisiana to $263 in Delaware.
• Some public health workers earn so little that they qualify for government assistance. During the pandemic, many have found themselves disrespected, ignored or even vilified. At least 34 state and local public health leaders have announced their resignations, retired or been fired in 17 states since April.
• States, cities and counties whose tax revenues have declined during the current recession have begun laying off and furloughing public health staffers. At least 14 states have cut health department budgets or positions, or were actively considering such cuts in June, even as coronavirus cases surged in several states.

https://khn.org…

Full report; Hollowed-Out Public Health System Faces More Cuts Amid Virus:
https://khn.org…

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Comment:

By Don McCanne, M.D.

The United States spends more per capita on health care than any other nation, and yet we have one of the most inequitable health care systems of all, which results in mediocrity. Our public health system should be the best, but all you have to do is look at the impact of the Covid pandemic to realize how poor the performance is. The six takeaway points listed reveal that much of the responsibility rests with failures of our political leadership.

We select our political leaders. We have some homework to do.

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

By Adrianna McIntyre, Robert J. Blendon, John M. Benson, Mary G. Findling, Eric C. Schneider
Journal of Health Politics, Policy and Law, Vol. 45, No. 5, October 2020

Abstract

Ten years after its enactment, public support for the Affordable Care Act (ACA) still only reaches a scant majority. Candidates for the presidency—and the sitting president—have endorsed health reforms that would radically transition US health care away from the current system upon which the ACA was built. Few opinion surveys to date have captured dominant preferences among alternative health reform policies or characterized attitudes and experiences that might be associated with policy preferences. Using a 2019 nationally representative telephone survey, this article considers how variations in political values, attitudes toward government, and experiences with the health care system relate to competing health reform preferences. Differences between those who favor Medicare for All over building on the ACA largely reflect different levels of satisfaction with the status quo and views of private health insurance. By contrast, differences between ACA supporters and those who would favor replacing it with a state-based alternative reflect sharply different political values and attitudes. Key differences remain significant after controlling for demographic, health, and political characteristics. Overwhelming public support still eludes the ACA, and reaching consensus on future directions for health reform will remain challenging given differences in underlying beliefs.

Conclusion

The Affordable Care Act has become a fundamental part of the US health care system in its first ten years. However, public support remains middling, with approval at 50% in April 2020 (KFF 2020). Given a choice, only about one-third of Americans most favor keeping and improving on the law; the other two-thirds are split between supporting more expansive Medicare for All reforms and letting states take the lead. Results from this survey make evident that the views, values, and attitudes that comprise each of these groups different from those who support maintaining and strengthening the ACA are not the same. Respondents who favor Medicare for All share many common values and attitudes with respondents who want to build on the ACA—and most have a favorable view of the ACA itself — but tend to be more dissatisfied with their own experiences with the current health care system, including their health care costs. In contrast, those favoring a state-based option tend to have similar levels of satisfaction as those who want to build on the ACA, but starkly different opinions on taxation and the broader role of government in health care. A broad consensus on future directions for health reform will likely continue to be difficult to achieve given these differences in underlying beliefs. However, the one key thing those who support improving the ACA and those favoring Medicare for All agree on is the need to move toward universal coverage.

https://read.dukeupress.edu…

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Comment:

By Don McCanne, M.D.

In this study, survey participants were required to choose their preference of one of three alternative reform policies. The 11 percent who did not choose an option were excluded from the results. Of the three options, one-third of the remaining participants favored keeping and improving on the Affordable Care Act (ACA), one-third favored Medicare for All, and one-third favored replacing ACA with a state-based alternative. The study then attempted to define differences in values, attitudes and experiences that might explain the differing preferences.

Actually the groups favoring ACA and favoring Medicare for All had much in common, especially agreeing that the nation needs to move toward universal coverage. Those favoring state-based reform had distinctly different political attitudes, especially in their opposition to taxation and opposition to a broad role of government in health care. The other differences between the three groups were comparatively of such minor significance that it would be more accurate to say that the participants (presumably representing the nation) were divided into two groups – two-thirds supporting comprehensive reform with a broader role for government, and one-third rejecting a major role for government. The authors in their report state, “those favoring a state-based option held more negative attitudes toward government on every measure, including saying things run by the federal government are not run too well or not well at all.”

It seems that a consensus should be able to be reached between the pro-ACA and the Medicare for All groups. The most important differences between them demonstrated in this study were in the degree of satisfaction with the status quo and in their views on private health insurance. It is likely that the great majority of privately insured Americans who remain healthy and have little need for their insurance are satisfied. It is the minority who have been deprived of care they think they should have had or who have faced financial hardship that they thought their insurance should have prevented. They need to understand that the single payer model of an improved Medicare for All would remove such barriers to care for all of us, including those who reject social solidarity.

Although the one-third who are ideologically opposed to Medicare for All will likely remain inflexible, the one-third who believe that our private insurance system is working well for them need to be better informed. The few who learn each year through unfortunate personal experiences are not enough to swing the political pendulum. We have to do a better job of educating the public at large.

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Profiteering, Corruption and Fraud in U.S. Health Care

By John Geyman, M.D.

From the Preface

We have to raise, and answer, who is health care for – for corrupt and fraudulent scammers or patients and their families?

This book has four parts: (1) to bring historical perspective to the changes that have transformed U.S. health care from a mission of service to an unaccountable profit-driven non-system; (2) to describe the adverse impacts of these changes on patients, our population, and taxpayers; (3) to describe and illustrate how corruption and fraud pervade all parts of the medical-industrial complex from hospitals, nursing homes, and hospice to the drug, medical device, and medical information industries; and (4) to ask and try to answer what can be done about all this?

Much of what comes to light here may surprise readers who hope that this problem is not as dire as it is. But you will see that it is. In fact, the current COVID-19 pandemic is exposing the huge shortfalls in our supposedly good health care system, underfunded and neglected public health, increasingly unaffordable care of unacceptable quality, and growing health care disparities and inequities. All that, plus an inadequate federal response to the pandemic.

This will be a rough ride, so buckle up. We need to bring this problem front and center so we can deal with it in the public interest.

From Chapter 11: Reform Is Achievable, but a Matter of Political Will

I. Case For and Against Four Alternatives

1. The Status Quo, with Inadequate Response to the COVID-19 Pandemic
2. Build on the Affordable Care Act (ACA)
3. Medicare for Some: Variants of a Public Option
4. Medicare for All

From the Conclusion

We have a political teeter totter in play. On one end are corporate money, Wall Street traders and investors, and those many profiteers in our free-wheeling market-based system. On the other end are physicians, nurses and other health professionals committed to serving the public without fiscal and bureaucratic barriers between them and their patients.

The answer to how we deal with these challenges will test our democracy to the core. Given the stakes, we’d better be up to coping with them, since they will make all the difference for generations to come.

https://www.amazon.com…

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Comment:

By Don McCanne, M.D.

How can the United States have the most expensive health care system of all nations yet have it fail miserably in meeting health care goals for so many of us? John Geyman explains the structural defects resulting from a misplaced emphasis on neoliberal policies designed to ensure business successes of the health care/insurance industry when what we need is systemic reform that is designed specifically to ensure affordable and accessible care for each of us. He shows us the flaws in our system that we need to correct and then provides a pathway for reform.

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Comment:

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

Geyman reveals in vivid detail the corruption that’s hollowing out our health care system, and what’s needed to stop it. A must read for anyone seeking to diagnose and treat what’s wrong with health care.

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By Sayeh Nikpay, India Pungarcher, Austin Frakt
Journal of Health Politics, Policy and Law, Vol. 45, No. 5, October 2020
Published online June 19, 2020

Abstract

Through the 2000s, high health care spending and growing numbers of uninsured were widely viewed as public policy crises. The Affordable Care Act (ACA) attempts to address both. At the time of its passage, the ACA’s expanded coverage options were expected to have a significant positive impact on the economic conditions of US households through lower spending on premiums and out-of-pocket payments, greater financial security, improved job mobility, and improved health. The ACA was also expected to reduce the growth rate of health care spending. Ten years after its passage, we compare expected and realized effects of the ACA on its key economic outcomes: coverage, access to care, financial security, labor market decisions, health, and health care spending.

Expected Effects of the ACA on Economic Outcomes as Enacted

A goal of the ACA was to achieve near-universal coverage through consumer protective regulation of private health insurance, an individual health insurance mandate, and subsidies in the form of Medicaid expansion for low-income households and tax credits for middle-income households.

According to the CBO, the ACA’s reforms were expected to increase coverage by 32 million Americans by 2019, enhancing financial security through protection from catastrophic health spending while reducing out-of-pocket costs. By improving the quality and affordability of alternatives to employer-sponsored insurance (ESI), the ACA’s coverage gains were also expected to alleviate “job lock,” wherein individuals are discouraged from leaving their job for fear of losing (or paying more for) coverage. The CBO (2014) estimated that the ACA would encourage 2.5 million Americans to leave the labor force by 2023, likely to retire or become self-employed.

The second goal of the ACA was to reduce the nation’s health spending growth rate. The law, as enacted, attempted to reduce health care spending by various means: increased insurer competition, reduced federal tax subsidies for generous ESI plans (the “Cadillac tax,” subsequently repealed), and a host of Medicare and Medicaid payment reforms and reimbursement cuts. Reimbursement cuts were focused mainly on hospitals and Medicare Advantage plans, cuts in the growth rate of payments to providers, and “delivery system reforms” (DSRs), which tie payment to quality and/or spending goals.

The CBO estimated that the ACA would lower federal deficits by $198 billion, and that cost-control provisions would reduce federal spending by approximately $416 billion over 10 years, relative to the status quo. Economists expected that many of these mostly federally focused cost-control measures would have spillover effects on private health spending. Some economists therefore suggested that reforms like those in the ACA could reduce national health spending by $590 billion over 10 years relative to the estimated total national health spending over that period without the ACA, and slow the growth rate of spending by about 10%.

Realized Economic Effects of the ACA

Coverage: Between 2009 and 2018, the uninsured rate decreased from 15.1% to 8.9%, with the largest decrease occurring after implementation of the ACA’s coverage provisions. Between 2013 and 2014, the uninsured rate fell from 13.3% of Americans (41.8 million) in 2013 to 7.9% of Americans (25.6 million) in 2014. The number of Americans with coverage in the individual market increased over this period from 11.4% (35.8 million) to 14.1% (46.1 million), while Medicaid enrollment increased from 17.5% (54.9 million) to 19.5% (61.7 million).

Importantly, the ACA’s coverage gains were not due to the erosion of ESI. The probability of losing ESI changed by less than 1% while rates of gaining nongroup and public coverage among the uninsured increased by 3% and 5%, respectively.

Nevertheless, coverage gains have fallen short of CBO estimates. Most of the discrepancy can be attributed to post-ACA legislative, executive, and judicial actions. Because some states did not expand Medicaid coverage — made optional by a 2012 Supreme Court ruling—2.3 million Americans are without affordable coverage options, too wealthy to qualify for (non-expanded) Medicaid but too poor to qualify for marketplace subsidies. Elimination of the individual mandate by Congress, elevation of nonregulated coverage options by executive order, and regulations that increase barriers to marketplace enrollment such as shortened enrollment periods have further eroded coverage gains. Although the number of individuals enrolled in the ACA’s marketplaces remained relatively stable, falling from 12.2 million to 11.8 million between 2017 and 2018, the uninsured rate did increase 0.5 percentage points, leaving an additional 1.86 million Americans uninsured.

Financial Security and Access to Care: The ACA makes health insurance more affordable to many Americans— especially those with high-cost medical conditions.

With coverage expansion came reduced out-of-pocket spending and increased access to care. Relative to those in nonexpansion states, individuals in Medicaid expansion states are 11% more likely to have no out-of-pocket medical or premium expenditures, have about $1,000 less in past-due debts, are 11% less likely to use payday loans, are 2.8% less likely to file for bankruptcy, and have greater improvement in credit scores. Gaining coverage increases office-based primary care visits by 24.1%, prescription drug use by 19%, and use of certain high-value medical screenings by 9.9–11.6%.

While out-of-pocket spending declined for Americans who gained coverage, per-capita out-of-pocket spending actually increased over all Americans by $3,041 between 2009 and 2018. This increase likely results from higher prevalence of high-deductible health insurance plans, including among those with ESI. The fraction of employees enrolled in a high-deductible plan increased from 8% to 29% between 2009 and 2018. At the same time, the deductible for an average single plan increased by $748.

Labor Market Decisions: Although several studies and the CBO predicted large increases in self-employment and retirement, there is little evidence they materialized. Other than the broad inference that new coverage options under the law may not be sufficiently attractive to draw people out of the labor force (despite predictions to the contrary), it is not clear specifically why. One possibility is that the near-continuous attacks on and erosion of the law’s provisions raised doubts about the durability of its protections.

Health: The preponderance of evidence suggests that health insurance improves health. Therefore, it is not surprising that those who gained coverage through the ACA’s Medicaid expansion or extension of employer-sponsored coverage to young adults saw gains in self-reported health. Two recent studies showed that the ACA’s coverage provisions reduce mortality. Linking mortality and survey data on Americans who were the targets of the ACA Medicaid expansion, Miller and colleagues found that the Medicaid expansion averted 19,200 deaths over its first four years.

Health Care Spending: The ACA was expected to modestly reduce the growth of health spending. Federal Medicare spending growth has slowed from 6.8% in 2009 to 6.4% in 2018, and Medicaid spending growth has slowed from 8.8% to 3.0%, over the same time. However, private spending on health care has increased from 3.5% to 5.8% between 2009 and 2018, and out-of-pocket expenditures have also increased. As a result, national health care spending growth increased from 4% to 4.6%.

In fact, studies suggest that many of the ACA’s delivery system reforms (DSRs) have had only modest effects on spending. ACOs appear to have resulted in a few percentage points of savings to Medicare, but the extent to which these are attributable to the program is debated. The evidence on savings from Medicare Bundled Payments is also mixed. Although the Center for Medicare and Medicaid Innovation has launched 37 new payment models, the effects on spending are unknown.

There are several reasons that the ACA’s DSRs had a modest impact on spending at best. First, the ACA was implemented at the same time as a wave of provider consolidation. The consequence is higher commercial market prices. Second, DSRs relied on provider incentives that may have been underpowered. In other words, the incentive to reduce costs was small relative to the wider health care system’s incentives for volume over value. Additionally, these reforms were often voluntary, meaning that if the targets for savings are too aggressive, nobody will participate. Finally, the cost of implementing the DSRs may have eaten away at modest DSR savings.

Discussion

The architects of the ACA sought to increase coverage and reduce costs and the law was expected by economists to increase access to care, financial security, and job mobility. Although legislative, executive, and judicial actions subsequent to the law’s passage have weakened it in a variety of ways, gains in coverage, access to care, financial security, and health have been surprisingly durable. Yet, these benefits are not evenly shared. For some low-income individuals in Medicaid nonexpansion states, there is little change in these outcomes from the pre-ACA period. For others, even subsidized marketplace coverage comes with high deductibles and cost sharing that impose significant financial burdens.

Conclusion

The ACA provides coverage to millions of Americans, with documented improvements in health care access, reduced financial burden, and better health. On the whole, there is little evidence it has made a substantial contribution to reducing health care spending, reflecting the fact that we have not figured out a politically feasible way forward on substantial cost control. Medicaid expansion remains uncertain in many states, and the outcome of the 2020 or subsequent elections could bring repeal back into political feasibility.

In many ways, we are in a qualitatively similar position as we were in 2010: uninsurance and financial security remain issues for many Americans, as does health spending. The ACA has changed the status quo—the individual market is dramatically reformed, for example—but it has not resolved key health care issues that have sustained US policy debates and fueled health economics scholarship for decades.

https://read.dukeupress.edu…

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Comment:

By Don McCanne, M.D.

This important review of the promises and results of the Affordable Care Act shows that there have been some isolated improvements in the various goals for reform, but the overall impact is that ACA “has not resolved key health care issues that have sustained US policy debates and fueled health economics scholarship for decades.”

We still have the most expensive system of all nations, and we still fall far short on crucial goals of a high performance system. The small gains of ACA missed so many of the goals and left in place so many of the profound dysfunctions that it is fair to conclude that ACA has been a miserable failure.

What can we do? There are basically three approaches we can consider. We can repeal ACA and replace it with a system that relies more heavily on markets and individual responsibility; we can build on ACA, or we can replace the health care financing system with single payer Medicare for All.

The conservatives who have contended that we should repeal and replace ACA have been left in the awkward position that there is no functional replacement that would meet their goals of reducing government spending and regulation in health care while ensuring that people would receive the health care that they need. The high costs of health care and the wide gap in income and wealth have made it impossible to provide private sector solutions for the majority of Americans. For everyone to have health care, government transfers (taxes) are critical and regulatory management is essential.

The evolving political momentum seems to be that we should build on ACA, considering that the Republican position on replacement has been discredited, and the Democratic Party leadership has been successful in dismissing single payer reform while favoring the neoliberal approach of building on ACA. But that is why today’s report is so important. ACA has been a failure, so what measures are proposed to build on ACA that could turn it around to achieve the goals of universal coverage, access and affordability?

Expand Medicaid?

The Supreme Court transferred more of the control of Medicaid to the states, and the conservative states have demonstrated that they will not adjust their programs to adequately meet the health care needs of low-income individuals and families for which the program was designed. The basic flaw is that, having been designed as a welfare program for the poor, it does not have the political support that a more egalitarian, universal program such as Medicare has (though Medicare is universal only for selected segments of our population, but at least it has a “we’re all in this together when we retire” element to health care coverage). So Medicaid needs to be folded into a comprehensive program that is there for all of us.

Expand subsidies for exchange plans?

The expansion of coverage through government subsidies of private health plans has had only a very modest impact, falling short by leaving tens of millions uninsured, and perpetuating low actuarial value plans that leave many underinsured with subsidies that are dependent on maintaining employment in lower income occupations – obviously a flawed policy concept. Also it leaves in place our very expensive and burdensome administrative complexity that, in total, wastes hundreds of billions of dollars that should be going to health care or toward lowering health care spending. Thus those in the exchange plans should also be folded into a more efficient, comprehensive program that covers all of us.

Continue to rely on employer-sponsored plans?

Over 60 million people leave their employment each year. Employer-sponsored plans are a highly unstable and inequitable method of financing health care.

Reduce eligibility for Medicare to age 60?

Boy does this leave a lot of people out. A few might benefit, but it does very little to correct the deficiencies that are confirmed by today’s report to still exist in spite of a decade under ACA. Even if many of the other measures were enacted (the concept of building on ACA) the profound inefficiencies and inequities in our system would be perpetuated. Medicare itself is still an inadequate program, needing significant improvements that would obviate the need for supplemental coverage such as Medigap or a retirement health benefit.

Offering Medicare as a public option?

Adding one more option to our highly fragmented, dysfunctional financing system leaves in place the profound deficiencies that cry out for reform. Also, the concept of offering Medicare as an additional option leaves unanswered design features such as which risk pool would cover the option and how would that risk pool be funded? If included in the current Medicare risk pool, would the participants be required to share the higher costs of the aged, disabled, and those with chronic renal disease? Rather than having a separate public option, it would be much more logical to fold everyone into one universal program that is funded equitably.

Today’s report on the failure of ACA along with the consideration of bogus replacement plans and grossly inadequate adjustments to ACA really leads to the conclusion that we need to enact and implement a single payer improved version of Medicare for All – a truly universal, comprehensive, efficient, equitable, and affordable plan for everyone.

But Joe Biden says we can’t pay for Medicare for All. Well, he is flat out wrong on that one. Innumerable studies have shown that a well designed single payer system will not cost any more that what we are already spending and would likely cost less. On the other hand, Joe Biden’s proposal leaves in place ACA and the various other programs and builds on them – adding new spending to that which already exists. His proposal costs more than single payer. Yes, Medicare for All shifts more spending to the tax system, but that is more than offset by eliminating private spending of premiums, including employer contributions to their plans, and of out-of-pocket spending for insurance cost-sharing and uncovered services.

This important report should be shared widely since, again, it shows that ACA “has not resolved key health care issues that have sustained US policy debates and fueled health economics scholarship for decades.” With single payer Medicare for All we can finally resolve this issue. It has become an absolute imperative.

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