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

The Issue

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

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

What the Study Found

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

The Big Picture

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

The Bottom Line

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

https://www.commonwealthfund.org…

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

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

Abstract

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

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Reader response:

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

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

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

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

By Charles Pack, Redbank

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

https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

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

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

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

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

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

Abstract

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

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

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

Working Paper 2020-08 (208 pages):
https://www.cbo.gov…

Blog by CBO Director Phillip Swagel:
https://www.cbo.gov…

Comment:

By Don McCanne, M.D.

As stated in the Abstract, “In this paper, CBO describes the methods it has developed to analyze the federal budgetary costs of proposals for single-payer health care systems that are based on the Medicare fee-for-service program.” Since their reports are provided for Congress, the emphasis is on federal spending rather than on our total national health expenditures. There should be no surprise that they do predict an increase in federal spending since the design of a single payer system does precisely that; it shifts health care spending to the federal government since financing is primarily through the tax system.

They do indicate that total national health expenditures would not change much when compared to our current spending, estimating somewhere between a decrease of $0.7 trillion to an increase of $0.3 trillion. They may have underestimated the savings in that, though they do credit the savings from the reduction of the administrative waste of the private insurers, they do not seem to quantify the very large savings from the reduction of the administrative burden placed on the health care delivery system, though they do acknowledge it as being a source of improved efficiency in the system. A recent systemic review by Christopher Cai, James Kahn and colleagues of twenty economic analyses of single payer indicate that they would all result in long-term net savings.

In indicating that increased demand would produce “increased congestion” in the health care system, they seem to underestimate the ability of the system to self-correct by giving a lower priority to services that are not of much benefit, though queue management is still important in any system.

Some of the experts consulted previously have been criticized for some of their assumptions in their single payer work, and others are experts in the aged and long term care and are not noted for their single payer work. There is also a notable absence of other academics who have long-standing reputations for their credible contributions to the single payer literature. In spite of that, this CBO report is still very useful in that it does what it says it does; it provides a description of CBO’s methods of analyzing single payer and thus would be helpful in understanding future single payer reports from them.

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By Stuart M. Butler
Brookings, December 9, 2020

SUMMARY

The American health system is rife with gaps and inequities. The result is inadequate or no insurance and services for millions of families and unacceptable differences in resources and health conditions related to income, race, and location. Resources are misallocated, the health care infrastructure in many communities is inadequate, and our financial support for health coverage is disjointed and inefficient.

It is time to move towards a health system in America that provides adequate, affordable, and accessible care to all U.S. residents, and that reaches this goal by refining existing programs, correcting the subsidy system, and using the power of federalism. Achieving this goal requires us to:

• Create an effective, grassroots community health system by expanding health clinics, creating other local points of access, focusing on social determinants of health, and addressing gaps in Medicaid.
• Reform the tax treatment of employment-based coverage to create universal subsidies that allow effective choices of coverage in an arrangement that could be described as “Medicare Advantage for All.”
• Use program flexibility and state innovation to create a truly national system with appropriate state variation.

SECTION SUBTITLES OF THIS REPORT

CHALLENGE

LIMITS OF HISTORIC AND EXISTING POLICIES

POLICY RECOMMENDATIONS

• Strategic principles for action.
• Create an effective grassroots population health system
  • Action: Expand community health centers.
  • Action: Make additional access points available.
  • Action: Focus on social determinants.
  • Action: Create an option for non-expansion states.
• Achieve equitable subsidies for insurance: Transition from employer-sponsored insurance to Medicare Advantage for All?
  • Action: Replace the tax exclusion with universal tax credits.
  • Action: Move to Medicare Advantage for All.
  • Create a national system with state variation
  • Action: Make greater use of waivers.

CONCLUSION

A byproduct of the COVID-19 pandemic is a better understanding today of the structural weaknesses of the U.S. health system and a growing appreciation and acceptance of what a reformed system should look like. Still, Americans hesitate to embrace big change in health care, even when they agree on the need for it. Fortunately, reform does not require a wholesale abandonment of the current system and the implacable opposition that likely would be triggered if that were attempted. There are many programs and elements of the current system we can build on and make consistent. Moreover, many of the key ideas discussed in this report have their roots in both political parties, and so, with genuine outreach to leading lawmakers on Capitol Hill, the Biden Administration could achieve bipartisan progress on health reform. Moreover, structural change does not have to come in the form of one giant bill; it can be achieved through a series of bills and administrative actions. Indeed, with a clear, shared vision of the objectives, some bold leadership, and a willingness to build on or remodel some existing parts of today’s system, there is a bipartisan path to an equitable, inclusive, and comprehensive American health system.

https://www.brookings.edu…

Comment:

By Don McCanne, M.D.

Many will remember that it was Stuart Butler who created the Heritage Foundation model that was used as the framework for the Affordable Care Act. It was selected by the Democrats as a model that would have the support of the Republicans because of its conservative bona fides. As it turned out, though the Republicans initially cooperated, it was decided that it was more important to deny President Obama a political success, and so the Republicans fought the measure, requiring the Democrats to make compromises that fell quite short of the equitable, comprehensive reform they intended.

Stuart Butler was not really satisfied with the result either. In the meantime, he wisely moved from the Heritage Foundation which had taken a more reactionary turn, and aligned himself with the moderate Brookings Institution. With the election of Joe Biden as president, an opportunity has arisen to repair the defects in the original ACA legislation, and so Butler presents his views here on what he believes would be “a bipartisan path to an equitable, inclusive, and comprehensive American health system.”

If you believe that reform should be based on making improvements in the Affordable Care Act, as Biden has supported, then the proposal is an effective model of expanding coverage and making it more equitable. It is important to understand it since it is likely that it, or a very similar model, will have strong support by the Biden camp, fulfilling his stated desire to work across the aisle. Just as ACA provided beneficial changes in health care financing, this expansion and correction would as well.

But there are very serious deficiencies in this proposal. Above all, it would leave in place most of the current, highly inefficient, administratively complex and costly health care financing infrastructure which is a major cause of our outrageously high health care costs. In fact, of all of the models of reform, this is perhaps the most expensive, when achieving affordability is one of the primary goals of reform.

Butler points out that his model would be bipartisan because it includes specific policies that come from each side of the political spectrum and some policies on which there is mutual agreement. Although the policies expanding health care justice would certainly be welcome, other policies that further privatize the system, such as a move towards private Medicare Advantage for All, should be rejected since private plans have been responsible for many of the injustices in health care today.

We’ve stated several times before that we need to get the policy right and then change the politics to enable enactment and implementation of those policies. Butler has it backwards. He is trying to clear the political hurdles by accepting flawed policies that would appeal to the ideological preferences of those on the right, assuming that the left will accept any compromises as long as reform is advanced, as they did with ACA.

If we want the most affordable program that is truly universal, comprehensive, and especially is equitable, then we need to enact a well designed, single payer, improved Medicare for All, but we’ll need to travel the rough political road of convincing Joe Biden that Medicare for All is what we want and need.

In the meantime, try to understand Stuart Butler’s proposal so we can explain to President Biden and everyone else why we do not want to go that route.

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American Hospital Association, December 2020

Introduction

Health care coverage has never been more important as the nation battles the COVID-19 pandemic – now and for the foreseeable future. Two-thirds of the population relies on the private sector for health insurance coverage and thus access to health care. While private health insurance coverage has long served as the backbone of our national system, that very coverage and the security it offers millions of Americans is eroding at an alarming pace. Health care insurance was originally designed to be a straightforward financial agreement between a health plan and a consumer: the consumer paid a premium in exchange for coverage of a set of health care services offered by a certain group of providers. If disputes arose, consumers could expect that adjudication of the claim would follow a fair, efficient, and transparent process. This agreement, underpinning America’s system of health insurance for decades, is beginning to slip away in some markets across the country, and the COVID-19 public health emergency is further shining light on its erosion.

Not only are private health insurance plans the dominant source of health care coverage for most Americans, but employers, as well as the Medicare and Medicaid programs, rely on private health plans to provide or administer their health benefits. Approximately one-third of Medicare beneficiaries are enrolled in a private Medicare Advantage health plan, and nearly all states enroll some or all of their beneficiaries into Medicaid managed care plans.

Coverage through these plans is eroding as some health insurers restrict access to health care services by abusing utilization management programs and changing health plan rules in the middle of a contract year. For example, prior authorization, one of the most widely used utilization management tools, is designed to help patients obtain the right care in the right place. Insurers use prior authorization to ensure that providers order care that is consistent with clinical guidelines and protocols, as well as to confirm that such care is covered by the patient’s plan. This tool was designed to primarily help guide (and monitor) providers’ decision-making around treatments that are new, particularly high cost, or that have a history of questionable use. However, some plans are now applying prior authorization to a wide range of services, including those for which the treatment protocol has remained the same for decades and there is no evidence of abuse.

Unjustified use of utilization management tools like prior authorization has a number of negative implications for patients and the health care system. Patients are often blindsided by denials and can face unexpected medical bills as a result. The extensive approval process that doctors and nurses must go through adds billions of wasted dollars to the health care system and contributes to clinician burnout.

Evidence of the negative impact of these practices is mounting. The Department of Health & Human Services Office of the Inspector General (OIG) warned in a September 2018 report that high rates of Medicare Advantage (MA) health plan payment denials and prior authorization delays could negatively impact patients’ access to care. In 2019, a federal court found that the largest commercial insurer in the United States was abrogating the entire point of health insurance by systematically denying medically necessary, covered behavioral health services for financial reasons. It is worthy of note that in response to COVID-19, many health insurers, including at the urging of government, scaled back the use of many of these tactics precisely because they create barriers to care. State governments, as the primary regulators of insurance, have also taken action. For example, New York State passed a number of insurer accountability measures at the beginning of the COVID-19 to help ensure patient access to care and to remove unnecessary burdens on providers on the front lines.

In 2019, the American Hospital Association (AHA) fielded a survey to better understand the impacts of health plan utilization management practices on patients and providers. More than 200 hospitals and health systems responded. Their data was supplemented with interviews and group discussions with several hundred additional hospital and health system executives. The following report documents our findings related specifically to prior authorization and payment delays and denials. While these findings pre-date the COVID-19 public health emergency, they remain not only relevant but serve to underscore the urgency to address these issues as hospitals remain on the front line of care for COVID-19 patients. The report offers policymakers solutions to reduce the risk and burden of these programs while still enabling health insurance plans to compete on quality, benefit package design, provider networks, and other important aspects of coverage.

(This nine page report then discusses problems with interacting with the private commercial insurers, especially with prior authorization and with reimbursement delays and denials. They then discuss their view of potential policy solutions.)

Conclusion

Certain health plan practices threaten patient access to care and drive excessive administrative costs and burden in the health care system. While these concerns pre-date COVID-19, the current public health emergency both highlights and demands immediate action to protect patients and providers. Regulators should increase their oversight of health plans and implement a comprehensive simplification agenda, beginning with streamlining prior authorization requirements and processes, as well as monitoring for abusive payment delays and denials. These efforts will go a long way to addressing unnecessary costs in the system and allow for a more rational, navigable health system for patients.

https://www.aha.org…

AHA Comments on “Medicare for All”

By Tom Nickels, Executive Vice President AHA
American Hospital Association, February 27, 2019

America’s hospitals and health systems are working with policymakers to help expand coverage and improve affordability for all Americans. However, we are opposed to “Medicare for All,” as it would impede our shared goals.

To start, a one-size-fits-all approach would disrupt coverage for the more than 180 million Americans who are covered by employer-sponsored health plans. That coverage, and plans sold on the marketplaces, offer benefits that Medicare doesn’t. Importantly, enrollees in these plans are protected from catastrophic costs.

Further, the government can be an unreliable business partner, as we just witnessed with the longest partial government shutdown in our nation’s history. Congress also has a history of slashing provider payments for government health programs to meet its budgetary goals.

Additionally, important delivery system reforms to improve care, enhance quality and reduce costs would no longer be a priority once government controls all payments to providers.

Finally, public programs like Medicare and Medicaid reimburse providers less than the cost of delivering care for patients, which exacerbates access problems.

The AHA believes there is a better alternative to help all Americans access health coverage – one built on fixing our existing system rather than ripping it apart and starting from scratch. In addition to expanding Medicaid in the remaining non-expansion states, we support strengthening the marketplaces to improve their stability and affordability, and increasing enrollment efforts to connect people to coverage.

https://www.aha.org…

Comment:

By Don McCanne, M.D.

It is no surprise that members of the American Hospital Association (AHA) recognize the abuses of the private commercial insurance plans since they have to deal with them on a daily or even hourly basis. Although this report focuses on prior authorization and payment abuses, the extensive other problems, especially private insurers being the primary source and cause of the hundreds of billions of dollars in administrative waste in health care financing, should lead us to the conclusion that this industry should be eliminated. But what does AHA say?

In slamming the private commercial insurance industry, including private employer-sponsored plans, AHA certainly recognizes the source of these problems. But what about public insurance programs such as Medicare and Medicaid? AHA’s expressed complaint in today’s report is not with government administered plans but rather with private Medicare Advantage and the private Medicaid managed care plans.

AHA’s proposed solutions for prior authorization and payment abuses would leave in place our very expensive, fragmented and highly dysfunctional health care financing system, and would only tweak some of the administrative complexities. If the corrective measures would reduce the insurers’ net revenue, being masters of innovation, they would find other means of milking more out of the system. It is in their nature, and they will not change.

The hospitals would clearly benefit from a well designed, single payer, improved version of Medicare that covered everyone, so why do they not support it? The statement from AHA advances specious arguments such as the trite contention that “a one-size-fits-all approach would disrupt coverage.” Actually we should want the current coverage to be disrupted since it is the source of much of the dysfunction with health care financing.

Medicare does need to be improved and that would occur with enactment of Medicare for All, but the only real complaint AHA has is that the reimbursement rates are low. With the PNHP single payer model, hospital payment would be converted to global budgets, much like fire departments. The government would have to budget enough funds to be certain that the capacity of the system is adequate and that distribution is appropriate for the needs.

AHA and the AMA should concede that the health care system should be designed and financed to meet the health care needs of the patients. That means that the system needs to be adequate and then the physicians and hospitals will do just fine. And just think how pleasant the task will be when the system is finally cleared of all of the administrative garbage dumped on us by the private insurers.

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