PNHP

Vermont Medical Society endorses single payer

Vermont Medical Society endorses single payer

VMS is the second state medical society to endorse single-payer health care, joins national medical groups American College of Physicians and Society of General Internal Medicine in supporting Medicare for All.

By Clare Fauke
PNHP, November 23, 2020

The Vermont Medical Society (VMS) overwhelmingly endorsed a resolution supporting a single-payer national health program, also known as Medicare for All, at its annual meeting on Saturday, Nov. 7. The VMS, which represents 2,400 Vermont physicians and physician assistants, is only the second state medical society in the U.S. after Hawaii to formally endorse a national single-payer health care program.

The historic vote by VMS follows a year of rapid movement among physicians and other health professionals towards single-payer reform. In January 2020, the 159,000-member American College of Physicians announced its endorsement of Medicare for All, along with a “universal public choice” reform model. In August, the 3,300-member Society of General Internal Medicine endorsed a similar resolution. Meanwhile, more than 50 municipalities have passed resolutions endorsing Medicare for All, including major cities such as Philadelphia, Detroit, Seattle, San Francisco, Minneapolis, and Cook County, which includes Chicago. These resolutions reflect growing public support for a national health program: Last week, a Fox News election exit poll found that 72% of voters now favor Medicare for All reform.

The VMS resolution was introduced by Dr. Jane Katz Field, a pediatrician and vice president of the Vermont chapter of Physicians for a National Health Program (VTPNHP). “The need for universal single-payer health care has never been more urgent,” said Dr. Katz Field. “Thirty million Americans were already uninsured before the COVID-19 pandemic, and millions more continue to lose coverage as they lose their jobs. Today the Vermont Medical Society recognizes the need to move away from a broken health system that ties health care to employment, and towards a system of equitable and universal coverage.”

https://pnhp.org…

Comment:

By Don McCanne, M.D.

It has been a long, slow process, but we are now seeing support for single payer reform moving into the leadership of organized medicine – the state medical associations and even the AMA. Young physicians and medical students recognize the serious deficiencies in health care in the United States, and they are determined to do something about it. With their efforts, we may soon see formal endorsement of Medicare for All by their delegate bodies, eventually including the AMA. It can’t come too soon.

At this Thanksgiving time, we can be thankful that this movement for health care justice for all is coming from our future health care professionals. We will be in good hands.

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Fauci Awards: Special thanks on this Thanksgiving Day

What if public health officials got awards instead of death threats?

Video by Adam Westbrook and Emily Holzknecht
The New York Times, November 25, 2020

The Fauci Awards (6 minute video):
https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

As a resident of Orange County, California, I want to give my special thanks to Dr. Nichole Quick, who appears in this video.

Our home looks down on Dana Harbor, which is our favorite place to walk. Signs are posted indicating that face masks are required, as is social distancing. To no surprise in this conservative county, compliance is relatively poor. In response, I designed the following T shirt:

In spite of my sincerity, I decided that I could face repercussions by wearing this shirt, so I don’t. Instead, we walk in our own neighborhood which has light traffic because of the dead end streets. Though we wear our masks and maintain social distancing, it is still a pleasure to greet our neighbors as we walk by, something new for us this year since previously our schedules had been too full for neighborhood walks. We can add to our list our thanks for the nice neighbors we have.

And may the spirit move us to achieve health care justice for all.

Happy Thanksgiving!

(Perplexed? Me too.)

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Current Affairs: Why Private Health Insurance Makes No Sense

It’s important for everyone to understand exactly why it needs to be gotten rid of.

By Nathan J. Robinson
Current Affairs, November 21, 2020

Everyone has health, everyone needs healthcare. It is in all of our interest to have as good of healthcare as possible, delivered as inexpensively as feasible. We should all want it to be easy to get the care we need, and for nobody to fret about money when they go to the doctor.

I want to explain as clearly and simply as possible, then, why having for-profit private health insurance companies is fundamentally irrational and harmful.

(The author describes, with diagrams, how money flows in health care now, and how it would eventually flow in a single payer Medicare for All system.)

We have made sure in this model that the pool of money collected from the people who need healthcare is the same as the pool used to buy healthcare, by routing these funds through a different kind of artificial legal construct called a government, which operates by different rules and has a mandate of securing the common good of all the little dot-people on the left rather than a particular subset of wealthy people. Even better, because there is only one government, instead of many insurance companies, the monopoly on health financing gives greater power to bargain with the providers for better rates. The government is essentially a “corporation” comprised of everybody that can exercise the collective will of the people on the left as determined through a democratic process.

From your perspective as one of the magenta dots, what you care about is not whether the flow of funds is called a “tax” or a “premium,” but what the size of the green arrow going from you to the healthcare financing institution is (i.e. how much you pay) and what the size of the arrow coming back from the providers is (i.e. what you get in return). If you get a better deal under the single-payer system, it doesn’t matter how much it raises your taxes, because that amount is more than canceled out by the savings you get through not paying premiums and copays anymore.

Under no sensible theory do we want private, for-profit institutions diverting money that should be spent keeping you well. (I should note, too, that government spending already constitutes a huge part of American healthcare. We are simply talking about eliminating the part of national healthcare spending that is not conducted in the public interest, by switching it from being routed through a badly-designed institution to being routed through a well-designed one.)

I have presented my explanation here in a very simple way, and you may think this is all a thunderingly obvious point that does not need little graphics with dots in order to grasp. But there are plenty of people in the country who either do not understand it or are lying about it. Consider Pete Buttigieg, one of the main Democratic candidates for president this year. Pete Buttigieg criticized a single-payer health plan on the grounds that it would raise taxes and cost trillions of dollars. As you can see, while Buttigieg’s criticisms sound real, they are actually irrelevant. We are talking about which type of institution our healthcare dollars should flow through. Should they be called “premiums” and skimmed by insurance companies with no institutional mandate to care about everyone, or should they be called “taxes” and routed through a democratic, collectively-owned institution that has a mandate to serve universal needs?

Try to think less about words like “taxes” and “trillions of dollars” and more about what is actually going on and what it means for you.

Let’s have some clarity and ask the questions that matter, the most important of which is: how does a for-profit health insurance industry make any rational sense at all? The answer to which is clear from thinking about the basics of how it works. It doesn’t make sense. It doesn’t.

https://www.currentaffairs.org…

Comment:

By Don McCanne, M.D.

How often have you heard people say that we can’t afford the taxes to pay for single payer Medicare for All? Even President-elect Joe Biden said during the campaign, “How are you going to pay for it?”

Regular readers here understand the efficiencies of funding our entire health delivery system through equitable taxes, but it is sometimes difficult to explain that to individuals who are hung up on the concept that taxes are bad. Although the full article is somewhat long, it is very useful to explain to those willing to read it why paying for health care through the tax system is a vastly superior method to our current inefficient and inequitable method of financing health care.

The full article should be shared with those who still think that private insurance is a better way to fund health care when clearly public financing is the right way to go.

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Will telemedicine improve acute care management?

Improve Emergency Care? Pandemic Helps Point the Way

Momentum is gathering for telemedicine, which could alleviate a longstanding problem: wait times.

By Austin Frakt
The New York Times, November 23, 2020

The pandemic may present an opportunity to reshape the future of emergency medicine.

The coronavirus has already prompted health care leaders to rethink how to deliver care to make the most of available resources, both physical and digital. If the shift to greater use of telemedicine continues after the pandemic, it could reduce reliance on the emergency room, where crowding has long been a problem.

This could happen if telemedicine increases the ability for doctors to see more patients more quickly.

Of course, telemedicine isn’t a solution for every health problem. And patients with limited digital fluency and access may get left behind as reliance on telemedicine grows. But the potential payoff is large: A review of medical records of older patients found that 27 percent of emergency room visits could have been replaced with telemedicine.

On average, a patient visiting an emergency room will wait about 40 minutes. Although that’s down from about an hour a decade ago, 17 percent of patients visiting an emergency department in 2017 waited over an hour. About 2.5 percent waited more than two and a half hours.

As many studies have documented, longer wait times can be harmful. Longer waits can also increase costs.

Additionally, many people end up waiting in the emergency department on the advice of other medical providers, though they may not need to. Their problems could be handled elsewhere.

Once the pandemic fades, the momentum from telemedicine may continue, with the possibility of making progress on a problem that shouldn’t wait.

NYT Reader Comment:

By Don McCanne, M.D.

How should an acute problem be managed? By telephone? By telemedicine? By an urgent primary care office visit? By an urgent care center? By an emergency department? Should a private insurance company be dictating the approach? Should a less appropriate approach be dictated by the source of payment whether due to a lack of insurance or through very high deductibles, or due to restrictions of provider networks established by private insurers?

Sorting these approaches through triage based on clinical circumstances can improve the efficiency of our health care system, but it would be far more effective if we remove one important stumbling block: disrupting entrance into the health care system based on our dysfunctional, fragmented system of financing health care.

If we had a well designed, single payer improved Medicare for All system that removed the dictates of private insurance bureaucrats, with their provider networks and prior authorization requirements, then we could improve the flow within our health care delivery system, obtaining the appropriate care at the appropriate place at the appropriate time for the appropriate patient. Addition of the option of telemedicine can only improve this flow when it is appropriate for the clinical circumstances.

https://www.nytimes.com…

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Vermont Medical Society endorses single-payer health care reform

VMS is the second state medical society to endorse single-payer health care, joins national medical groups American College of Physicians and Society of General Internal Medicine in supporting Medicare for All

FOR IMMEDIATE RELEASE
Nov. 23, 2020
Contact: Clare Fauke, PNHP Communications Specialist, clare@pnhp.org

The Vermont Medical Society (VMS) overwhelmingly endorsed a resolution supporting a single-payer national health program, also known as Medicare for All, at its annual meeting on Saturday, Nov. 7. The VMS, which represents 2,400 Vermont physicians and physician assistants, is only the second state medical society in the U.S. after Hawaii to formally endorse a national single-payer health care program. 

The historic vote by VMS follows a year of rapid movement among physicians and other health professionals towards single-payer reform. In January 2020, the 159,000-member American College of Physicians announced its endorsement of Medicare for All, along with a “universal public choice” reform model. In August, the 3,300-member Society of General Internal Medicine endorsed a similar resolution. Meanwhile, more than 50 municipalities have passed resolutions endorsing Medicare for All, including major cities such as Philadelphia, Detroit, Seattle, San Francisco, Minneapolis, and Cook County, which includes Chicago. These resolutions reflect growing public support for a national health program: Last week, a Fox News election exit poll found that 72% of voters now favor Medicare for All reform. 

The VMS resolution was introduced by Dr. Jane Katz Field, a pediatrician and vice president of the Vermont chapter of Physicians for a National Health Program (VTPNHP). “The need for universal single-payer health care has never been more urgent,” said Dr. Katz Field. “Thirty million Americans were already uninsured before the COVID-19 pandemic, and millions more continue to lose coverage as they lose their jobs. Today the Vermont Medical Society recognizes the need to move away from a broken health system that ties health care to employment, and towards a system of equitable and universal coverage.”

Dr. Katz Field added that the VMS also endorsed a second resolution reaffirming the group’s support “for universal access to comprehensive, affordable, high quality health care, centered on increased investment in primary care, reduced administrative burden and public health interventions that address the social determinants of health.” According to the resolution, any national health system would need to provide equitable access, minimal cost sharing, and fair reimbursement to practitioners.  

Aside from funding the program through a publicly financed system, VMS developed a list of “core criteria” that a national health program would have to meet: 

  • Affordability, with no cost sharing for patients;
  • Universal, equitable coverage for all U.S. residents;
  • Comprehensive and high quality coverage for all medically necessary services;
  • Fair reimbursement of physicians and other clinicians, particularly those in primary care;
  • Collective participation by physicians and other practitioners in negotiating rates and policies;
  • Global operating budgets for hospitals (similar to the way fire departments are funded);
  • Elimination of for-profit health insurance companies in order to reduce administrative costs and burdens on clinicians.

The VMS’ endorsement comes at a pivotal time for health care reform in Vermont and nationally. Both of Vermont’s U.S. senators (Bernie Sanders and Patrick Leahy) support Medicare for All legislation in the Senate. Vermont’s U.S. representative, Peter Welch, is a sponsor of Medicare for All legislation in the House. Many single-payer advocates are also asking their members of Congress to pass emergency coverage for the duration of the COVID-19 pandemic. 

Physicians for a National Health Program is a nonprofit research and education organization whose more than 23,000 members support single-payer Medicare for All reform.

AMA recognizes racism as a threat to public health

A Historic Day For Black Women, A Historic Day For The American Medical Association

The AMA and its House of Delegates overwhelmingly voted for the first time to adopt policies that name and act on racism as a public health threat.

By Aletha Maybank
Essence, November 18, 2020

Betsey, Lucy, and Anarcha. The names of three enslaved women were memorialized on screen during the third episode of the first season of HBO’s Lovecraft Country. These names symbolize three women who were stripped further of any sense of human dignity during their time held captive and surgically experimented on without anesthesia for years by a prominent, white physician, J Marion Sims, to preserve one of the earliest engines of capitalism: the Black woman’s womb.

Dr. Sims has been considered the ‘father of gynecology’ — he invented the vaginal speculum still used today, and in 1875, he was elected President of the American Medical Association (AMA), the oldest, largest, and considered the most powerful organized body of medicine in the country. In reality, Sims’ presidency despite his gross use of power and disturbing legacy is not an isolated moment of racist norms within the AMA. This troubling history of medical experimentation is deeply connected to the health inequities Black women still experience to this day — a heartbreaking reminder of how systemic racism and health care have been intertwined for centuries.

In recent years, AMA has begun to reckon with not only its own racist past, but also the racist past of the larger field of medicine, in which it has been highly influential.

And this past Monday marked an historic day for the entire of community of medicine and the broader society at large: the American Medical Association and its House of Delegates for the first time in its history passed and adopted policy that sheds light on the harms and tragedies of racism for all of society and medicine to see. The 600+ delegates from across the nation voted overwhelming to adopt policies that name and act on racism as a threat to the public’s health, rid our healthcare system of racial essentialism, and support the elimination of race as a proxy for ancestry, genetics, and biology in medical education, research, and clinical practice.

It is racism, not race that produces higher death rates among Black women during childbirth, and of the babies that they bear. Years of institutional and structural racism has produced the highest rates of heart disease and high blood pressure for Blacks. Racism has produced the highest rates of getting and dying from COVID-19. How powerful it is that one of this nation’s founding tenets is now a recognized threat to its existence and the existence of the most targeted and harmed by the profession whose code of ethics demands that we “do no harm.” But we know that racism in medicine has created and perpetuated generations of harm.

While not exactly known, a confluence of events pushed the AMA to this critical juncture in history – the presidency of the first Black AMA President, the leadership of the Black Lives Matter movement, resurgence of white supremacist action and terror, previous efforts of AMA’s Commission to End Health Disparities, recent AMA policy for the establishment of the AMA’s Center for Health Equity, the exposure of long-standing inequities by COVID-19, and the countless public murders of Black women and men at the hands of police, to name a few.

As a matter of time, most would say AMA’s recent actions are long overdue. We cannot go back. However, we can and must now better understand the harms of racism and work to dismantle and redesign injustice out of our culture and systems.

A core strategy to ensure justice in our systems is centering the voices of those most marginalized. Many of our brave leaders of the reproductive justice movement have long said, “listen to Black women.” Black women bring their minds and their hearts, as well as their lived experiences to justice work – it is personal in every way. The toll racism takes upon Black women, whether advocating inside or outside of organizations, is often underappreciated.

This Tuesday, as the deliberations of the AMA’s House of Delegates ensued, Black women physicians shared their stories experiencing and witnessing discrimination and racism at the hands of medicine and of police. Their stories, along with other AMA voices of student and physicians, changed hearts and minds and moved the house of medicine toward a brighter day.

As Black women leading justice work – formally and in our everyday lives, exhaustion permeates our minds and hearts. Black women have fought in body and voice, in silence and with great stir. And the cost to our health has been great and unjust exemplified by the extraordinary lives of Betsey, Lucy, and Anarcha – our ‘mothers of modern gynecology.’

The way forward for the AMA and other historically white institutions in our nation necessitates meaningful and deliberate action from many more accomplices, not only those of us most marginalized historically, operating in coalition and with great urgency.

Our collective freedom demands it.

Aletha Maybank, MD, MPH, recently joined the American Medical Association (AMA) in April 2019 as their inaugural chief health equity officer and vice president. Her role is to embed health equity in all the work of the AMA and to launch a Health Equity Center.

https://www.essence.com…

AMA: Racism is a threat to public health:
https://www.ama-assn.org…

Comment:

By Don McCanne, M.D.

With all of the bad things happening recently, one good that has come out of this is the awakening of those of us who have long recognized that racism is still with us and that is a bad thing, but who have been insensitive to the prevalence and intensity of structural racism. By our passivity and sometimes blindness to subtle and even frank racism, we have been unintentional accomplices to the perpetuation of structural racism. Our awakening allows us to first recognize our role and then to do something about it (which won’t be addressed here because of the complexity of the subject).

Although Physicians for a National Health Program (PNHP) has long supported primarily single payer health care reform, we also support other policies of health care justice, including addressing the racial inequities and injustices that can result in adverse health outcomes. In our reawakening we are currently revising our mission statement which should more clearly express this goal.

The American Medical Association (AMA) has, through the decades, supported the interests of physicians. They have not been very big on issues of health care justice, although they have not been totally blind to the topic. On average, their membership has been more politically conservative than the membership of PNHP, though there is overlap in both organizations, but that has caused the AMA to continue to reject comprehensive, universal, equitable health care coverage for everyone. However, especially with the input of students in medicine and the other health professions, that resistance has been subsiding.

This week the AMA House of Delegates has taken a giant leap forward by approving “policy that sheds light on the harms and tragedies of racism for all of society and medicine to see.”

It is hoped that this introduces a new era for the AMA in which they join with organizations such as PNHP in strongly supporting health care justice for all. Since their current policies on health care financing fall far short and would perpetuate most of the current injustices, we would urge them to finally come on board and support single payer improved Medicare for All. At least, considering the HOD resolution they adopted this week, we know that they do have their compass pointed in the right direction.

(Don McCanne is a member of both PNHP and the AMA.)

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Biden Ran on a Return To Normalcy, but There’s Nothing Normal About the American Health Care System

In poll after poll, Americans have indicated their preference for a universal, single-payer health care system. Compromise and half-measures are not acceptable. Medicare for All remains the goal.

By Jonathan B. Kotch, M.D., M.P.H. and Jonathan Michels
Common Dreams, November 20, 2020

The federal response to the deadly coronavirus pandemic under President Trump has been a public health disaster with nearly 250,000 Americans dead and no clear end in sight.

In sharp contrast, President-elect Joe Biden pledged to mount a serious response against the coronavirus. Biden implored Americans in a recent speech to continue to wear face masks and announced a panel of health care experts to begin to counter a surge of COVID-19 hospitalizations throughout the country.

On the matter of health reform, however, the president-elect offers measures that would merely bolster and even expand the same private health insurance system that has generated increasing profit during the pandemic while depriving the country of the resources necessary to produce an adequate supply of PPE. Physicians, nurses and other frontline health care workers are fighting COVID-19 with their hands tied behind their backs.

Biden ran on returning the country to normalcy, but there was nothing normal about the American health care system even before the pandemic. In fact, our dysfunctional health care system remains an outlier among the rest of the developed world for not providing universal health coverage.

The American health care system devours an ever-increasing share of our economy with health spending accounting for an astounding 17.9 percent of the GDP, the highest in the world. Yet we have little to show for it. Americans suffer some of the worst health outcomes compared to other industrialized nations. Even before the coronavirus hit the U.S., life expectancy was on the decline. Our infant and maternal mortality rates are higher than those of any comparable country, and racial and ethnic disparities in infant and maternal mortality are getting worse.

The quality of American health care isn’t any good either. Shockingly, more than 250,000 Americans die each year from medical errors. That’s nearly as many as the amount of people that have died from COVID-19 as of this writing.

Is that the kind of return to normalcy that Americans want, need, or deserve?

The answer, of course, is no.

In poll after poll, Americans have indicated their preference for a universal, single-payer health care system. An exit poll on election day conducted by Fox News revealed that 72 percent of voters wanted a government-run health care system.

That publicly-funded system, more commonly known as Expanded and Improved Medicare for All, is within our grasp. All we need to do is call out those Senators and Congresspeople who are in the pockets of the private, for-profit health care industry. According to Open Secrets, health care providers, Big Pharma, medical equipment manufacturers, and drug and medical product retailers pumped $178 million into the 2020 election cycle so far. Separately the insurance industry (including but not limited to health insurance) added another $85 million. The new kid on the block, adark-money group called the Partnership for America’s Health Care Future, has been targeting Democrats who support either Medicare for All or the “public option” in its 2020 election year ad campaigns. No wonder legislators continue to ignore the clear desire of their constituents for a health care system that puts the public, not the shareholder, first.

For health care reform advocates who want to purge profiteering from health care, returning to “normal” is not an option.

More than 10 years after the passage of the Affordable Care Act (ACA),87 million Americans remain uninsured or underinsured. The ACA has not changed the fact that medical bills continue to push millions of people into personal bankruptcy, with Americans having borrowed a stunning $88 billion to pay for medical treatment in 2018 alone. Nor has the ACA halted the inexorable increase in premiums, deductibles and copayments that are blocking access to care for millions of workers and their families who have employer-based group health insurance that is too expensive to use.

Biden’s public option plan, which would enable people to enroll in publicly-funded insurance plans that would compete against private insurers on the ACA’s marketplace exchanges, won’t change this picture either. A 2013 analysis conducted by the Congressional Budget Office predicted that a public option would have “minimal effects” on the number of uninsured. For a real world example, we need only to look at the abysmal failure of the nonprofit health insurance co-ops that were given a similar mandate to compete with private insurance under the ACA. Out of the 26 original co-ops, only three exist today.

The public option is destined to fail as long as private health insurers are allowed to thrive. They will find new and increasingly sophisticated ways to undermine public insurance by cherry-picking the healthiest subscribers for themselves and shunting the more expensive, chronically ill patients to public insurance, compromising the potential savings that universal public financing of health care would yield.

While the historic election of Biden and Harris removed the immediate threat of a draconian take-down of the ACA, it does not augur well for the kind of transformative social change that Americans need right now. The struggle continues. Compromise and half-measures are not acceptable. Medicare for All remains the goal.

Dr. Jonathan B. Kotch, a board-certified specialist both in Pediatrics and Preventive Medicine, is Research Professor Emeritus in the UNC Gillings School of Global Public Health.

Jonathan Michels is a freelance journalist and a premedical student based in Winston-Salem, North Carolina. He is a member of the media team for Students for a National Health Program.

https://www.commondreams.org…

Is it a “good” public option or a “bad” public option?

Interview with Dr. Ed Weisbart

KTRS 550am, November 19, 2020

PNHP-MO chair Dr. Ed Weisbart appeared on KTRS radio to discuss the urgent need for single-payer Medicare for All, especially during the COVID-19 pandemic. “We’re all in this together,” he said, adding that, “you really, desperately want everyone around you to get health care when they need it.”

But given that president-elect Joe Biden does not support Medicare for All, Dr. Weisbart also outlined what a good and bad version of a public option would look like.

In a best-case scenario, he said, the public option would be truly public (not administered by commercial insurance companies), would offer generous benefits that exceed those of the traditional Medicare program, and would start big by auto-enrolling everybody who is uninsured (while also giving individuals the ability to opt out). In a worst-cast scenario, commercial insurers would use the public option as a means of not covering sicker, more expensive patients.

https://soundcloud.com…

President Obama on trading off health policy for political victory

A President Looks Back on His Toughest Fight

The story behind the Obama Administration’s most enduring—and most contested—legacy: Reforming American health care

By Barack Obama
The New Yorker, October 26, 2020, Published November 2, 2020

When I think back to those early conversations, it’s hard to deny my overconfidence. I was convinced that the logic of health-care reform was so obvious that even in the face of well-organized opposition I could rally the American people’s support.

As for the political hazards that Axe and Rahm worried about, the recession virtually guaranteed that my poll numbers were going to take a hit anyway. Being timid wouldn’t change that reality. Even if it did, passing up a chance to help millions of people just because it might hurt my reëlection prospects—well, that was exactly the kind of myopic, self-preserving behavior I’d vowed to reject.

The question was whether we could get it done. Any major health-care bill meant rejiggering a sixth of the American economy. Legislation of this scope was guaranteed to involve hundreds of pages of endlessly fussed-over amendments and regulations.

There was also the question of how to pay for the changes. To cover more people, I argued, America didn’t need to spend more money on health care; we just needed to use that money more wisely.

In other words, both the politics and the substance of health care were mind-numbingly complicated. I was going to have to explain to the American people, including those with high-quality health insurance, why and how reform could work. For this reason, I thought we’d use as open and transparent a process as possible.

Among many progressives, the need to replace private insurance and for-profit health care with a single-payer system like Canada’s was an article of faith. Had we been starting from scratch, I would have agreed with them; the evidence from other countries showed that a single, national system—basically, Medicare for All—was a cost-effective way to deliver health care. But neither Massachusetts nor the United States was starting from scratch. Teddy, who despite his reputation as a wide-eyed liberal was ever practical, understood that trying to dismantle the existing system and replace it with an entirely new one would be both a nonstarter politically and hugely disruptive to the economy. Instead, he’d embraced the Romney proposal and helped the Governor line up the Democratic votes in the state legislature required to get it passed into law.

The slow march toward health-care reform consumed much of the summer. As the legislation lumbered through Congress, we looked for any opportunity to help keep the process on track. The good news was that the key Democratic chairs—especially Baucus and Waxman—were working hard to craft bills that they could pass out of their respective committees before the traditional August recess. The bad news was that the more everyone dug into the details of reform, the more differences in substance and strategy emerged—not just between Democrats and Republicans but between House and Senate Democrats, between the White House and congressional Democrats, and even between members of my own team.

Politically and emotionally, I would have found it a lot more satisfying to just go after the drug and insurance companies and see if we could beat them into submission. They were wildly unpopular with voters, and for good reason. But, as a practical matter, it was hard to argue with Baucus’s more conciliatory approach. We had no way to get to sixty votes in the Senate for a major health-care bill without at least the tacit agreement of the big industry players.

By the end of June, they’d hashed out a deal, securing hundreds of billions of dollars in givebacks and broader drug discounts for seniors using Medicare. Just as important, they’d gotten a commitment from the hospitals, insurers, and drug companies to support—or at least not oppose—the emerging bill.

It was a big hurdle to clear, a case of politics as the art of the possible. But for some of the more liberal Democrats in the House, where no one had to worry about a filibuster, and among progressive advocacy groups that were still hoping to lay the groundwork for a single-payer health-care system, our compromises smacked of capitulation, a deal with the devil. More than a few constituents wrote in to ask whether I’d gone over to the dark side.

A preliminary report by the Congressional Budget Office, the independent, professionally staffed operation charged with scoring the cost of all federal legislation, priced the initial House version of the health-care bill at an eye-popping one trillion dollars. Although the C.B.O. score would eventually come down as the bill was revised and clarified, the headlines gave opponents a handy stick with which to beat us over the head. Democrats from swing districts were now running scared, convinced that pushing forward with the bill amounted to a suicide mission. Republicans abandoned all pretense of wanting to negotiate, with members of Congress regularly echoing the Tea Party’s claim that I wanted to put Grandma to sleep.

The only upside to all this was that it helped me cure Max Baucus of his obsession with trying to placate Chuck Grassley. In a last-stab Oval Office meeting with the two of them in early September, I listened patiently as Grassley ticked off five new reasons that he still had problems with the latest version of the bill.

“Let me ask you a question, Chuck,” I said finally. “If Max took every one of your latest suggestions, could you support the bill?”

“Well . . .”

“Are there any changes—any at all—that would get us your vote?”

There was an awkward silence before Grassley looked up and met my gaze. “I guess not, Mr. President.”

I guess not.

To overcome the possibility of a filibuster, Harry couldn’t afford to lose a single member of his sixty-person caucus. And, as had been true with the Recovery Act, this fact gave each one of those members enormous leverage to demand changes to the bill, regardless of how parochial or ill-considered their requests might be.

This wouldn’t be a situation conducive to high-minded policy considerations, which was just fine with Harry, who could maneuver, cut deals, and apply pressure like nobody else. For the next six weeks, as the consolidated bill was introduced on the Senate floor and lengthy debates commenced on procedural matters, the only action that really mattered took place behind closed doors in Harry’s office, where he met with the holdouts one by one to find out what it would take to get them to yes. Some wanted funding for well-intentioned but marginally useful pet projects. Several of the Senate’s most liberal members, who liked to rail against the outsized profits of Big Pharma and private insurers, suddenly had no problem at all with the outsized profits of medical-device manufacturers with facilities in their home states and were pushing Harry to scale back a proposed tax on the industry.

Whatever it took, Harry was game. Sometimes too game. Occasionally, he’d dig his heels in on some deal he wanted to cut, and I’d have to intervene with a call.

For us, the slog through the Senate was a P.R. nightmare. Each time Harry’s bill was altered to mollify another senator, reporters cranked out a new round of stories about “backroom deals.” And things got markedly worse when Harry decided, with my blessing, to strip the bill of something called the “public option.”

From the very start of the health-care debate, policy wonks on the left had pushed us to modify the Massachusetts model by giving consumers the choice to buy coverage on the online “exchange,” not just from the likes of Aetna and Blue Cross Blue Shield but also from a newly formed insurer owned and operated by the government. Unsurprisingly, insurance companies had balked at the idea of a public option, arguing that they would not be able to compete against a government insurance plan that could operate without the pressures of making a profit. Of course, for public-option proponents, that was exactly the point. By highlighting the cost-effectiveness of government insurance and exposing the bloated waste and immorality of the private-insurance market, they hoped the public option would pave the way for a single-payer system.

It was a clever idea, and one with enough traction that Nancy Pelosi had included it in the House bill. But, on the Senate side, we were nowhere close to having sixty votes for a public option. There was a watered-down version in the Senate Health and Education Committee bill, requiring any government-run insurer to charge the same rates as private insurers, but, of course, that would have defeated the whole purpose of a public option. My team and I thought a possible compromise might involve offering a public option only in those parts of the country where there were too few insurers to provide real competition and a public entity could help drive down premium prices over all. But even that was too much for the more conservative members of the Democratic caucus to swallow, including Joe Lieberman, of Connecticut, who announced shortly before Thanksgiving that under no circumstances would he vote for a package containing a public option.

When word got out that the public option had been removed from the Senate bill, activists on the left went ballistic.

I found the whole brouhaha exasperating. “What is it about sixty votes these folks don’t understand?” I groused to my staff. “Should I tell the thirty million people who can’t get covered that they’re going to have to wait another ten years because we can’t get them a public option?”

It wasn’t just that criticism from friends always stung the most. The carping carried immediate political consequences for Democrats. It confused our base (which, generally speaking, had no idea what the hell a public option was) and divided our caucus.

Olympia Snowe braved a blizzard to stop by the Oval and tell us in person that she’d be voting no. But it didn’t matter. On Christmas Eve, after twenty-four days of debate, with Washington blanketed in snow and the streets all but empty, the Senate passed its health-care bill, titled the Patient Protection and Affordable Care Act—the A.C.A.—with exactly sixty votes.

We weren’t docked yet—not even close, it would turn out—but thanks to my team, thanks to Nancy, Harry, and a whole bunch of congressional Democrats who’d taken tough votes, we finally had land within our sights.

This piece is adapted from “A Promised Land,” which was published on November 17th by Crown.

https://www.newyorker.com…

Comment:

By Don McCanne, M.D.

Perhaps it’s the order of things? First we define optimal health policy, and then we enact and implement it. Or do we?

It is certainly logical to specify policy in advance and then design legislation to meet those goals. Include everyone by making it universal. Make the system more affordable and more efficient by eliminating administrative waste and introducing administered pricing through negotiation. Make participation affordable for each individual by funding the system with equitable, progressive taxes. Improve access through central planning and separate allocation of capital improvements. Also improve access by eliminating financial barriers to care and eliminating restrictive provider networks. Ensure portability of care by placing the entire health care delivery system in a single, universal financing system. Of course, that model is a single payer improved Medicare for All program that has been well described by Physicians for a National Health Program and by others.

Then you follow the rule that you don’t compromise on any policy before you sit down at the negotiating tables. But what really happens? President Obama abandoned single payer because we were not “starting from scratch.” But that is not a valid reason. The original Medicare program did not start from scratch (even though it was limited to a specific sector of our population – a policy compromise).

Obama writes that Ted Kennedy, a long-time advocate of a universal health care system, supported Massachusetts Governor Romney’s more limited reform proposal because “trying to dismantle the existing system and replace it with an entirely new one would be both a nonstarter politically and hugely disruptive to the economy.” But disrupting a health care economy that is not working and replacing it with one that would is precisely what we should want to do. But then, there is the politics.

Policy we can get right, but it is the politics that screws things up. If, at the beginning, you modify policies in order to fix the politics, you will end up with a mediocre result, or worse. On the other hand, if you begin with perfect policies, the politics often will result in serious damage to the policy product, but it does not necessarily have to. Some of the programs of the New Deal and the Great Society were passed without having to make major political compromises that would have impaired much of their effectiveness.

So where do we stand now? Donald Trump’s “beautiful” health program likely never existed and anyway has been eliminated from consideration by his loss in the election. Bernie Sanders single payer Medicare for All proposal would certainly have begun the process with policy first, but he lost the nomination to Joe Biden who has stated up front that he will not support Medicare for All.

So what is Biden recommending? Basically tweaks to the current highly dysfunctional system. He does not propose meeting any of the policies listed above, thus violating the rule that you should begin with uncompromised policies. He does have one proposal previously supported by others and that is the public option. But Obama explains that the political barriers erected by the private insurance industry were too great to get it approved as part of the Affordable Care Act. So Biden is beginning with grossly inadequate policy proposals that are so weak that several of them may be able to clear the political process, except the public option (which is undesirable for other reasons).

Basically Biden is modifying policy to comply with the politics. He has it backwards. We need to start with solid policy proposals and then modify the politics to accomplish the goals. Admittedly that is not easy, but it is possible. If you begin with inadequate policy proposals, it is impossible to achieve the goals.

If we want efficient, affordable, equitable, comprehensive health care for all, then we are going to have to change the politics. The election is over, but now is when the real politics begin. Get with it.

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Job-based health insurance no longer meets needs of employers, workers

Publicly funded, privately provided universal care would free businesses, nonprofits, municipalities and government agencies to focus on more important matters.

By Daniel C. Bryant, M.D.
Portland (Maine) Press Herald, November 19, 2020

In the United States, health care has been tied to employment since World War II, when employers compensated for wage controls by offering health care coverage to help them recruit and retain workers. However, an arrangement that may have made sense in the 1940s may not still make sense today. Three examples of the problems that employer-based health insurance can cause – all here in Maine and in just the last few months – bring home that point.

• The contract talks at Bath Iron Works in June: BIW’s June 13 “last, best and final offer” to workers included an increase in deductibles, prescription drug co-pay and out-of-pocket maximums in 2022, and a 5 percent annual increase in employee contributions in 2021-2023. Local S6 District Lodge 4’s June 11 negotiations update told members: “Depending on your medical plan and specific medical conditions that you or your family may have, the changes in health care could eat up the proposed wage increase.” Deciding the pros and cons of these details is far beyond me, but what isn’t is that neither BIW nor the union should have had to be mired down in them, a strike looming, when there were other, more pressing workplace issues to negotiate.

• The threatened strike at Calais Regional Hospital: Having worked without a contract since the last one expired in 2018, staff gave notice Nov. 10 that they would strike Nov. 18 and 19. The hospital’s September 2019 filing for bankruptcy protection had delayed negotiations, but employees and the Maine State Nurses Association sent to the hospital board of directors a petition of no confidence, including their concern with their employer-based health care: “In the most recent bargaining session, CRH management threatened to double (and in some cases triple) employees’ health care deductibles and out-of-pocket expenses, causing a net pay decrease for many hospital employees. Employees report that their insurance bills are sometimes not being paid in a timely manner, resulting in multiple billings from providers over months; and even some bills progressing to collection.”

To avoid a strike, the union requested, among other things, that the board “immediately ensure that none of the hard-working employees (who have kept this hospital running through these very difficult times) incur a pay decrease because of exorbitant increases in their benefit costs.” On Nov. 11 the strike was averted when agreement was reached on health insurance and paid time off, though the proposed contract, set to last two years, still needs to be ratified by the bargaining unit. Rural hospitals have enough problems these days without having to deal with the minutiae of their own employees’ health care coverage.

• Changes to University of Maine System retirees’ health coverage: UMaine System retirees have voiced opposition to the decision to move them from a group plan to a health care exchange where they would be required to pay for medical expenses up front and then be reimbursed. “The Maine Education Association and unions representing faculty and staff have filed grievances and said the changes were done against signed contracts between the system and retired employees,” the Press Herald reported Wednesday. “Jim McClymer, president of the Associated Faculties of the Universities of Maine, said Monday the system has denied the grievances filed by the three unions representing employees and they will now head to arbitration.”

Replacing antiquated, employer-based health insurance arrangements with a publicly funded, privately provided universal health care system would be liberating to these three Maine employers, and indeed to all businesses, hospitals, academic centers, municipalities, etc., allowing them to focus all their attention on more relevant concerns.

Few people drive Nash 600s (made 1941-49) anymore.

https://www.centralmaine.com…

Patients delay care because of ‘liquidity sensitivity’ (i.e., no money in their pockets)

The Liquidity Sensitivity of Healthcare Consumption: Evidence from Social Security Payments; NBER Working Paper 27977

By Tal Gross, Timothy Layton & Daniel Prinz
National Bureau of Economic Research, October 2020

Abstract

Some consumers lack the cash needed to pay for medical care. As a result, they either delay care until they can pay for it or they forgo the care altogether. To test for such a possibility, we study the distribution of monthly Social Security checks among Medicare Part D enrollees. When Social Security checks are distributed, prescription fills increase by 6-12 percent. In that sense, drug consumption of low-income Medicare recipients is “liquidity sensitive.” We then study recipients who transition onto a program that eliminates copayments. When those recipients do not face copayments, their drug consumption becomes less liquidity sensitive. That finding implies that, beyond risk protection, generous insurance also provides recipients with the ability to consume healthcare when they need it rather than when they have cash. Further, we find that recipients whose drug consumption is most liquidity sensitive exhibit price elasticities of demand that are twice the size of the average elasticity, suggesting that more-generous insurance causes recipients both to re-time prescription filling and also to start filling prescriptions that they otherwise would not fill. We present a stylized model that uses this finding to call into question the conventional interpretation of demand-response to price as solely inefficient moral hazard.

From the Introduction

There exists broad agreement among economists that health insurance ought to involve some form of cost sharing: copayments, coinsurance rates, or deductibles. Theory suggests that cost sharing can limit moral hazard (Zeckhauser, 1970), and empirical evidence confirms that cost sharing reduces spending (Manning et al., 1987; Aron-Dine et al., 2013; Shigeoka, 2014; Brot-Goldberg et al., 2017). Indeed, motivated by that evidence, high-deductible health insurance plans have become increasingly common in the United States.

Those cost-sharing mechanisms may introduce a particular challenge for low-income consumers. A large literature suggests that many low-income households wait to consume until their income arrives. Olafsson and Pagel (2018), for instance, find that low-income consumers purchase 70 percent more goods on days when they receive their paychecks. That finding is consistent with many other studies: consumption responds to both predictable and unanticipated changes in income. One might call such a pattern “liquidity sensitivity:” consumers often delay many of their purchases until their income arrives.

From the Conclusion

The results above suggest that Medicare Part D recipients delay the purchase of prescription drugs until their Social Security checks arrive. We estimate a 10–12-percent increase in prescription fills among low-income recipients facing subsidized copayments on the day that their checks arrive. Even among the general Part-D population that receives no subsidies, prescription fills increase by roughly 6 percent on Social Security paydays.

Those increases in prescription fills upon payday diminish when recipients’ copayments are reduced. In addition, we use the transition to lower copayments to estimate a price-elasticity of demand. Recipients who tend to fill their prescriptions on their Social Security paydays exhibit a much higher elasticity of demand.

The results thus suggest that discussions over cost-sharing mechanisms need to go beyond the traditional trade-off between moral hazard and risk protection. Some low-income consumers exhibit healthcare consumption that is “liquidity sensitive,” and so cost sharing leads to additional complications for them.

More generally, this paper emphasizes an additional benefit of full insurance. Full insurance not only reduces the uncertainty faced by consumers. It also allows low-income recipients’ consumption to be less sensitive to their liquidity. Liquidity sensitivity may be even more of an issue for other populations beyond Medicare recipients. For instance, consider adults who lack stable employment and thus face volatile incomes. That population does not have to wait a few weeks for a Social Security check—they may wait months for work. For them, full insurance allows the smoothing of healthcare consumption between employed and unemployed states. But for any population, the timeliness of healthcare consumption can have medical consequences. And so making healthcare consumption less liquidity sensitive ought to be a worthwhile policy goal.

https://www.nber.org…

Comment:

By Don McCanne, M.D.

This emphasis on consumerism in health care – making patients sensitive to the costs of health care by requiring out-of-pocket payment of deductibles, copayments, or coinsurance – is based on the concept that it is a “moral hazard” to use insurance to pay health care costs in full when that “hazard” can be avoided by requiring patients to pay a portion of the costs out-of-pocket so then they will accept only the care that they really need and are willing to pay for.

This study shows that low-income patients will delay or avoid care – in this case prescription drugs – when they do not have the funds needed for cost-sharing, though they will often obtain that care once they receive their Social Security checks. This suggests that we should redefine “moral hazard.” Rather than defining it as health care that might be declined if patients had to pay for it, we should define moral hazard as a barrier – a hazard – that policy wonks erect that is designed to save costs by preventing patients from receiving care that they should have since it was recommended by their physicians. That’s not a moral compromise; that’s a moral failure.

So now the policy community is dishing out policies based on “liquidity sensitivity.” Liquidity sensitivity comes into play when out-of-pocket health care costs exceed an individual’s discretionary income – an event much more likely to occur with lower-income individuals – though larger deductibles can also exceed the discretionary income of middle-income individuals.

Most individuals who support health care reform support reform that is equitable – fair for everyone. It would be far more equitable to eliminate cost-sharing and thus avoid liquidity sensitivity for those without higher incomes, while, at the same time, fund the entire health care system with equitable, progressive taxes. Now that’s fair.

Consumer-directed health care, moral hazard, liquidity sensitivity – let’s dump those in the trash bin of health policy concepts representing moral failure. Regular readers already know that we can fix this with a well designed, single payer, improved Medicare for All. Let’s do it!

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