By Paul Shafer Nicole Huberfeld Ezra Golberstein
Health Affairs Blog, May 8, 2020

The coronavirus pandemic has led to record numbers of American workers being laid off or seeing their hours and paychecks dwindle. The economy is on the brink of a deep recession, and waves of coronavirus infections may continue for the foreseeable future. Medicaid will be a crucial piece of the puzzle that helps to ensure access to health care while protecting people from further financial ruin. Yet, one of Medicaid’s key provisions has been weakened by recently approved section 1115 “demonstration projects”, commonly referred to as waivers, that eliminate or reduce retroactive coverage. These waivers will diminish coverage for thousands of people seeking testing and treatment for COVID-19 and other medical care.

Retroactive eligibility is a long-standing feature of Medicaid that covers health care expenses for three months prior to the application date, provided that the beneficiary would have been eligible during that period. Before the Affordable Care Act (ACA), a handful of states imposed narrow restrictions on retroactive eligibility, but these limitations were paired with expansions of eligibility and had exemptions for vulnerable groups. Recently, however, many states—including Arizona, Arkansas, Florida, Indiana, Iowa, Kentucky, and New Hampshire—have gained Department of Health and Human Services (HHS) approval for 1115 waivers that drastically limit or completely eliminate retroactive eligibility, though four have been stayed by courts or halted by states as part of litigation challenging the legality of those waivers that include work requirements (Arkansas, Kentucky, Indiana, and New Hampshire).

A core purpose of Medicaid is supporting people when they need help, which is why Medicaid has continual open enrollment and retroactive eligibility to cover the cost of care when those who are eligible aren’t already enrolled before a crisis. States should restore full retroactive eligibility immediately to protect thousands of newly-unemployed workers from even greater health and economic suffering.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

In the absence of a universal health care financing program it is inevitable that many will remain uninsured because they do not qualify for whatever programs are available, or they simply cannot afford them. Thus the Medicaid program was established to provide a safety net for the uninsured who need health care but are too poor to purchase it.

When a low-income uninsured individual does develop a disorder that requires health care there is an administrative delay between the onset of the disorder and the time that enrollment can be completed. Thus the program provides for retroactive eligibility to cover care that was provided before enrollment could be completed.

Some states, for reasons of their own, have decided to create barriers that would prevent otherwise qualified individuals from receiving health care benefits under the program. For instance, the income level to qualify may be set so low that most poor people will not be able to participate. Currently there is also a fad of establishing a work requirement to determine eligibility even when such a requirement cannot reasonably be met.

The subject of this particular Health Affairs article is the effort of some states to reduce or eliminate retroactive eligibility even if the individual racked up considerable expenses because of the severity or abruptness of the disorder before the Medicaid application could be processed.

But the purpose of the Medicaid program is to cover expenses for poor individuals who are uninsured, and the program recognizes that retroactive eligibility is sometimes essential to provide that coverage. So why do some states want to defeat the program by prohibiting retroactive eligibility, or by introducing other policies that prevent individuals from receiving the benefits for which the program was designed? It seems cruel, but how could cruelty be their policy goal? Or is it just an intense ideological opposition to having government play a role in addressing such societal needs even if cruelty happens to be an unintended consequence of such a policy?

Although there is a perpetual dispute over states’ rights, this is one instance where the federal government should prevail. Avoidable cruelty cannot be tolerated in a just society.

We could end much of this nonsense by establishing a single payer national health program – an improved version of Medicare that covers everyone while eliminating financial barriers to care. It seems futile to ask them to stop being cruel; let’s just take it out of their hands instead and enact and implement Medicare for All. I can’t imagine that they would respond with demonstrations using placards that say, “WE WANT MORE CRUELTY.” But then I confess that I really don’t understand what all is going on today.

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

The fragmented US hospital system, made up of private and community hospitals, has made it harder to fight coronavirus.

By Daniel Skinner
Al Jazeera, May 11, 2020

The coronavirus pandemic arrived at a pivotal moment in the US healthcare, just as scrutiny over hospital pricing and practices was gaining traction, including at the Democratic presidential debates.

The crisis has provided a closer look at US hospitals, and has done so in multiple ways. We have seen the often dangerous work performed by committed healthcare professionals, but also the precarious conditions those professionals have been forced to work in.

Though a number of different proposals for overhauling the US healthcare have been put forward by liberals and progressives, it is curious that they fail to question our dependency on a fragmented collection of private hospitals that can hardly be said to be a system.

As Elizabeth Rosenthal has argued, Americans often criticise pharmaceutical and insurance companies without noticing that hospitals are in many ways a far bigger – and more expensive – problem. Among COVID-19’s lessons is that we need a national strategy for hospitals.

While Senator Bernie Sanders based his vision of “Medicare for All” on the Canadian system, where private hospitals contract with a government “single payer”, the UK approach, where the government owns most of the hospitals and employs the healthcare professionals working in them, may be what the US needs.

The high-profile hospitalisation for COVID-19 of Prime Minister Boris Johnson put UK hospitals in the international spotlight. Americans may be confused when they hear Johnson – a conservative politician – praise the National Health Service (NHS) as “unbeatable”. After all, Americans have been falsely told by their own conservative politicians that they should fear an NHS-like system.

We have not reached the point where a UK-style nationalisation of hospitals is being widely discussed but there are a number of reasons why it should be. Consider just three reasons among many.

First, COVID-19 illustrates the difficulties of coordinating US hospitals. As the virus spread, and realising the dangers that a fragmented system posed, New York state moved to coordinate its hospitals in such a way that Governor Andrew Cuomo could declare that: “We are one healthcare system.” Specifically, Cuomo established a process by which hospitals in parts of the state that had an excess supply of ventilators and personal protective equipment (PPE), but did not face a wave of coronavirus patients, would shift those resources to high-need areas.

But it was difficult to make this happen. Those who might say that such coordination is a logical response to a pandemic but not a preferable way to organise hospitals during normal times, are missing one of COVID-19’s lessons: namely, that we could vastly improve the general quality of care by better organising our hospitals.

Second, the need for politicians to assure Americans that patients’ medical bills for COVID-19 treatment will be “taken care of” illustrates not only the poor positioning of our system to handle health crises, but deep flaws in the approach itself.

One-off, disease-specific appropriations to cover patients’ expenses during a pandemic – while cancer and heart disease patients still risk bankruptcy – is poor health policy. This, of course, is a result of the larger, more protracted design flaws in US healthcare.

With millions of Americans lacking health insurance access at all, and millions more “underinsured” because of the out-of-pocket costs required by the plans they do have, Americans often go to hospital emergency rooms without knowing whether the bills they receive will be paid by insurance companies, or whether their treatment will end up costing them thousands – or even tens of thousands – of dollars.

As physician Adam Gaffney has eloquently argued, changes in how we finance hospitals might even remove the need for hospital payments altogether by re-envisioning them as truly public goods modelled on parks, public schools or libraries.

The American dependency on private hospitals limits the role the federal government can play in setting prices and putting in place a system of care that can be understood by patients.

While a federal law, known as the Emergency Medical Treatment and Active Labor Act, requires that most hospitals must care for patients to a point of stabilisation, what hospitals charge those patients for that care, the collection practices hospitals employ, and whether any follow-up care or even referrals are provided is as variable as the number of hospitals themselves.

This is unsustainable and dangerous, especially when one considers that the chaotic current landscape of US community includes 5,198 community hospitals, 2,937 (or 56.5 percent) of which are privately owned and not-for-profit, and 1,296 (25 percent) of which are “investor owned”, for-profit facilities.

An additional 965 community hospitals (18.5 percent) are owned and administered by state and local governments. And these community hospitals are to be distinguished from the current federal system of 209 non-speciality hospitals, which include facilities run by the US Department of Veterans Affairs and Indian Health Service.

Third, on the whole, market competition has made US hospitals worse, not better.

Ranking systems that distinguish “best” hospitals from others only serve to devalue other hospitals, especially those located in rural and other under-served areas. These hospitals cannot compete with their better-funded competitors, which creates a vicious cycle of negative perceptions and disinvestment that only further hurts rural and other hospitals serving as safety nets, especially in poorer US communities.

COVID-19, which has decimated many already-hurting US hospitals, is likely to leave struggling hospitals ripe for the picking by growing hospital systems, which continue to buy up smaller hospitals as part of an ever-growing plan of increased market domination.

While consolidation might at first glance appear to offer benefits for coordination during times of national crisis, the motives that drive these institutions are still not those of the national interest. One post-COVID-19 project should be understanding the effects of consolidation, and the role of large systems, within the pandemic response.

As progressives are quick to note, Democrats have gone out of their way to save the current system from itself. For political reasons, ranging from inadequate congressional support for larger reform to a desire to minimise disruption for patients, the architects of the Affordable Care Act were not able to address the structural flaws in US healthcare. The best they could do, working under political constraints in place in 2009, was to extend the existing system – from Medicaid to private insurance – to populations that typically fell through the cracks. While the Affordable Care Act brought healthcare access to millions of Americans, and is believed to have saved thousands of lives, it only postponed the need to restructure the system itself.

To be sure, there is political wisdom in leaving US hospitals as they are. Justified or not, many Americans hold generally positive views of their local hospitals. Even more politically problematic is the fact that organisations such as the American Hospital Association have formidable lobbying operations that keep legislators from acting. The motivations of these organisations in resisting the nationalisation and even increased oversight of hospitals are rooted in maintaining the financial incentives that drive that system, not in the best interests of patients or populations.

Considering how unpopular for-profit health insurance companies are, consigning them to the dustbin of history is clearly less politically charged than a major rethinking of hospitals. But this does not mean that we should accept the status quo.

A national commission should be tasked with understanding why US hospitals were so poorly equipped to handle the pandemic. A key piece of this story is likely to be equity. While certain hospitals have fared well, many have not, but the reasons for the differences are not always clear. We are only beginning to make sense of the failures that led to equipment shortages and capacity problems.

An inquiry should also assess differences in how the US’s for-profit and non-profit hospitals have fared, with an eye towards whether the non-profit hospitals served their local communities in a way that warrants the generous tax exemptions they receive.

If Democrats and Republicans – and the pressure groups that inform them – wish to keep the nationalisation of US hospitals off the bargaining table, Congress will need to address these issues, and more.

COVID-19 has exposed the vulnerability of American hospitals. Rethinking them must be one of the pandemic’s enduring legacies.

Daniel Skinner is Associate Professor of Health Policy at Ohio University’s Heritage College of Osteopathic Medicine.

https://www.aljazeera.com…

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Comment:

By Don McCanne, M.D.

The combination of a health crisis plus an economic crisis that has disrupted the lives of everyone of us certainly lays fertile ground for reassessing our health care system and its financing. Already much has been written about how we would have been better off if we already had in place the popular single payer model of an improved Medicare that included everyone – a publicly administered and taxpayer financed social insurance program.

As long as our attention is already directed to revising our health care financing system, it seems appropriate to give more thought to another very successful model of single payer reform – a national health system in which the facilities are owned by the government and the health care professionals are employees of the government.

In this article, health policy professor Daniel Skinner calls on us to rethink the role that the fragmentation of the U.S. hospital system played in the often less than stellar performance in response to the COVID-19 pandemic.

We should give thought to issues such as the differences in the mission of a public or non-profit hospital that is dedicated to patient service versus an investor-owned hospital that has a mission to maximize returns for the investors. We should consider the rationale of a response to the pandemic that is based on a single disease when we must also ensure that the system can effectively meet the needs of patients with a multitude of other disorders that also require medical attention.

The PNHP model of single payer Medicare for All would convert for-profit hospitals to non-profit status. Is that enough? Just as many of our non-profit private insurers have adopted the egregious policies of the investor-owned insurers, would conversion of for-profit hospitals to non-profit status provide enough incentive to place patient service well above a common business ethic? But then, with government ownership and management, there can be a tendency for conservatives and austerity-minded moderates to underfund health programs that may result in impaired capacity or inadequate public health preparedness as we have seen during this pandemic. The increasing dominance of neoliberal politicians is thrusting more austerity upon us.

At any rate, it is clear that we need to dump the private insurers and establish our own universal social insurance program – a single payer improved Medicare for All. Should we also nationalize the hospitals, creating a system of socialized medicine, or should we merely convert the for-profit hospitals to non-profit status? Merely having that conversation may ease the fears of those who are worried that Medicare for All would be a move too far to the left when the alternative under consideration would be a shift all the way to socialized medicine. For some of us that would be fine, but single payer Medicare for All is not a bad position of compromise.

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

By Anna Wilde Mathews and David Benoit
Morningstar, May 8, 2020

Atul Gawande is in advanced discussions to step down as chief executive and take on a less operational role as chairman of Haven, the health-care venture backed by Amazon.com Inc., Berkshire Hathaway Inc. and JPMorgan Chase & Co., according to people with knowledge of the matter.

Dr. Gawande, a prominent surgeon and professor at Harvard University, wants to move away from day-to-day management of Haven and focus more on policy and advocacy work, particularly related to the current coronavirus pandemic, the people said.

Haven has launched a search for a new CEO, but has yet to settle on a candidate, the people said. There hasn’t been a final decision on the leadership structure, the people cautioned.

His transition suggests the health-care venture’s slow start since its splashy unveiling in January 2018. The venture has shown few public signs of impact, after its announcement by the three parent companies rattled health-care investors and pushed down the shares of major insurers.

The founding companies framed the venture as an altruistic effort to overhaul health care, reining in costs and improving outcomes, and said they would start with their own employees.

Despite the initial hype, the venture’s efforts so far have been of limited scope. It has launched pilot projects testing health-benefits approaches. This included a program for around 30,000 JPMorgan employees in Ohio and Arizona, who were given a menu of flat costs for health-care services, according to people with knowledge of the matter.

Haven has been spending much of its early time building data systems on employee health-care tendencies across the three companies, these people said.

An author known for his work on health-care quality, Dr. Gawande was a high-profile choice to lead the venture. His hiring was seen as a signal that the partners’ ambitions were set higher than conventional tweaks to health coverage.

https://www.morningstar.com…

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Wiktionary

pie in the sky

1. (idiomatic) A fanciful notion; an unrealistic or ludicrous concept; the illusory promise of a desired outcome that is unlikely to happen.

Etymology

The phrase is originally from the song “The Preacher and the Slave” (1911) by Swedish-American labor activist and songwriter Joe Hill (1879–1915), which he wrote as a parody of the Salvation Army hymn “In the Sweet By-and-By” (published 1868). The song criticizes the Salvation Army for focusing on people’s salvation rather than on their material needs:

You will eat, bye and bye,
In that glorious land above the sky;
Work and pray, live on hay,
You’ll get pie in the sky when you die.

https://en.wiktionary.org…

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Comment:

By Don McCanne, M.D.

Three billionaires with great financial success in the business world – Warren Buffett, Jeff Bezos and Jamie Dimon – decided that they could buy health care reform, and they chose popular physician-writer Atul Gawande to orchestrate that reform.

It was not as if they could invent a new wheel. While totally ignoring effective reform such as a single payer national health program, they delved into some of the current, hot trends. Big data was supposed to open doors, but apparently all they got was a collection of big data on their employees, stashed away in the cloud. Price transparency – the darling of the consumer-directed movement – brought menus of prices but not much else. Because much of their activity was behind closed doors, we don’t know what else they considered or attempted, but obviously the higher quality, lower cost, replacing-volume-with-value goal remained elusive for them as they now seem to be winding down, or at least likely recognizing that their ambitious processes and goals were pie in the sky.

All is not lost. Buffett, Bezos and Dimon are not stupid. They have the intelligence to understand the vast superiority of the single payer model of an improved Medicare for All, although they may have to look past ideological preferences as they acquire greater knowledge of the topic – a task that the PNHP leadership is quite willing to assist in.

At PNHP we do not serve pie in the sky, just the design of a financing infrastructure that really does provide affordable, high quality health care for everyone. Buffett, Bezos and Dimon need to check it out.

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

By Eagan Kemp, Melinda St. Louis, Taylor Lincoln, and Michael Tanglis
Public Citizen, May 7, 2020

Summary of Findings

The vast majority of the largest health insurers say they are offering at least some fee waivers for the treatment of COVID-19 patients, but these fee waivers contain significant restrictions and most are set to expire long before the pandemic can reasonably be expected to end.

Most of the fee waivers are set to expire soon. Of the 25 largest health insurers, 21 have announced that they are waiving all costs – such as deductibles and co-payments – for COVID-19 patients, at least for in-network care, and two are offering fee-waivers for some COVID treatment. But 15 of the 23 fee-waiver offers are set to expire by July 1, including 11 by June 1.

Few of the fee waivers appear to cover costs for out-of-network care. Only two of the 25 largest insurers affirmatively state that they will cover patients’ costs for care provided by both in-network and out-of-network providers. This distinction is important because many patients might not be able to obtain care from in-network practitioners due to the high rate of hospitalization in some locations.

Up to 60 percent of people in private insurance plans may not be covered by the fee- waivers because they are in self-insured plans. The fee waiver offers universally exclude those in self-insured plans unless the employers that underwrite the plans opt-in. About 60 percent of people who receive insurance through employers are in self-insured plans.

Some insurers are providing few, if any, expanded benefits for coronavirus treatment. Two large insurers – CareSource and WellCare – appear to be offering little beyond their normal coverage.

Descriptions of testing benefits need improvement. Although Congress has mandated free testing for COVID-19 with few restrictions, many of the large health insurers’ descriptions of testing benefits are unclear and/or appear to impose restrictions that the recent legislation did not call for.

From the Introduction

To the extent that insurers are offering increased benefits voluntarily, they are likely seeking to earn good will. But the fine print attached to the increased benefits is apt to reinforce Americans’ perception that private insurers’ benefits are incredibly difficult to navigate and are riddled with financial hazards and pitfalls.

While Americans would welcome blanket protection from costs for coronavirus treatment, this would only serve as a temporary solution to the broader problem that plagues American health care. The system is unfathomably complicated, ridiculously expensive to administer and rations care according to people’s ability to pay. This is not only morally bankrupt but, as the spread of coronavirus indicates, it is also dangerous from a public health standpoint because we are all affected by the community’s overall health and ability to obtain needed care.

Lawmakers and some insurers were right to move in the direction of free care for coronavirus, but stopping there would not make sense. There are many health conditions that, although less publicized than coronavirus, are even more deadly. If free care makes sense for COVID-19 patients, the same is true for those suffering from cancer, heart disease, complications at birth and myriad other conditions.

The most sensible way to untangle the thicket of our health care system, protect Americans from crushing costs, and create a healthier and more productive society is to implement Medicare for All, under which patients would receive the care they need for free and providers would be compensated at a fair rate for services rendered.

https://www.citizen.org…

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Comment:

By Don McCanne, M.D.

The nation’s private health insurers now have a chance to prove to us that they are worthy of controlling our health expenditures. During the worst pandemic in a century, combined with a catastrophic economic downturn, what are they offering us?

Perhaps they best show their true colors by their conditional offer to waive deductibles and copayments for treatment of COVID-19 patients, but you’d better get sick and recover before the end of the month since this offer by several of the larger insurers (United Health, Anthem, CVS/Aetna, Health Care Service Corporation, Cigna, Florida Blue, Blue Shield of California, Independence Health Group, Anthem Blue Cross of California, Highmark Group) expires by June 1. That means that you have about one more week to become ill with the virus in order to qualify for this great offer.

Also, during this crisis there is a greater likelihood that care may be provided out-of-network because of the urgent nature of the disease and the strained capacity of the delivery system. Of course the insurers can’t be expected to cover those out-of-network expenses since they have no contracts with the providers. Also, the majority of employer-sponsored plans are self-insured, and the insurers provide only the administrative services, so they can’t be expected to waive the cost sharing in these plans either since it’s not their money. And the benefits for COVID testing? Just try to figure that out.

How would this compare to the single payer model of Medicare for All? All medical costs for COVID would be covered. Not only that, but all other medical problems such as heart attacks, cancer, other infectious diseases, injuries, and whatever else would be covered as well.

Besides, if we leave the private insurers in control, what are they going to do about the uninsured? Just what they’re doing now – nothing!

But ask the insurers, and they’ll tell you that they are doing something right. Look at their record profits!

And this is the private insurance that some politicians are telling us that we don’t want to have taken away from us? Medicare for All? How are we going to pay for that!? Well, the $4 trillion that we are already paying is more than enough. We just have to make it affordable for each of us through equitable, progressive funding of a universal risk pool: single payer Medicare for All.

Don’t forget, if you want the COVID deal that your insurer may be offering you, you’d better get sick this week or the deal may expire. Your ambulance service may even offer curbside pickup, but that also expires, after you do.

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

World Federation of Trade Unions, May 6, 2020

The World Federation of Trade Unions, representing 100 million members across the five continents, expresses its deepest concern at the latest developments in the research sector on treatment and vaccination against the new coronavirus. The antagonisms between business groups, pharmaceutical industries and imperialist states in the field of virus treatment and the development of a vaccine, can only cause concern to the peoples of the world.

To this day, there are hundreds of scientific groups working to develop a vaccine and antiviral drugs through “partnerships” between states and business groups. That is, through a form of publicly funded research, which will benefit the pharmaceutical industries that are going to sell the vaccine and drugs (such is the case of “collaboration” between “Johnson & Johnson” and “Sanofi” groups with the US Department of Health). At the same time, the imperialists, the same imperialists who are bathing peoples in blood around the world in order to serve their own interests, organize telethons to raise funds for the new vaccine.

The fact that mass production and sale by large pharmaceutical companies is necessary for a vaccine to be put into circulation in the capitalist states, only creates suffering for the workers and the poor popular strata throughout the world. People cannot forget the negative consequences of the pursuit of profit in the pharmaceutical sector, as have shown the examples of the USA and EU countries, in which large business groups refused to sell millions of doses of vaccines produced by them to governments, requesting that the states fully assume responsibility in cases of adverse effects and at the same time blackmailing in order to get high sale prices.

At the same time, there are many examples of pharmaceutical industries that refused to put similar coronavirus vaccines into circulation in the past, because the profitability of such an investment would be…low! In fact, as scientists have mentioned, precious time which would enable us to deal with the new coronavirus was lost.

Furthermore, in these circumstances, militant trade unions around the world should not underestimate the aggressiveness of the USA, whose president, Trump, attacks China, the WHO and all those who do not align with their geo-strategic games. But this aggressiveness is not a mere one-person tactic, but the aggressiveness of the US imperialism as a whole. Especially now, at a time when the United States was exposed, they lost their shine and the social injustice that reigns in the United States was unmasked; now, at a time when the US ruling class is going to sharpen its aggressiveness and its threats against peaceful coexistence among peoples.

Faced with the barbarism of a system that treats the worker as expendable, the international class-oriented trade union movement must rise up; We must inform the world working class that it has nothing to expect from the games and business tricks of transnational corporations. What we do need to do is step up the fight for a patent-free coronavirus vaccine that is free, safe, free for all. That any business activity in the health sector must cease and that the struggle for a universal, free, public healthcare system with high-quality health services for all must be intensified! We must fight globally for a health system that will not only not slow progress, but will also put this progress at the service of the people and the working class. The WFTU is committed to being on the side of every trade union that is going to fight in that direction across the globe.

The Secretariat:
http://www.wftucentral.org…

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Trump will urge Supreme Court to strike down Obamacare

By Susannah Luthi
POLITICO, May 6, 2020

President Donald Trump on Wednesday said his administration will urge the Supreme Court to overturn Obamacare, maintaining its all-out legal assault on the health care law amid a pandemic that will drive millions of more Americans to depend on its coverage.

The administration appears to be doubling down on its legal strategy, even after Attorney General William Barr this week warned top Trump officials about the political ramifications of undermining the health care safety net during the coronavirus emergency.

https://www.politico.com…

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3 years in, no sign of Trump’s replacement for Obamacare

PBS News Hour, December 31, 2019

Nearly three years after taking office, Americans still are waiting for Trump’s big health insurance reveal.

Back then, Trump made it sound that his plan — “much less expensive and much better” than the Affordable Care Act — was imminent.

Trump says a health insurance overhaul can be done in a second term if voters give him a Republican Congress as well as a reelection win. But Trump and the GOP had that chance when they were in full control and unable to deliver, because Republicans don’t agree among themselves.

https://www.pbs.org…

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Comment:

By Don McCanne, M.D.

Pretty strong statement. But, you know, we’ve been speaking for decades about the terrible deficiencies in our health care financing system – the most costly system on earth yet one that, on universality, affordable access, efficiency, and equity, falls significantly behind the systems of all other wealthy nations. And now the COVID-19 pandemic is shining light on just how terrible our system is, again considering what we are spending on it.

President Trump is headed down a path to further bash what we do have, and yet he has failed to deliver on his “much less expensive and much better” plan. Without the pandemic, we’re already spending $4 trillion, and yet people are still facing financial hardship, physical suffering and sometimes even premature death!

It really is time for opening our minds, and getting down to frank talk about the facts. WFTU has something to say about this. Too political, you say? Well, we’ve already proven that our industry-friendly politics have failed us.

WFTU appropriately warns us about “the games and business tricks of transnational corporations.” In response, we must gear up to fight for “a universal, free, public healthcare system with high-quality health services for all.” We’re already paying for it. We should have it.

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

By Claire K. Ankuda, Katherine A. Ornstein, Kenneth E. Covinsky, Evan Bollens-Lund, Diane E. Meier, and Amy S. Kelley
Health Affairs, May 2020

Abstract

Medicare Advantage (MA) plans have increasing flexibility to provide nonmedical services to support older adults aging in place in the community. However, prior research has suggested that enrollees with functional disability (hereafter, “disability”) were more likely than those without disability to leave MA plans. This indicates that MA plans might not meet the needs of older adults with disability. We used data for 2011–16 from the National Health and Aging Trends Study linked to Medicare claims to measure and characterize switches in either direction between Medicare Advantage and traditional Medicare in the twelve months before and after onset of disability. While the rate of switches from Medicare Advantage to traditional Medicare increased slightly after disability onset, people with greater levels of disability were more likely to switch to traditional Medicare, compared to those with lower levels: 36 percent of those who switched from Medicare Advantage to traditional Medicare needed help with two or more activities of daily living, compared to 14.3 percent of those who switched from traditional Medicare to Medicare Advantage. This indicates the potential benefit of including functional measures in MA plan risk adjustment and quality measures. Furthermore, the highest-need older adults with disability may experience lower-quality care in Medicare Advantage and thus leave before accessing the program’s expanded benefits.

From the Introduction

While MA plans are required to cover all services covered by traditional Medicare (with the exception of hospice, which is carved out of MA plans), there are several reasons why older adults may be more likely to switch from Medicare Advantage to traditional Medicare after becoming disabled. To control costs for postacute care often needed by older adults with disability, MA plans may limit networks of skilled nursing facilities, pressure the facilities to shorten beneficiary lengths-of-stay, and employ burdensome prior authorization procedures. Limited provider networks may affect the quality of care and satisfaction of MA beneficiaries, as older adults in Medicare Advantage are more likely than those in traditional Medicare to be served by skilled nursing facilities and home health agencies with lower quality ratings. Limited networks and less flexible options may especially challenge people with disability, who often rely on caregivers. The additional coordination needed to find in-network, accessible providers in MA plans may be a barrier. This raises the concern that participation in Medicare Advantage poses unique barriers to care for older adults with disability. This is especially worrisome given that this population is highly vulnerable, with high levels of health needs and risk of significant morbidity and mortality—especially if their needs are not met.

From the Discussion

This nationally representative study of adults ages sixty-five and older demonstrated that people are more likely to switch from Medicare Advantage to traditional Medicare following the onset of disability than from traditional Medicare to Medicare Advantage, and that the characteristics of people who switch from Medicare Advantage to traditional Medicare are different from those of people switching from traditional Medicare to Medicare Advantage. While other studies have demonstrated that high-need older adults are more likely to switch from Medicare Advantage to traditional Medicare than the reverse, this is the first study to show the temporal relationship between onset of disability and disenrollment from Medicare Advantage. Furthermore, older adults who are of nonwhite race or from high-risk socioeconomic groups are more likely to switch insurance coverage than are those of white race and with higher incomes and education levels, while those who are more severely disabled are more likely to prefer traditional Medicare. These findings have important implications for measuring quality, appropriately risk-adjusting payments, and reducing disparities within the MA program.

In 2017 the Government Accountability Office conducted an assessment of MA plans with high levels of beneficiaries’ switching to traditional Medicare, using claims to estimate the health status of individuals who switched plans. Consistent with our results, the assessment found significant levels of health bias, or higher rates of disenrollment by individuals in poor health.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Even though Congress and both Republican and Democratic administrations have continued to advance policies favoring the private Medicare Advantage plans while neglecting the traditional Medicare program, the private insurance industry continues to demonstrate what a bad deal the taxpayers are receiving from their plans (though acknowledging that healthier beneficiaries are often satisfied with their care).

This study shows that people who develop functional disabilities tend to disenroll from the private Medicare Advantage plans and move into the traditional Medicare program. This is particularly true of nonwhite individuals from high-risk socioeconomic groups who were in poorer health, including those with more severe disabilities.

As our politicians continue in their efforts to privatize Medicare, it is working superbly well for the Wall Street investors who are choosing insurance stocks, but privatization is not serving well Medicare beneficiaries who have the greatest health care needs. Instead, our politicians should improve the traditional Medicare program, while eliminating the private sector that has brought us higher costs and lower quality (the opposite of what they promised). Then we should expand Medicare to cover everyone through an efficient, effective and more equitable single payer model of Medicare for All. The sooner the better.

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By Eve Ottenberg
CounterPunch, April 24, 2020

The elephant in the Covid-19 infected room is Medicare for All. Maybe it really, finally is time for it. With at least 26 million people suddenly unemployed and many of those losing their health coverage during a deadly plague – how are people supposed to pay for a doctor if they get sick? And many will get sick. Covid-19 is highly contagious. For some it’s fatal, others mild, but for many it’s like being hit by a Mack truck. Currently, stimulus money will cover the medical bills of uninsured Covid-19 patients. But if the government can pay for this, why not cancer and heart disease? Why should the nature of a person’s illness determine whether they go bankrupt, or whether they try to spare their family the bills by foregoing treatment and dying? The U.S. spends more on health care than any other industrialized nation, but as is well known, our health outcomes are much worse.

With 87 million people un- or underinsured, that number is soaring as workers get laid off. Add in 500,000 homeless and a very grim health care picture emerges. Despite the pandemic, thousands of medical workers have been let go, and many lack proper protective equipment to deal with this pestilence. Some have protested this. Some have been fired for such protests. Fired – for protesting hospital failures to protect nurses, doctors and nurses aides, many of whom have contracted this plague and died as a direct result of those failures. Some medical staff are suing their hospitals. At first glance, they appear to have a strong case.

So far the federal government has proved shockingly inept about medical supplies, with states purchasing their own only, in some cases, to have the feds seize their shipments. This has happened at the national level as well. The government of Peru recently hid the flight plan of planes bringing medical equipment for precisely this reason. It’s as if all our rulers know how to do is steal supplies. For setting up a system to purchase and distribute them, they seem incompetent.

Onto this grisly scene strides Democratic presidential candidate Joe “I would veto Medicare for All” Biden. His ties to the health care racket are particularly disturbing, and sooner or later could come under media scrutiny. Such could seriously injure his campaign. So expect the Trumpsters to exploit this. The only way out of this deadly, vote-killing thicket, is for Biden to flip flop, fast, and adopt the Sanders Medicare for All plank. Biden showed some flexibility bout Covid-19 treatment, announcing that the government should pick up the tab for the uninsured. But the larger change in policy is what counts. These parlous times demand an about-face, regardless of whether it alienates Biden’s insurance donor base. The question is, can a leopard change its spots?

This pandemic has revealed how desperately the U.S. needs a functioning public health care system – as desperately as any third world country. Bodies pile up in hospital corridors and metropolitan newspapers, like The Boston Globe, run expanded obituary sections – 16 pages of death notices on one day last week. We may never know how many people had this disease and how many it killed, because from the start, testing was inadequate. Trump has seemed reluctant to test, perhaps because it would reveal the true extent of the disaster caused by his administration’s incompetence. But if we already had Medicare for All when the pandemic struck, patients would have received tests and treatment, instead of being turned away from hospitals to die at home.

It could not be plainer: now is the time for Medicare for All. Despite the dearth of press commentary advocating this, high percentages of Americans support the idea, just as high percentages support the governors’ lockdown policies. But our political and corporate elites ignore the inconvenient public preference for expanded health coverage. There’s just too much money to be made keeping things as sickeningly unfair as they are. Recently the biggest U.S. insurer, UnitedHealth, was reported to have earned $5 billion in the last three months. And pharmaceutical companies expect a bonanza. Covid-19 could be around for years, so will desperate customers for treatments and, should one ever come to market, a vaccine. But without government health care, don’t expect such life-saving medicines to be cheap.

https://www.counterpunch.org…

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Comment:

By Don McCanne, M.D.

Sometimes it just needs to be said.

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By Barbara Caress
The New School, Center for New York City Affairs, Urban Matters, April 29, 2020

The Covid-19 pandemic is hitting the underfinanced hospitals serving thousands of poor and working-class New Yorkers the hardest. The emergency federal funds for hospitals haven’t corrected their inequitable status vis a vis far better-off private hospitals, and have even reinforced it. Now it’s up to State and City policymakers to straighten things out and make New York City’s hospital system work better for everyone.

That system has three principal elements. The city’s 11 public hospitals and clinics are administered by NYC Health + Hospitals. Then there are the private community hospitals serving low-income neighborhoods, which the State designates as “safety net” hospitals. Finally, there are the five large, private, and well-financed citywide hospital networks.

The system’s inequities show up in hospital net operating revenues and depth of financial reserves. In recent financial statements, the public and community hospitals reported operating deficits. They ranged from an annual average of -$2.9 billion in the public system to -$21 to -$114 million a year for individual safety net institutions. In contrast, the five large private networks earned more than they spent. New York-Presbyterian’s net annual income was $557 million, according to a recent report from the Citizens Budget Commission.

New York-Presbyterian also had $14 billion in financial reserves, and each of the four other big systems had net assets of at least $1 billion. By contrast, NYC Health + Hospitals was $5.6 billion in the hole while Maimonides, the best-reserved of the safety nets, had $371 million on hand – enough to operate for three months at its then-current spending rate.

Then Covid-19 struck, flooding hospitals with sick people, many needing intensive care. Under orders from Governor Andrew Cuomo, hospitals stopped doing what earned them the most money. Most surgeries were postponed; clinics were curtailed or closed. The numbers of people treated for heart attack, stroke, cancer, and other serious illnesses plummeted – contributing to some 4,000 “excess” non-Covid deaths from mid-March to mid-April compared to the same period a year ago.

The networked hospital systems are currently losing $350-$450 million a month, according to Ken Raske, president of the Greater New York Hospital Association. While that’s hardly good news, the big systems can afford to carry losses for many months. But not the public and safety net hospitals. They not only have few or no reserves; most also serve communities suffering the worst effects of the pandemic. Queens, the Bronx, and Brooklyn have the largest share of cases and the smallest share of private, well-resourced beds.

The assets and connections of the networked hospitals also continue to privilege them during the current crisis. Taking advantage of extremely low interest rates, NYU Langone hospital secured $300 million lines of credit in mid-April. Not that they couldn’t meet expenses, but it probably looked like a good opportunity for borrowing. A Mount Sinai Hospital trustee, Rich Friedman of Goldman Sachs, was able to get a favor from Warren Buffet’s private jet service to bring 500,000 N95 masks and 1.2 million surgical masks via a private Chinese airfield for use in Mount Sinai’s networked hospitals.

On the flip side are the chronically under-resourced public hospitals. In mid-April, at the crest of the outbreak, Mayor Bill de Blasio told reporters that H+H’s 11 hospitals had enough personal protective equipment (PPE) “for the next week.” An April 26 New York Times story reported that State-owned Downstate University Hospital in Brooklyn was not even that fortunate. Nurses and doctors there were wearing plastic tarps and using duct tape to secure their face shields. Meanwhile, interns and residents at hard-pressed public Elmhurst Hospital in Queens have been promised $300 per week in hazard pay; that’s $150 less than doctors at Mount Sinai are receiving.

On March 30 Governor Cuomo announced that the State plans to treat all the state’s hospitals as part of one system, sharing “supplies, staff, and other resources as needed.” As advisors to this effort, the Governor introduced Ken Raske and Michael Dowling, CEO of the state’s largest health care provider, Northwell Health. There were no public hospital or safety net attendees. Two days later, by Executive Order, the State Health Department was empowered to use the National Guard to move ventilators and PPE to the most overburdened hospitals.

Grand plans; no follow-up. Each week the State Health Department hosts a webinar on Covid-19 for the provider community. None of the three webinars since the governor’s announcement have mentioned his one state, one system plan.

The public funding that ought to be an equalizer has also been lacking. For example, the first $30 billion tranche of emergency Federal Covid-19 help to hospitals was distributed to the states based on numbers of Medicare fee-for-services patients. Despite being the epicenter of the US outbreak, New York State hospitals received $12,000 per Covid-19 case. Florida hospitals got 10 times that figure; Nebraska hospitals got 25 times New York’s per-case allocation.

New York State hospitals will fare better in the next wave of Federal funds; they’re expected to receive about 40 percent of $10 billion going to hardest-hit areas, with the lion’s share coming to City hospitals. But this allocation will rely on numbers of intensive care unit (ICU) beds and Covid-19 admissions per hospital. Missing from the distribution formula will be the percentage of a hospital’s resources used by Covid-19 patients, the amount a hospital has spent on treatment, what it can expect in insurance reimbursements, or even how many of its patients are uninsured. The networked hospitals contain 60 percent of the city’s total beds and a higher proportion than that of ICU beds. They will get most of the money. The public and safety net hospitals, despite bearing a disproportionate burden, will get less.

Typically, the safety net and public hospitals depend on City and State subsidies to keep afloat – and here, the severe economic contraction created by the pandemic paints a bleak picture, too. State Comptroller Thomas DiNapoli expects a revenue loss of $9-$15 billion this State Fiscal Year. The City’s Independent Budget Office has forecast losses of $2.9 billion, $6.7 billion, and $4.4 billion in City Fiscal Years 2020, 2021, and 2022. That makes it likely that State and City subsidies will be smaller.

What might be done to secure a better future for the safety net and public hospitals as well as community health centers, public health departments and school health clinics – all programs serving poor and working-class New Yorkers? These five things.

First, the Governor needs to rescind the Medicaid cuts he insisted be in the most recent State budget. This is not the time to cut Medicaid hospital reimbursements or reduce safety net hospital payments. During the pandemic, the State is paying enhanced Medicaid rates to hospitals. That needs to continue, with a shift towards chronically underfinanced psychiatric and substance abuse services disproportionately located at public and safety net hospitals and health centers.

Second, the State needs to quickly respond to the enormous increase in the number of uninsured resulting from layoffs and loss of employer-based health coverage. A million more New Yorkers are uninsured today than were six weeks ago. Some will qualify for Medicaid – but most won’t. They need deeper subsidies than currently exist to secure “Obamacare” insurance. The right to coverage should also be extended to all New Yorkers, regardless of citizenship status.

Third, the State should implement the governor’s announced integrated hospital program as permanent policy, insuring that scarce resources are allocated according to community need.

Fourth, the State Legislature should consider capturing the excess revenue of non-profit hospitals, as recommended in the recent Citizens Budget Commission report. In 2018, the five large private systems serving New York City earned $1.5 billion more than they spent. A substantial chunk of that money would go a long way toward redressing hospital inequality.

Fifth, and most critically, State and City governments need to commit to equality. Every institution ought to have the resources to provide the best, needed care. Whether a hospital is located in Elmhurst or Manhattan’s Upper East Side is an accident of history. Geography and ownership ought not be destiny. That’s why we have government.

Barbara Caress is a health care consultant who teaches health policy at Baruch College.

http://www.centernyc.org…

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Comment:

By Richard N. Gottfried, Chair of the Health Committee of the New York State Assembly, and author of the New York Health Act, a bill to establish single-payer universal health care coverage in New York

This article on hospital inequality in the COVID-19 epidemic is an excellent analysis by Barbara Caress, a long-standing keen analyst of our health care system. The article is focused on New York, but it is relevant to the whole country.

I would add some key points.

The epidemic has shined a bright light on every problem in the health care system (and most other parts of our society), but those problems have been with us long before the epidemic. Unless we learn from the epidemic and take strong action, these problems will still be with us long after the epidemic.

Almost every problem we face in health and health care is made worse, and harder to solve, because of the way we pay for health care. The wealthiest hospitals have the highest percentages of patients with private health insurance. Public hospitals and “safety net” hospitals have far fewer privately insured patients and many more are on Medicaid and Medicare. But Medicare and Medicaid both pay substantially less than the cost of providing care. And these lower-income patients are more likely to be uninsured or unable to pay for care left unpaid by their insurance deductible.

Under the NY Health Act single-payer system, every patient would be fully covered, with no deductibles, copays or out-of-network charges (because there would be no restricted provider network). There would be huge savings from eliminating insurance company administrative and marketing costs and profit, dramatically cutting provider administrative costs, and using the state’s negotiating power to lower excessive drug prices. Using those savings, payments to health care providers, including hospitals, would be required to cover costs and ensure an adequate supply of services. That means all hospitals would be paid much more than Medicare and Medicaid pay. The only reduction in payments would be to account for reduced administrative costs.

The disparities we see in hospital care for COVID-19 patients are an extension of long-standing disparities, which are rooted in disparities in how we pay wealthy hospitals versus public and safety net hospitals. Universal, publicly accountable, single-payer health coverage is the essential component to resolving those disparities and protecting the care for all of us.

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