By Jonathan Martin, Maggie Haberman and Matt Stevens
The New York Times, October 2, 2020

President Trump’s announcement early Friday that he had contracted the coronavirus upended the presidential race in an instant, inviting significant questions about his cavalier attitude toward the pandemic and the future of his campaign just 32 days before the election.

Mr. Trump had already been trailing in the polls to Joseph R. Biden Jr., in part because of his mishandling of a virus that has unsettled the day-to-day lives of voters for over six months. He compounded his difficulties by disregarding and at times belittling the basic precautions, such as wearing a mask, that his health advisers were urging Americans to take to protect themselves.

Now, though, his personal indifference toward the virus could threaten his own health, the stability of the country and his already dimming hopes for re-election.

After the coronavirus shut down the country in March, though, Mr. Trump finally ran headlong into a foe that could not be attacked, ignored or fully overwhelmed with his usual tactics.

Yet that did not stop him from trying to effectively will it away. Not only did he repeatedly predict that the virus would fade on its own, he has also consistently minimized the threat, prodding states, schools, businesses and even athletic teams to return to normal.

Not only has he defied the advice of his health advisers on masks, he has also repeatedly mocked the practice, putting him out of step with the majority of the country and even some in his party.

https://www.nytimes.com…

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NYT Reader Comment:

By Don McCanne, M.D.

Although President Trump has always been reluctant to admit an error in judgment, he has the opportunity to save perhaps hundreds of thousands of lives by doing so now. He should be frank with his ardent supporters as he explains to them why they and the rest of us must follow the science in extinguishing this scourge. Making a dent in the economy is a small price to pay for preserving human life on a wholesale basis.

https://www.nytimes.com…

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Prospect Medical, which mostly serves low-income patients, has suffered a litany of problems: broken elevators, dirty surgical gear, bedbugs and more. Its owners, including Leonard Green & Partners and Prospect’s CEO, have cashed in.

By Peter Elkind with Doris Burke
ProPublica, September 30, 2020

In the decade since Leonard Green & Partners, a private equity firm based in Los Angeles, bought control of a hospital company named Prospect Medical Holdings for $205 million, the owners have done handsomely.

Leonard Green extracted $400 million in dividends and fees for itself and investors in its fund — not from profits, but by loading up the company with debt. Prospect CEO Sam Lee, who owns about 20% of the chain, made $128 million while expanding the company from five hospitals in California to 17 across the country. A second executive with an ownership stake took home $94 million.

The deal hasn’t worked out quite as well for Prospect’s patients, many of whom have low incomes. (The company says it receives 80% of its revenues from Medicare and Medicaid reimbursements.) At the company’s flagship Los Angeles hospital, persistent elevator breakdowns sometimes require emergency room nurses to wheel patients on gurneys across a public street as a security guard attempts to halt traffic. Paramedics for Prospect’s hospital near Philadelphia told ProPublica that they’ve repeatedly gone to fuel up their ambulances only to come away empty at the pump: Their hospital-supplied gas cards were rejected because Prospect hadn’t paid its bill. A similar penury afflicts medical supplies. “Say we need 4×4 sponges, dressing for a patient, IV fluids,” said Leslie Heygood, a veteran registered nurse at one of Prospect’s Pennsylvania hospitals, “we might not have it on the shelf because it’s on ‘credit hold’ because they haven’t paid their creditors.”

In March, Prospect’s New Jersey hospital made national headlines as the chief workplace of the first U.S. emergency room doctor to die of COVID-19. Before his death, the physician told a friend he’d become sick after being forced to reuse a single mask for four days. At a Prospect hospital in Rhode Island, a locked ward for elderly psychiatric patients had to be evacuated and sanitized after poor infection control spread COVID-19 to 19 of its 21 residents; six of them died. The virus sickened a half-dozen members of the hospital’s housekeeping staff, which had been given limited personal protective equipment. The head of the department died.

The litany goes on.

https://www.propublica.org…

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Comment:

By Don McCanne, M.D. 

Above is the opening of a long investigative report by ProPublica. If it were fiction, it might be an interesting read, but for those of us concerned about the abuses of the medical-industrial complex, it is a very painful read indeed.

Most operating revenues here come from public funds – Medicare and Medicaid – while debt is used to build cash reserves. Massive dividends are going to private equity investors while patients are being shortchanged on their care.

Should we continue to grant the private sector enormous control over our health care dollars, or is it time to insist on public administration of our funds – 60 percent of which we already pay through the tax system and most of the rest through channels such as private insurance, forgone wage increases and out-of-pocket expenses?

We need single payer, improved Medicare for All, but that would be only the beginning. Today’s report cries out for a massive increase in regulatory oversight. It’s time to exercise people power.

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

By Amy E. Cha, Ph.D., M.P.H., and Robin A. Cohen, Ph.D.
CDC, National Center for Health Statistics, September 2020

Data from the National Health Interview Survey

Key findings

• In 2019, 14.5% of adults aged 18–64 were uninsured in the United States.
• Among uninsured adults aged 18–64, the most common reason for being currently uninsured was that coverage was not affordable.
• The percentage of uninsured adults who were uninsured because coverage was not affordable increased with age, from 66.8% among those aged 18–29 to 80.9% among those aged 50–64.
• Hispanic adults (30.4%) were more likely than non-Hispanic white adults (22.3%) to indicate that they were uninsured due to ineligibility.
• Men (26.8%) were more likely than women (14.6%) to indicate that they were uninsured because coverage was not needed or wanted.

Summary

In 2019, 14.5% of adults aged 18–64 were uninsured at the time of interview. Among uninsured adults aged 18–64, the most common reason for being currently uninsured was because they perceived that they could not afford the cost of coverage, followed by not being eligible, not wanting coverage, the process of signing up was too difficult or confusing, could not find a plan that meets their needs, and they signed up for coverage, but the plan has not started yet. In 2019, the percentage of adults who were uninsured due to cost was higher among women, adults aged 50–64, and adults in fair or poor health. The percentage of adults who were uninsured due to ineligibility did not vary by age but was higher among women and adults in fair or poor health. In contrast, the percentage of adults who were uninsured because coverage was not needed or wanted was higher among men, adults aged 18–29, and adults with excellent, very good, or good health. Individuals without health insurance experience barriers to health care such as not having a usual source of care and postponing or forgoing care due to cost, which may lead to negative health outcomes.

https://www.cdc.gov…

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Comment:

By Don McCanne, M.D.

This report is important because it shows how well (or not) our health care financing system was working under full implementation of the Affordable Care Act but before the onset of the COVID-19 pandemic. It demonstrates that 14.5% of adults under age 65 were uninsured, and the primary reason was the fact that health insurance coverage was not affordable.

This confirms that the current health care financing system is not functioning satisfactorily, so intervention is an imperative.

What choices do we have?

• Maintain the status quo. No politician supports this, and they shouldn’t because it would perpetuate personal financial hardship, physical suffering and premature death.
• Continue to implement President Trump’s largely random policies designed to reduce government spending and regulation. The numbers of uninsured will continue to increase and actual health care will continue to be less and less affordable. Financial hardship, suffering and death would increase. Not acceptable.
• Enact and implement Joe Biden’s proposals for reform that would tweak the current system, leaving in place the Affordable Care Act and possibly adding a public option. Health care spending would increase, the burden of our profound administrative waste would increase, and many would still be left without adequate coverage. It would fail to achieve the goals of universality, affordability and administrative efficiency. We can do better, much better.
• Enact and implement a well designed, single payer, improved Medicare for All. Coverage for all essential health care services would include absolutely everyone. Since it is funded through equitable progressive taxes, it would be affordable for each of us. The current administrative waste would be largely recovered, returning to society enough funds to pay, through equitable taxes, for the additional care required by those currently uninsured or underinsured. Universal, affordable, equitable, efficient – meeting all of our goals in a system we can afford.

We do need gifted leadership to move forward. Unfortunately that leadership was difficult to identify in last night’s presidential debate. It’s clear the current team has failed us. So do we take our chances on a new team that has already rejected the single payer Medicare for All model? Or might their political position be malleable?

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

By Matthew Fiedler, Ph.D.
The New England Journal of Medicine, September 24, 2020

There is broad agreement that policy changes could improve the U.S. health care system. But that is often where agreement ends, and different policymakers have starkly different visions for how policy should change. While Covid-19 is dominating policy discussions for now, two other health care policy issues are still poised to feature prominently in the 2020 U.S. elections: what role government should play in ensuring broad health insurance coverage and how to cope with the lack of competition in many health care provider markets.

To understand current U.S. debates over health insurance, the first step is to recognize that there is no consensus about what problem policymakers should aim to solve — a gap that reflects both different assessments of the facts and, probably more important, differences in values. At the risk of oversimplifying, there are two broad camps. The first holds that federal policy should aim for universal coverage and deeply subsidize coverage for low- and moderate-income people, a position that reflects judgments that health insurance substantially improves health and financial security, that improving the financial well-being of lower-income people is particularly important, and that governments should have broad latitude to intervene in the health care system to improve their citizens’ well-being. Policymakers in the second camp generally disagree with each of these judgments, at least to some degree, and believe that even existing federal coverage programs, particularly those serving lower-income people, are too expansive.

Policymakers in the first camp have generally supported one of two broad policy approaches. The first seeks to fill the gaps in the United States’ current patchwork coverage system while preserving its overall structure, effectively continuing the approach taken under the Affordable Care Act (ACA), which drove a large decline in the uninsured rate over the past decade. These approaches would make coverage more affordable for people who currently lack it, including by encouraging all states to expand their Medicaid programs under the ACA to cover all low-income adults (or creating alternative mechanisms to cover this group) and by expanding the ACA’s subsidies for people who purchase coverage on the individual market. They would also seek to ensure that people actually enroll in coverage for which they are eligible, through streamlined enrollment procedures and, in some cases, automatic enrollment. Democratic presidential nominee Joe Biden has adopted this basic approach to expanding coverage, although the form of autoenrollment in his plan would fall short of achieving universal coverage.

Others in the first camp have supported instead replacing the current U.S. coverage patchwork with a single integrated coverage program financed entirely by tax dollars. Many proposals in this vein, including the one from Senator Bernie Sanders (I-VT), would enroll everyone in a government-run plan with minimal cost sharing, but such a program could in principle include cost sharing or allow a choice of private plans. Relative to approaches to expanding coverage that maintain the current U.S. patchwork of coverage types, this type of system would most likely be simpler and thus impose smaller administrative and hassle costs on patients and health care providers, but it would require the federal government to collect much more revenue and would involve much greater disruption to existing coverage arrangements. Proposals eliminating a role for private insurers would be particularly simple but would forfeit any benefits that may flow from innovation by private insurers in areas such as benefit design or utilization management.

By contrast, the Trump administration’s policy agenda places it squarely in the second camp. As the president entered office, his administration supported legislation that would repeal or sharply curtail many of the ACA’s coverage provisions, including its Medicaid expansion, subsidies for obtaining coverage on the individual market, and the mandate that all individuals obtain insurance, while also reducing eligibility and funding for the pre-ACA Medicaid program. The Congressional Budget Office concluded that several proposals the administration supported would have increased the number of uninsured by more than 20 million, thereby returning the uninsured rate to roughly its pre-ACA level, and would have substantially reduced federal spending. Although only the individual mandate was ultimately repealed, the Trump administration has included similar proposals in its annual budgets and is asking the U.S. Supreme Court to strike down the entire ACA in a case being heard this fall.

(The article also discusses market concentration, competition, impact of COVID-19, and other policies such as capping prices or introducing a public option.)

Regardless, in light of the deep differences among 2020 candidates, voters’ choices this fall — whether driven by health care or other issues — will shape the health care system for years to come.

https://www.nejm.org…

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Comment:

By Don McCanne, M.D.

Matthew Fiedler has provided us with an extremely brief but fairly concise description of the major alternatives in health care reform: one camp holds that federal policy should aim for universal coverage with government subsidization to make health care affordable; the other camp believes that even current, inadequate federal coverage programs are too expensive and should be curtailed.

The first camp is divided between those who would replace the current U.S. coverage patchwork with a single integrated coverage program financed entirely by tax dollars (single payer Medicare for All), and those who would fill the gaps in the United States’ current patchwork coverage system while preserving its overall structure (expand the Affordable Care Act).

The second camp is exemplified by the Trump administration’s efforts to reduce or eliminate existing government health programs even though that would greatly increase the number of uninsured while substantially reducing government spending on health care.

Fiedler states, “there is no consensus about what problem policymakers should aim to solve — a gap that reflects both different assessments of the facts and, probably more important, differences in values,” but that the forthcoming election “will shape the health care system for years to come.”

This choice matters. Will we have essential health care for everyone that is affordable for each of us, or will we perpetuate financial hardship, personal suffering and even premature death by minimizing a government role in health care?

Will those who support financial hardship, suffering and death please stand up so we know who you are. I don’t see anyone standing. So let’s get with it in ending this scourge on America.

Vote. And then follow up with the demand to our elected public stewards that they do the right thing.

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

By Marc A. Rodwin
Health Affairs Blog, September 24, 2020

The Trump administration and House Democrats share one idea regarding pharmaceutical price controls: They agree that the US should use an international price index that averages prices paid by other countries (mostly European) to cap the US prices. PhRMA has long opposed such policies, recently renewing its opposition. Unacknowledged and perhaps unknown to those proposing this reform is that at least 25 EU nations employ a pharmaceutical price index to cap their own drug prices. European nations use their price index somewhat differently than in US proposals. This blog post draws lessons from index price caps that are used in France, Germany, and other European nations. It concludes that, to be most effective, US pharma index price cap proposals should be modified to reflect real purchase prices and be employed as part of a broader cost-control strategy.

In July 2020, President Donald Trump signed an executive order indicating he would soon implement an earlier international price index (IPI) proposal that would cap drug prices in Medicare Part B (for drugs used in hospitals). The earlier proposal, included in a 2018 notice of proposed rulemaking would, as part of a broader reform of Part B payment, create an IPI based on the prices of sixteen nations (Austria, Belgium, Canada, Czech Republic, Finland, France, Germany, Greece, Ireland, Italy, Japan, Portugal, Slovakia, Spain, Sweden, and United Kingdom). The proposal aimed to phase down prices toward the IPI for selected single source drugs. The Centers for Medicare and Medicaid Services estimated it would reduce spending by 30 percent for selected drugs. However, as initially proposed, the policy would be difficult to implement because it lacks an enforcement mechanism.

In contrast, the House Democrats bill would cap drug prices for all of Medicare and private insurers based on an Average International Market (AIM) Index, which is the volume-weighted average of each drug price in Australia, Canada, France, Germany, Japan, and the United Kingdom. The legislation would establish Medicare drug prices by negotiation between the Department of Health and Human Services (HHS) and each pharmaceutical manufacturer, with prices capped at 120 percent of the AIM Index. The HHS would negotiate prices for at least 25 new branded drugs a year that lacked competition; it could negotiate up to 250 drugs prices each year. Medicare Part D health plans that cover drugs purchased outside of hospitals would retain the option to employ other measures to negotiate lower prices. In selecting which drug prices to negotiate, HHS would prioritize drugs for which the greatest savings could be achieved. Manufacturers would have to offer the price as set by Medicare to insurers covering drugs outside of Medicare, as well—but private insurers could negotiate their own prices. Subsequently, price increases would only be allowed to control for inflation. Manufacturers that did not conclude a price negotiation or comply with the price agreement would be assessed an excise tax, set initially at 65 percent of their annual gross sales and increasing 10 percent each quarter up to a maximum of 95 percent. Firms that charged Medicare or private insurers more than the price cap could be subject to a monetary penalty 10 times the difference between the negotiated price and the price charged.

The good news is that these approaches are not purely theoretical; we have the experiences of European nations to learn from. When considering these proposals, policy makers should consider the following key lessons:

1. The IPI should be based on maximum reimbursement after discounts or on net prices—not on official prices.
2. Employ health technology assessment (HTA) to determine the therapeutic value of new drugs to cap reimbursement, in addition to employing a cap based on an IPI.
3. Employ index prices to cap prices for drugs that are superior to existing products, but cap prices of other drugs based on the price of comparable products.
4. Use competitive bidding to obtain drugs at lower prices than maximum reimbursement allowed.

Conclusion

If the US employs an IPI, it should calculate the index price using real maximum reimbursement in other nations rather than official prices as is done in the congressional and Trump administration IPI proposals. Even more important, an IPI is insufficient to effectively control pharmaceutical prices and spending. It is one tool that should be employed as part of a broader pharmaceutical price and cost-control strategy. That strategy can include: capping prices based on a drug’s cost-effectiveness or added therapeutic value, reimbursing new drugs no more than standard therapies unless independent HTA confirms that the new drug is superior, setting global drug spending budgets, and employing markets to obtain purchase prices below price caps.

Marc A. Rodwin, professor of law at Suffolk University Law School, teaches and conducts research on pharmaceutical and health policy, and biomedical ethics. He is currently evaluating health technology assessment and pricing policies in Europe and the US. He is the author of Conflicts of Interest and the Future of Medicine: The United States, France, and Japan (Oxford, 2011); and Medicine, Money, & Morals: Physicians’ Conflicts of Interest (Oxford, 1993).

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Drug prices in the United States range from $4 for some generics offered through membership programs to $2,125,000 for Zolgensma – a treatment for spinal muscular dystrophy. The average drug spending is about $1,200 per person per year – $346 billion in 2019 – per capita spending that is twice the average of other high-income nations.

Why? Prices are too high. Why? Essentially, we have refused to demand that the government regulate drug prices. We won’t even demand that the government negotiate better drug prices for the Medicare program.

We are back to proposals to allow drug purchases through Canada to take advantage of their lower prices. But there are tremendous logistical problems with that, not to mention that Canada, with one-tenth of the population of the United States, can hardly be expected to meet our needs without threatening the drug supply for their own citizens. Besides, it is somewhat silly for U.S. firms to ship to Canada drugs at a lower price and then send them back here with various private and government administrative costs added on to the prices. I have long said that we don’t need to import drugs from Canada; we need to import Canadian drug prices instead.

The anti-regulatory posturing on drug pricing may be coming to an end. As Marc Rodwin states, “The Trump administration and House Democrats agree that the US should use an international price index that averages prices paid by other countries (mostly European) to cap the US prices,” though the Democrats’ proposal is far more comprehensive. More importantly, Rodwin provides us with key lessons derived from the experiences of European nations.

We may struggle with trying to reprice a two million dollar drug, but we cannot allow that to set a new standard in price gouging by the pharmaceutical industry.

We really do need single payer, improved Medicare for All that includes comprehensive prescription coverage, but we need to be sure that our tax system is paying fair prices for our drugs. I just paid a $567 copay for a drug covered under Medicare Part D. Though I can afford that, too many can’t. We need a health care financing system that makes health care affordable for everyone. Instead of paying prices that too many cannot afford, we can make funding through progressive taxes the great equalizer. Everyone can afford that, even President Trump (his taxes for a year not being much more than my copay for one drug?)

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

The White House, September 24, 2020

Section 1. Purpose. Since January 20, 2017, my Administration has been committed to the goal of bringing great healthcare to the American people and putting patients first.

On December 22, 2017, I signed into law the repeal of the burdensome individual-mandate penalty…

Executive Order 13813 of October 12, 2017… My Administration increased the availability of renewable short-term, limited-duration healthcare plans… My Administration expanded health reimbursement arrangements… My Administration also issued a rule to increase the availability of association health plans…

Economic Report of the President (February 2020), my Administration’s expansion of health savings accounts…

my Administration acted to dramatically increase the accessibility and availability of telehealth services for Medicare beneficiaries…

waivers allow States to move away from the ACA’s rigid structure …

my Administration has paved the way for a new wave of innovation to allow patients to safely send their own medical records to care providers of their choosing…

CMS has acted to offer Medicare beneficiaries prescription drug plans with the option of insulin capped at $35 in out-of-pocket expenses…

Executive Order 13937 of July 24, 2020 low-income Americans who receive care from a federally qualified health center will have access to insulin and injectable epinephrine at prices lower than ever before…

Executive Order 13938 of July 24, 2020 my Administration will be the first to complete a rulemaking to authorize the safe importation of certain lower-cost prescription drugs from Canada…

Executive Order 13939 taking action to eliminate wasteful payments to middlemen by passing drug discounts through to patients…

Executive Order 13948 of September 13, 2020 ensure that Medicare patients receive the lowest price that drug companies offer comparable foreign nations…

Further Consolidated Appropriations Act, 2020, I also signed into law the repeal of the medical device tax, the annual fee on health-insurance providers, and the “Cadillac” tax on certain employer-sponsored health insurance…

Executive Order 13877 make sure patients have access to meaningful price and quality information prior to the delivery of care…

My Administration implemented a “site neutral” payment system between hospital outpatient departments and physicians’ offices…

The ACA is neither the best nor the only way to ensure that Americans who suffer from pre-existing conditions have access to health-insurance coverage. I have agreed with the States challenging the ACA, who have won in the Federal district court and court of appeals, that the ACA, as amended, exceeds the power of the Congress. The ACA was flawed from its inception and should be struck down. However, access to health insurance despite underlying health conditions should be maintained, even if the Supreme Court invalidates the unconstitutional, and largely harmful, ACA.

My Administration has always been committed to ensuring that patients with pre-existing conditions can obtain affordable healthcare, to lowering healthcare costs, to improving quality of care, and to enabling individuals to choose the healthcare that meets their needs.

My Administration has taken unprecedented action to improve the quality of and access to care for individuals with HIV, as part of our goal of ending the epidemic of HIV in the United States by 2030.

February 9, 2018, I signed into law the repeal of the Independent Payment Advisory Board…

October 24, 2018… billions of dollars of funding for important programs to support prevention and recovery…

June 6, 2018… improve options for veterans to receive care outside of Department of Veterans Affairs (VA) healthcare providers…

Department of Veterans Affairs Accountability and Whistleblower Protection Act of 2017… more power to discipline employees…

December 18, 2018… support for research into sickle cell disease…

In response to the COVID-19 pandemic, my Administration launched Operation Warp Speed…

Sec. 2. Policy. It has been and will continue to be the policy of the United States to give Americans seeking healthcare more choice, lower costs, and better care and to ensure that Americans with pre-existing conditions can obtain the insurance of their choice at affordable rates.

Sec. 3. Giving Americans More Choice in Healthcare. The Secretary of the Treasury, the Secretary of Labor, and the Secretary of Health and Human Services shall maintain and build upon existing actions to expand access to and options for affordable healthcare.

Sec. 4. Lowering Healthcare Costs for Americans. (a) The Secretary of Health and Human Services, in coordination with the Commissioner of Food and Drugs, shall maintain and build upon existing actions to expand access to affordable medicines, including accelerating the approvals of new generic and biosimilar drugs and facilitating the safe importation of affordable prescription drugs from abroad.

Sec. 5. Providing Better Care to Americans. (a) The Secretary of Health and Human Services and the Secretary of Veterans Affairs shall maintain and build upon existing actions to improve quality in the delivery of care for veterans.

Executive Order:
https://www.whitehouse.gov…

Fact Sheet:
https://www.whitehouse.gov…

President Trump Delivers Remarks on the America First Healthcare Plan (video begins at 54 minutes):
https://www.youtube.com…

Transcript of speech:
https://www.whitehouse.gov…

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Comment:

By Don McCanne, M.D.

Although introduced with only limited fanfare, apparently the America First Healthcare Plan is the great health care plan that President Trump has been promising us. If you skim through the excerpts above, you’ll see that it is not much of a plan. The most significant change is to support the legal action to strike down the Affordable Care Act. The most highly emphasized positive measure is to establish as official U.S. policy “that Americans with pre-existing conditions can obtain the insurance of their choice,” though no mechanism is established to implement that policy once the Affordable Care Act is struck down. The majority of the measures are actually detrimental. His trademark dishonesty permeates his speech (even throwing in a gratuitous use of the term “communists”).

President Trump has not offered a credible “Replace” plan once the Affordable Care Act is eliminated. But Joe Biden’s proposal to merely tweak the current system is unsatisfactory as well, though not to as great of a degree. (And there are other issues that make this election important.)

We desperately need single payer, improved Medicare for All. Does anyone see a clear path forward from here?

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

Interview of Jonathan Gruber by Caroline Miller
American Healthcare Journal, September 9, 2020

Caroline Miller: Ten years on, how would you grade the Affordable Care Act?

Jonathan Gruber: Before the ACA was in place, people could say, “Well, we’ve got these market-based solutions, and they work,” but they never would. The ACA moved the bar in terms of saying, “Well, here’s a real market-based solution to healthcare.” If you’ve got something better, let’s see how it does.

I think having the law in place and covering those people sort of put the lie to the whole idea of “replace,” or that there’s some ambiguous market-based solution out there that’ll work.

CM: I know you helped design the single-payer system in Vermont. What are the lessons learned from that experiment, and should Green Mountain Care be a cautionary tale moving forward for Democrats on the federal level now that it’s become a priority for progressives?

JG: I think the bottom line is it shows that it’s just too expensive. Not in the sense that it’s too expensive for society. I said that single payer would probably lower social healthcare costs. It’s too expensive in the sense that single payer is a transfer of the burden on the private sector, to the burden of putting it explicitly on taxation, and people don’t like that transfer.

In Vermont, I found that if they did single payer, total healthcare costs would fall by at least 10 percent. That was a conservative estimate. But since they were moving away from employer insurance to government insurance, to pay for it, they would have had to more than double the entire tax bill of the state of Vermont, and that just killed it.

You could say that shouldn’t have killed it, because overall we should care about society’s total healthcare costs and who cares who bears them, but in fact people do care who bears them.

Right now, America has a system financed by a hidden tax: When our employers give us health insurance, they just pay us lower wages. Single payer would replace that with an explicit tax, which is literally raising people’s taxes, and as Vermont shows, that’s a politically difficult transition.

CM: What do you think the U.S healthcare system will look like in 2030?

JG: The bigger question is, will we take serious steps to control costs? Things like regulating prices, or forcing people into more rigorous value-based care? And that, I simply do not know.

If I had to guess, I’d say healthcare in 2030 will look a lot like healthcare in 2019, plus some “digital health stuff.”

CM: What would you say it should look like?

JG: After decades of trying to figure out market-based solutions to cost control, I don’t think there are any. I think it’s time to regulate healthcare prices. I do not see a purely competitive market-based solution to the excessive prices we charge in healthcare. Healthcare costs are a pricing problem. Our prices for things like specialist services, medical equipment and drugs are too high. I think we have to put in a smart regulatory regime where we start to bring those under control.

https://americanhealthcarejournal.com…

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Comment:

By Don McCanne, M.D.

Jonathan Gruber says, “After decades of trying to figure out market-based solutions to cost control, I don’t think there are any. I think it’s time to regulate healthcare prices.”

And what better way than enacting and implementing a well designed, single-payer, improved Medicare for All? But the people have to demand it.

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

By Jordan Rau and Emmarie Huetteman
Kaiser Health News, September 17, 2020

While rural hospitals have been closing at a quickening pace over the past two decades, a number of inner-city hospitals now face a similar fate. And experts fear that the economic damage inflicted by the COVID-19 pandemic on safety-net hospitals and the ailing finances of the cities and states that subsidize them are helping push some urban hospitals over the edge.

By the nature of their mission, safety-net hospitals, wherever they are, struggle because they treat a large share of patients who are uninsured — and can’t pay bills — or are covered by Medicaid, whose payments don’t cover costs. But metropolitan hospitals confront additional threats beyond what rural hospitals do. State-of-the-art hospitals in affluent city neighborhoods are luring more of the safety-net hospitals’ best-insured patients.

These combined financial pressures have been exacerbated by the pandemic at a time their role has become more important: Their core patients — the poor and people of color — have been disproportionately stricken by COVID-19.

Founded 168 years ago as the city’s first hospital, Mercy Hospital & Medical Center survived the Great Chicago Fire of 1871 but is succumbing to modern economics, which have underfinanced the hospitals serving the poor. In July, the 412-bed hospital informed state regulators it planned to shutter all inpatient services as soon as February.

Mercy is following the same lethal path as did two other hospitals with largely lower-income patient bases that shuttered last year: Hahnemann University Hospital in Philadelphia, and Providence Hospital in Washington, D.C., which ended its inpatient services. Washington’s only public hospital, United Medical Center — in the city’s poorest ward — is slated to close in 2023 as well, and some services are already curtailed.

Fifty-five percent of Chicagoans living in poverty and 62% of its African American residents live within Mercy’s service area, according to Mercy’s 2019 community needs assessment, a federally mandated report. The neighborhoods served by Mercy are distinguished by higher rates of death from diabetes, cancer and stroke. Babies are more likely to be born early and at low weight or die in infancy.

https://khn.org…

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Comment:

By Don McCanne, M.D.

One of the advantages of a well designed, single payer Medicare for All program is that central planning and separate budgeting of capital improvements and facilities are part of the program. Infrastructure improvements are based on medical need rather than based on investment opportunities for venture capitalists and other rent-seekers. As costly as our health care system is, we should be doing better in getting our health care resources to where they are needed.

As we revitalize our health care system, it is appropriate that extra attention be paid to ensuring that deficiencies due to racial inequities and poverty be addressed. Shutting down urban hospitals that serve these needs is certainly not the right way to go about it.

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

By Katherine Baicker, Ph.D., and Amitabh Chandra, Ph.D.
The New England Journal of Medicine, September 16, 2020

Political slogans paint stark choices for health care reform: “Medicare for All” or “Free-Market Competition.” These slogans are designed to be simple and appealing — but vague enough to obscure the trade-offs involved, allowing listeners to fill in their own notions and masking varying beliefs. “Medicare for All” appeals to preferences for universal coverage, but sidesteps necessary trade-offs over which Americans may disagree. “Repeal and Replace” may appeal to skepticism about government’s role in health care, but leaves voters to imagine what the “replacement” might be.

The direction each of us would choose for our health care system depends on our answers to some fundamental questions: How much do we want to spend to expand coverage for low-income Americans? What health insurance features are most important to us? And what should the roles of government and the private sector be in making those decisions? Answering these questions involves wrestling with unavoidable trade-offs. Expanding insurance to cover more Americans will require deciding how generous that coverage should be, given competing priorities for public resources. Implementation of a single-payer plan as envisioned in some proposals would involve trade-offs between coverage features and costs. Similarly, free-market competition could drive down prices for some Americans, but leave care unaffordable for others. There is no single right answer to these questions, and slogans can’t tell us how to prioritize.

These slogans often paint a picture of a deeply divided America, while obscuring both shared priorities and disparate preferences. Enduring reform must be built on clear goals that guide the way we deploy inherently limited resources. Expanding public insurance means either spending less on other public programs or raising taxes. Having insurance with more generous coverage and lower copayments means paying higher premiums. Though there is ample room to compromise over policies that are designed to achieve shared goals, there is little prospect for consensus on reforms without agreement on what we want from our health system.

Several surveys track Americans’ views about the health care system, but they don’t generally capture the extent of agreement about these fundamental trade-offs. To help illuminate where Americans might agree or diverge on fundamental reform issues, in terms of both means and ends, we worked with the University of Chicago Harris School of Public Policy and the Associated Press–NORC Center for Public Affairs Research to assess these views (see the Supplementary Appendix for survey details). We fielded surveys of a nationally representative sample of more than 2000 Americans, with two waves in February 2020 and May 2020 spanning the explosion of the Covid pandemic, though there are of course limits to the generalizability of any two snapshots. To elucidate some central trade-offs involved in redistribution and plan design, we focused on three aspects of preferences and priorities: how altruistic Americans are, the importance they place on various features of insurance plans, and their beliefs about government’s effectiveness in improving the health care system.

Some observers argue that expanding insurance pays for itself, but there is little evidence to support this claim: expanding public insurance primarily benefits the people who gain coverage, and it requires additional spending. Support for expanding insurance must therefore be built on substantial altruistic concern about other people’s coverage. Perhaps surprisingly, our respondents were much more concerned about others’ access to affordable health care than about their own. Some 54% of participants who were asked how concerned they were about Americans without health insurance reported being very concerned, whereas only 24% of those asked how concerned they were about (potentially) being uninsured themselves reported being very concerned. Although participants who identified as Republicans were substantially less concerned overall about insurance coverage than those who identified as Democrats, both groups expressed greater concern for uninsured Americans broadly than for themselves.

But though there may be broad support for expanding coverage (albeit by varied mechanisms), the viability of a policy that would enroll the population in a single plan hinges on the alignment of people’s coverage preferences. As our results suggest, we all want different things from our health insurance plans — and our preferences vary in ways that don’t line up with our party affiliations. We asked participants which aspects of insurance plans were more important to them, focusing on the inherent trade-offs between costs and coverage (e.g., higher premiums for broader coverage versus lower premiums but restricted networks). There was no dominant view, with preferences almost evenly divided on multiple trade-offs (see table). For example, 47% of Democrats and 46% of Republicans said they would prefer to have an insurance plan with lower costs but more restrictions on covered care (vs. higher premiums but fewer restrictions).

Different reform proposals involve different mechanisms for making decisions about the trade-offs in resource use and plan features. The single-payer approach, for example, relies on government to have primacy in the health care system and to assume many of the functions of private insurers. When we asked participants whether they had greater faith in government or in the private sector to address health system problems, we found big differences in views about the government’s role in financing health care: 79% of Democrats thought the government was not spending enough on improving the nation’s health, while only 31% of Republicans concurred. Relatedly, 78% of Democrats thought that Americans should spend less on health care themselves but pay more in taxes, whereas only 37% of Republicans held this view.

We also saw a sharp partisan divide in faith in government as compared with the private sector to expand access, improve quality, and control spending: 72% of Democrats but only 33% of Republicans said they trusted the government more than the private sector to reduce costs. The pattern was similar for guaranteeing insurance coverage. But the majority of both Democrats and Republicans said they trusted the private sector more than the government to drive innovation, with only 35% of Democrats and 18% of Republicans saying the opposite.

If we want to improve our health care system, we must confront the difficult trade-offs inherent in the allocation of limited resources for potentially lifesaving care. If we want to expand coverage to people who can’t afford it, we have to prioritize making the resources available to do so. And if we want to have more expansive plan features and more generous coverage, we have to be willing to pay higher premiums.

Expanding insurance coverage is a priority that many of us share, but a one-size-fits-all single-payer plan is unlikely to meet everyone’s needs. Americans vary in their level of concern about coverage, cost, and quality, but most are more concerned about those features for others than for themselves. People’s divergent preferences regarding features of their own insurance highlight the value of having varied options to choose from — and the challenge of designing one insurance plan that would satisfy everyone.

Views regarding the government’s role in improving the system are sharply divided along partisan lines, in keeping with evidence from many polls about political divisions in support for particular health policy provisions. Such divisions suggest that the prospects for large-scale reforms remain limited by the political landscape. A successful approach might be to extend insurance coverage protections while maintaining a range of insurance plan designs and private-sector incentives to drive innovation. This approach differs from those taken by many other countries (and touted in many reform proposals), but is in fact the core approach in Medicare Advantage, Medicare Part D, and the Affordable Care Act — and it seems to match Americans’ priorities.

A natural question is whether these views have been substantially affected by Covid. In fact, our survey results from February and May were quite similar, which suggests that we may be capturing durable, fundamental preferences about health care and its delivery.

Political slogans simply don’t capture the types of reforms that are likely to achieve a nuanced set of objectives. Like the health care system itself, Americans’ priorities for it are complicated. Successful reforms must be informed by those priorities, but the trade-offs involved mean that they’re unlikely to take “simple,” polarized forms. The good news is that there are policy options available that preserve choice and promote innovation while honoring our shared commitment to making lifesaving care available to all.

https://www.nejm.org…

Supplemental Appendix: Survey Instrument:
https://www.nejm.org…

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Comment:

By Don McCanne, M.D.

What do the American people really want out of their health care system? The authors of this NEJM article suggest that the prevailing rhetoric – such as “Medicare for All” and “Repeal and Replace” – may be simple and appealing, but that it is vague enough that it obscures the various health policy trade-offs involved. Of course, since they are simply labels, they communicate very little, but that does not mean that people do not have general concepts in mind when they use these terms. One term refers to a government-run health insurance program in which everyone is included, and the other refers to a program relying primarily on the private market for the financing of health care in which coverage is not guaranteed but is based on the ability to pay. These two approaches are driven more by ideology rather than by the specifics of beneficial health policy.

Policy considerations are fairly obvious. Should a health care financing system be designed to include everyone? Make it affordable for each of us? Provide us with choices of our hospitals and health care professionals? And so forth. Most people would agree that we should have a better health care system that’s affordable for all of us. But some people are hung up on the ideology. Should the system be based on social solidarity or based on free market competition?

Using an AP/NORC survey, people were asked about concerns about their own insurance coverage and concerns about Americans who did not have insurance coverage. Both Democrats and Republicans showed some concern about both, but they were more concerned about others having coverage than having their own. On this policy issue, individuals from both major parties seemed to be altruistic, though the Democrats were more so. When asked about plan variation in costs and coverage, there was no dominant view and no partisan preference. Yet Democrats greatly preferred to have the government spend more on health care, paid through taxes, whereas only about one-third of Republicans agreed. Also, Democrats had more faith in the government to expand access, improve quality and reduce costs than did the Republicans. Obviously, ideology does influence policy.

Since the authors are noted, influential authorities in the policy community, it is helpful to try to extract from this article what their approach would be. Policies may be beneficial or detrimental, which explains why there is little agreement when individuals are required to choose from various trade-offs (e.g., exposed to financial hardship or being denied benefits). On the other hand, political ideology is more fixed and thus drives greater divides.

In this case, the authors reject one-size-fits-all single-payer, presumably because people should have choices between the policy trade-offs, so theoretically we can ignore the ideological preference for a program that is taxpayer financed and publicly administered. Then the authors mention private insurance programs that are at least partially publicly financed to demonstrate their preference: Medicare Advantage, Medicare Part D, and the private plans of the Affordable Care Act, claiming that these seem to match Americans’ priorities. Is introducing into a public program the use of private insurance a beneficial policy preference or an ideological preference? Beneficial for whom? Not the patients.

What they miss is that policy trade-offs do not necessarily require giving away beneficial features. As an example, you do not have to reduce benefits to eliminate excessive cost sharing. You can trade off the profound administrative waste created by our private insurance industry in order to have a full benefit package without the necessity of including the financial barriers of cost sharing. And ideology? Why would we want to screw up beneficial health care policies with nutty right-wing innovations?

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