By Jeffrey T. Kullgren, MD, MS, MPH; Elizabeth Q. Cliff, PhD; Christopher Krenz, BA; Brady T. West, PhD; Helen Levy, PhD; Mark Fendrick, MD; Angela Fagerlin, PhD
JAMA Network Open, July 17, 2020

Abstract

Importance: Health savings accounts (HSAs) can be used by enrollees in high-deductible health plans (HDHPs) to save for health care expenses before taxes. Expansion of and encouraging contributions to HSAs have been centerpieces of recent federal legislation. Little is known about how US residents who may be eligible for HSAs are using them to save for health care.

Objective: To determine which patients who may be eligible for an HSA do not have one and what decisions patients with HSAs make about contributing to them.

Design, Setting, and Participants: This cross-sectional national survey assessed an online survey panel representative of the US adult population. Adults aged 18 to 64 years and enrolled in an HDHP for at least 12 months were eligible to participate. Data were collected from August 26 to September 19, 2016, and analyzed from November 1, 2019, to April 30, 2020.

Main Outcomes and Measures: Prevalence of not having an HSA or not making HSA contributions in the last 12 months and reasons for not making the HSA contributions.

Results: Based on data from 1637 individuals (American Association of Public Opinion Research response rate 4, 54.8%), half (50.6% [95% CI, 47.7%-53.6%]) of US adults in HDHPs were female, and most were aged 36 to 51 (35.7% [95% CI, 32.8%-38.6%]) or 52 to 64 (36.8% [95% CI, 34.1%-39.5%]) years. Approximately 1 in 3 (32.5% [95% CI, 29.8%-35.3%]) did not have an HSA. Those who obtained their health insurance through an exchange were more likely to lack an HSA (70.3% [95% CI, 61.9%-78.6%]) than those who worked for an employer that offered only 1 health insurance plan (36.5% [95% CI, 30.9%-42.1%]; P < .001). More than half of individuals with an HSA (55.0% [95% CI, 51.1%-58.8%]) had not contributed money into it in the last 12 months. Among HDHP enrollees with an HSA, those with at least a master’s degree (46.1% [95% CI, 38.3%-53.9%]; P = .02) or a high level of health insurance literacy (47.3% [95% CI, 40.7%-54.0%]; P = .03) were less likely to have made no HAS contributions. Common reasons for not contributing to an HSA included not considering it (36.8% [95% CI, 30.8%-42.8%]) and being unable to afford saving for health care (31.9% [95% CI, 26.2%-37.6%]).

Conclusions and Relevance: These findings suggest that many US adults enrolled in an HDHP lack an HSA, and few with an HSA saved for health care in the last year. Targeted interventions should be explored by employers, health plans, and health systems to encourage HSA uptake and contributions among individuals who could benefit from their use.

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

High-deductible health insurance plans have become more popular primarily because the plans are less expensive. The insurers are able to spend less on health care for two reasons. The risk of first dollar coverage is transferred from the insurer to the insured, and, with high-deductible plans, that may amount to a few thousand dollars per patient. The second reason is that patients might find that first dollar coverage may present enough of a financial hardship such that they may forgo care that they really should have – forgone care that the insurers don’t have to pay for.

Health savings accounts (HSAs) were established to make available funds that could be used so that the patient would not forgo beneficial health care services that fell under the deductible. Services that did not seem to provide adequate health care value could be rejected by the patient. Thus HSAs were designed to put the health care shopper in charge of their own spending since the HSA funds were their own funds anyway. HSA funds are tax-advantaged which benefits those with higher incomes, but does nothing for those whose incomes are too low to pay taxes.

The study by Kullgren, et al shows that many individuals who have HSA-eligible high-deductible health plans have not established a health savings account, and the majority of those who do have HSAs are not contributing funds to them. The majority of patients are at risk of facing financial hardship from the deductibles simply because the HSAs are not funded or do not even exist, thus patients may end up forgoing beneficial health care services. Also they add more administrative complexity to our health care financing system which is already overburdened with costly administrative excesses. Bad policy all the way around.

Under a well designed, single payer, improved Medicare for All, first dollar coverage is provided which eliminates financial barriers to beneficial health care services. The single payer model uses other more patient-friendly tools to prevent excessive health care spending. The patient has enough decisions to make without insisting that they must also make decisions on how health care dollars are spent. Many other nations provide health care at an average of half the per capita cost of what we spend, and they don’t require patients to become informed shoppers to do it. High-deductibles and HSAs should be replaced with first dollar coverage under single payer Medicare for All.

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By Amanda Terkel and Tara Golshan
HuffPost, July 22, 2020

For the first time, the Democratic Party platform mentions “Medicare for All,” according to a draft version released this week. It’s a victory for progressives who worked to make the transformation of the health care system a central issue in the presidential campaign.

“Generations of Democrats have been united in the fight for universal health care. We are proud our party welcomes advocates who want to build on and strengthen the Affordable Care Act and those who support a Medicare for All approach; all are critical to ensuring that health care is a human right,” the document reads.

Former Vice President Joe Biden, the party’s presumptive nominee for president, does not back Medicare for All, a policy that was central to the rival presidential campaign of Sen. Bernie Sanders (I-Vt.). So the platform does not endorse the idea, and the reference to it is brief. But supporters say it’s still a win to have their progress acknowledged ― and to have the idea enshrined in an official party document in a positive way.

“If this pandemic has taught us anything, it’s that health care is a human right and that the greed and cruelty of health insurance corporations must end,” said Josh Orton, a senior adviser to Sanders who was on the committee. “A majority of Democrats in the U.S. House support a Medicare for All system, and it shows real progress that our movement is now a part of the DNC platform itself.”

https://www.huffpost.com…

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Comment:

By Don McCanne, M.D.

Although the current draft of the Democratic Party platform doesn’t endorse Medicare for All, it does welcome both advocates of the Affordable Care Act and advocates of Medicare for All, acknowledging the support of both concepts within the ranks of the party. It is a first in that previous efforts to include single payer in the party platform have been rejected. So the mere mention of Medicare for All in the platform does represent progress.

The presumptive Democratic candidate for president – Joe Biden – has made it clear that he does not support Medicare for All and has implied that he would veto it if it came to his desk. The presumptive Republican candidate – President Donald Trump – has shown no interest in supporting Medicare for All.

So where does that leave us? As FDR said when special interests sought his support for another unrelated agenda, “Make me do it.”

That’s quite a task, having to pump up the politics such that the president can’t refuse, but that’s what we have to do.

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By Gordon Pennycook, James Allan Cheyne, Derek J. Koehler, and Jonathan A. Fugelsang
PsyArXiv, Preprint, Last edited June 24, 2020

Abstract

Does one’s stance toward evidence evaluation and belief revision have relevance for actual beliefs? We investigate the role of having an actively open-minded thinking style about evidence (AOT-E) on a wide range of beliefs, values, and opinions. Participants indicated the extent to which they think beliefs (Study 1) or opinions (Studies 2 and 3) ought to change according to evidence on an 8-item scale. Across three studies with 1,692 participants from two different sources (Mechanical Turk and Lucid for Academics), we find that our short AOT-E scale correlates negatively with beliefs about topics ranging from extrasensory perception, to respect for tradition, to abortion, to God; and positively with topics ranging from anthropogenic global warming to support for free speech on college campuses. More broadly, the belief that beliefs should change according to evidence was robustly associated with political liberalism, the rejection of traditional moral values, the acceptance of science, and skepticism about religious, paranormal, and conspiratorial claims. However, we also find that AOT-E is more strongly predictive for political liberals (Democrats) than conservatives (Republicans). We conclude that socio-cognitive theories of belief (both specific and general) should take into account people’s beliefs about when and how beliefs should change – that is, meta-beliefs – but that further work is required to understand how meta-beliefs about evidence interact with political ideology.

Conclusion

Our 8-item actively open-minded thinking about evidence (AOT-E) scale was strongly predictive of a wide range of beliefs, values, and opinions. People who reported believing that beliefs and opinions should change according to evidence were less likely to be religious, less likely to hold paranormal and conspiratorial beliefs, more likely to believe in a variety of scientific claims, and were more political liberal (in terms of overall ideology, partisan affiliation, moral values, and a variety of specific political opinions). Moreover, the effect sizes for these correlations was often large or very large, based on established norms (Funder & Ozer, 2019; Gignac & Szodorai, 2016). The size and diversity of AOT-E correlates strongly supports one major, if broad, conclusion: Socio-cognitive theories of belief (both specific and general) should take into account what people believe about when and how beliefs and opinions should change (i.e., meta-beliefs). That is, we should not assume that evidence is equally important for everyone. Furthermore, our findings provide clear support for the perspective that reasoning facilitates sound judgment, thereby undermining the idea that intuition commonly dominates reasoning. We also found essentially no support for motivated reasoning. Regardless future work is required to more clearly delineate why AOT-E is more predictive for political liberals than conservatives.

https://psyarxiv.com…

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Comment:

By Don McCanne, M.D.

This study revealed that people are sharply divided on open-minded thinking about evidence (AOT-E); that is, they are divided on believing whether or not beliefs and opinions should change according to evidence. More specifically, they find that AOT-E is more strongly predictive for political liberals (Democrats) than conservatives (Republicans). Since these differences are relative rather than absolute, we shouldn’t try to reach for a theory of all things here, but we can use this to try to understand why there is resistance to supporting Medicare for All when the evidence is overwhelming that it is a vastly superior model of health care financing when compared to the highly dysfunctional system under which we are suffering.

So now that we know that the political opponents to Medicare for All by and large do not believe that the evidence supporting the superiority of the model should be used to change their beliefs or opinions which cause them to reject the model, what should we do? We have expounded on the benefits of Medicare for All until we’re blue in the face, yet we don’t seem to budge their side. Should we abandon trying to present the evidence? If so, then what else can we do? Do we simply wait until they have an epiphany? That doesn’t seem to be working either. Should we ask them what we can do to help sway them? But if they already reject the evidence, then they certainly are not looking for other ways to be swayed.

Donald Trump just shifted from ridiculing face masks during the COVID-19 pandemic to recommending that people use them, based on the evidence. Evidence? Has anyone presented him with the evidence favoring Medicare for All? Wouldn’t it be worth a try?

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By Gordon Mosser
SSRN, May 12, 2020

Abstract

In the US, 30 million people have no health insurance, and the per capita cost of health care is far higher than it is in other countries. To address these problems, many have advocated establishing Medicare-for-All (M4A). This paper reviews seven reports on the costs of M4A that were written by scholars of health economics in universities or private foundations that study health care. Two of these reports also describe in detail how the program might be funded. Senators Bernie Sanders and Elizabeth Warren have also made suggestions for funding.

Judged from the conclusions of the seven reports, it appears that M4A would result in a net decrease in overall US healthcare costs of 5.7% on average. Under M4A, US health care would cost approximately $46,000 billion over 10 years. Over the same period, approximately $23,500 billion in new federal revenue would be needed in place of present-day payments from other sources.

This revenue could be raised in many different ways. In this review, 11 possible taxes and fees are highlighted in an example of how the necessary revenue could be raised. Under this example, it would not be necessary to impose a federal sales tax or any new taxes directly on low or middle income households, but high income households and wealthy Americans would likely pay higher taxes.

Published Reports on the Cost of Health Care under Medicare-for-All:

• Thorpe
• Blahaus
• PERI
• Friedman
• Urban Institute
• RAND
• Yale

See full report for the following:

• Cost: Factors That Could Change Healthcare Costs
• Cost: Conclusions and Assumptions of the Seven Reports
• Cost: Arriving at Overall Conclusions on Cost and Revenue Needed
• Funding: Proposals That Have Been Made for Raising the Necessary Revenue
• Funding: An Example of How the Necessary Federal Revenue Could be Raised

All of the reports project a large increase in spending by the federal government, as would be expected. Under M4A, a substantial portion of existing spending would be shifted into the federal budget. This represents new federal spending but not an increase in healthcare costs. Some political commentators have represented the dollar-volume of this shift as the cost of M4A, thus making the overall cost of health care in the US appear to increase enormously with M4A, more than 50%. This characterization is obviously misleading, perhaps intentionally so.

Concluding Comments

In discussions of Medicare-for-All, including Presidential debates, inevitably someone says, “This plan sounds all right, but how much will it cost?” The short and accurate answer is: “Nothing.” We are already paying for it. In fact, we estimate that we are overpaying by 5.7%, maybe more. Moreover, we are providing insurance coverage for fewer people than would be covered under Medicare-for-All, and those people who now have coverage are receiving fewer benefits than they would under Medicare-for-All.

We would need new federal revenue to fund the program, but this would not be new money. Most of it would be re-directed money. Currently this money flows from individuals, families, and businesses to insurance companies, and then to hospitals, physicians and other providers. Under Medicare-for-All, it would flow instead to the federal government before being transferred to providers, and the total amount transferred would be reduced.

Thus, the cost of health care under M4A should not be a barrier to its adoption. The principal barriers are instead fear of the unknown and the threat of disruption. The change to Medicare-for-All would be a monumental change, and the politics of making this change are not considered in this paper. It is clear that thinking about this change is perplexing and even frightening. We should, however, cease debating the cost and turn our attention to how to implement such a system, one that would both reduce the cost of health care in the US and generate substantial health benefits for those Americans who are currently uninsured or underinsured. To establish Medicare-for-All, the body politic will need to summon the will to enact change and to face the challenge of managing the transition.

Gordon Mosser, M.D., is a Senior Fellow in the Division of Health Policy and Management at the University of Minnesota School of Public Health.

https://papers.ssrn.com…

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Comment:

By Don McCanne, M.D.

Understandably, since single payer Medicare for All is a serious proposal which is supported by a majority of Americans, people would like to know what it would cost. Since final, definitive legislation has not been produced, precise estimates cannot be made at this time. However, based on analyses of the general concepts by Thorpe, Blahaus, PERI, Friedman, Urban Institute, RAND, and Yale, fairly reliable generalizations can be made. Gordon Mosser has compiled these estimates and has come up with a “golden mean” on what the major features of spending on single payer Medicare for All might be.

• Our current national health expenditures are already more than enough to pay for comprehensive health care for everyone through a well designed single payer model of an improved Medicare for All. Our total national health expenditures may actually decrease under such a model.
• Medicare benefits would be improved, providing more comprehensive coverage.
• Medicare eligibility would be expanded to include everyone.
• The efficiency of the single payer model of Medicare would dramatically reduce administrative waste, plus efficiencies in purchasing would recover enough funds to pay for much of the improved benefits and expanded coverage of Medicare for All.
• Since the system would be funded through the tax system, taxes will increase, but the additional amount paid in taxes by most individuals will be more than offset by the elimination of private spending for health care. On average, only the wealthy will pay more than they currently do.
• Since the taxes will be progressive, funding of health care will be more equitable, based on ability to pay, and thus affordable for each of us.
• What will the system cost? Nothing, since we are already spending enough to pay for it. To claim that the tax increases are increases in costs is either naive or outright dishonest.

So when someone asks, “How are we going to pay for Medicare for All?” The answer is, “We’re already paying enough, but we’re going to pay for it more fairly through equitable tax policies. For all but the very wealthy, average health care spending will decrease.”

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Just as a reminder, PLOS Medicine on January 15, 2020 published “Projected costs of single-payer healthcare financing in the United States: A systematic review of economic analyses,” by Christopher Cai, James Kahn, et al. They surveyed an even greater number of single payer cost analyses, and their results were essentially the same: “There is near-consensus in these analyses that single-payer would reduce health expenditures while providing high-quality insurance to all US residents.”

PLOS Medicine:
https://journals.plos.org…

Quote of the Day – Projected costs of single payer in the United States:
https://pnhp.org…

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By Jacob S. Hacker (Yale University), Paul Pierson (University of California, Berkeley)

Introduction

This is not a book about Donald Trump.

Instead, it is about an immense shift that preceded Trump’s rise, has profoundly shaped his political party and its priorities, and poses a threat to our democracy that is certain to outlast his presidency.

That shift is the rise of plutocracy – government of, by, and for the rich.

Chapter 1 – The Conservative Dilemma

Plutocratic populism is rather new; the political dilemma that gives rise to it is very old. What happens when an economic system that concentrates wealth in the hands of the few coexists with a political system that gives the ballot to the many?

Whenever economic elites have grossly disproportionate power and come to see their economic interests as opposed to those of ordinary citizens, they are likely to promote social divisions. They are also likely to come to fear a fair democratic process in which those citizens have significant clout. These elite responses to extreme inequality enter into politics mainly through conservative parties, which must navigate the tension between unequal influence and democratic competition. The Conservative Dilemma is not a problem of a particular moment. It is a problem inherent in democratic politics in contexts of extreme inequality.

Chapter 2 – Republicans Embrace Plutocracy

Extreme inequality creates three fundamental threats to healthy democratic politics: divergent elite interests, disproportionate elite power, and diminished elite commitment to democracy itself.

Chapter 3 – Organizing through Outrage

If finding groups Republicans could rely on to navigate the Conservative Dilemma took time, it was time well spent. For the groups that aligned with the GOP proved unusually skilled at creating durable shared identities that motivated citizens, and then getting those citizens to show up, not just on election day, but whenever big shows of strength were needed. These were groups, in short, that could rally their troops, creating sharp lines between friend and foe and instilling a sense of threat. And what best rallied those troops, they discovered, was outrage.

Chapter 4 – Identity and Plutocracy

If Republicans had weakened their embrace of plutocracy, they would have adopted economic priorities closer to those of less affluent GOP voters and diminished their reliance on divisive appeals. And if they had moderated their economic stances and softened their cultural appeals, they could have brought more nonwhite voters into the fold. They did neither – that they cultivated voter identities that were so intense, exclusive, and divisive; that they ramped up white backlash even as American society as a whole was becoming more tolerant – wasn’t because voters gave them no other options. Ultimately, it was because they chose plutocrats over everyone else.

Chapter 5 – A Very Civil War

In the new GOP, public officials either bent their knee to Trump, retired from the scene, or were demolished.

Yet if the past few years have witnessed a Republican civil war, it has been a very civil war, in which the side allegedly losing has made gains it could have scarcely contemplated just a few years before. Among the biggest winners were the right-wing plutocrats who had been at the heart of the establishment. When Trump took power, he handed much of the power to people loyal to the plutocrats, or to the plutocrats themselves. They brought their long-standing policy ambitions into the federal government and carried them out with a vengeance.

The plutocrats have gotten huge tax cuts. They have reaped the benefits of an unprecedented attack on regulations that police big corporations and protect consumers, workers, and the environment. And they have seen the nation’s powerful courts tilt even further in favor of elite economic interests.

Chapter 6 – Tyranny of the (Wealthy and Extreme) Minority

Although Republicans decisively lost the House of Representatives in 2018, they did not turn to moderation.

They recognized the widening gap between their priorities and those of the broader electorate. But they saw this growing divergence not as a problem with their priorities, but as a problem with their strategies. To these intense and focused factions, electoral and policy setbacks did not mean that Republicans had to attract wider support. They meant Republicans had to figure out how to win without it.

Conclusion

Moderation from economic elites is most likely to emerge in response to growing pressure from below.

Where, exactly, will that pressure come from?

(No spoiler here.)

https://wwnorton.com…

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Comment:

By Don McCanne, M.D.

Many of us who have been working so hard and so long on single payer reform – an improved Medicare for All – have had difficulty in understanding why an obviously vastly superior health care financing model has not been enacted and implemented long before now. Such a system would benefit all of us, although the very wealthy would pay more taxes (but not enough to be detectable without a careful perusal of their tax statements). With polling demonstrating popular support and with a model that should have strong appeal for almost everyone, it seems that it should have been put in place long ago.

In “Let Them Eat Tweets,” Jacob Hacker and Paul Pierson explain why that has not occurred. Simply, the very wealthy control the government; that is, we have a plutocracy. The plutocrats are opposed to the government taxation and regulation that would be required to establish a universal, equitable, publicly-administered and publicly-financed health care system; so we don’t have it.

The Constitution was designed to prevent a small group from gaining control of the government, yet it has happened even though the vast majority of U.S. citizens are worse off for it. The authors explain how this came to be. They do not attribute it to Donald Trump – its onset was decades before Trump entered the scene – but they do use the Trump administration to illustrate the adverse consequences of a plutocracy, including how only a relatively few individuals can have such great control over our government. As an example, at a time we desperately need a redistribution to partially ameliorate the injustices of profound income and wealth inequality, instead we got a massive tax reduction for the plutocrats and an increase in government deficit spending for the rest of us and our progeny, thus worsening the inequality.

If there is good news here, it is that “moderation from economic elites is most likely to emerge in response to growing pressure from below.” Even though our democracy has suffered damage under the plutocrats (details are in the book) we do still have a democracy that we can repair and use to align the interests of the plutocrats with the will of the people. Any keen observer of our politics will realize how difficult that will be, but we can do it.

Maybe we could start with single payer Medicare for All.

PNHP does not endorse any political party nor any candidate for office.

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59 years ago today I was released from Parchman Farm Penitentiary after being arrested in Jackson, MS for using a so-called “white” restroom during the Freedom Rides of 1961. pic.twitter.com/OUfgeaNDOm

— John Lewis (@repjohnlewis) July 7, 2020

“Do not get lost in a sea of despair. Be hopeful, be optimistic. Our struggle is not the struggle of a day, a week, a month, or a year, it is the struggle of a lifetime. Never, ever be afraid to make some noise and get in good trouble, necessary trouble.”

John Lewis
February 21, 1940 – July 17, 2020

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By Héctor E. Alcalá, Amanda E. Ng, Sujoy Gayen, and Alexander N. Ortega
The Journal of the American Board of Family Medicine, July 2020

Abstract

Introduction: Discrimination can compromise access to and utilization of health care and lead to poorer health. As such, it is important to understand the factors associated with experiences of discrimination in health care.

Methods: Using data from the 2015 to 2017 California Health Interview Survey (n = 63,100), this study examined whether insurance types and sites of usual sources of care were associated with reasons for perceived discrimination in health care and whether the reasons were associated with delaying health care. Odds of study outcomes were calculated among insured adults using logistic regressions. Insurance coverage types and sites of usual sources of care were the main independent variables. Six reasons for lifetime discrimination in health care were examined: 1) dissatisfaction with the health care system, 2) race or skin color, 3) age, 4) way the participant speaks English or other barrier to communication, 5) insurance status or type, and 6) income or education.

Results: Adults with Medicaid perceived more discrimination due to race or skin color relative to those with employer-sponsored coverage. This association does not vary by race/ethnicity. Perceived discrimination due to 1) dissatisfaction with the health care system, 2) insurance status or type, and 3) barriers to communication were each associated with increased delays in getting needed medical care.

Conclusions: Findings highlight potential insurance types and sources of care that could contribute to perceptions of being discriminated.

From the Discussion

This study observed that insurance type and sources of care are associated with lifetime perceptions of discrimination in health care. Perceived discrimination in health care was higher for those whose regular source of care is the ED relative to those whose regular source of care is a doctor’s office or HMO, but it did not vary substantially once specific reasons for discrimination were considered. In addition, participants receiving Medicaid were more likely to perceive discrimination in health care, with race or skin color being the only specific reason, when compared with their counterparts with employer-sponsored coverage. This supports prior work that observed that Medicaid patients reported lower satisfaction when compared with individuals with other types of insurance. The present study built on prior research that focused solely on racial and ethnic discrimination and showed that individuals with Medicaid were more likely to report perceiving racial or ethnic discrimination in health care.

Conclusions

This study observed that, even considering substantial health care reform, the experiences patients have in the health care setting vary systematically. Because this seems to be conditioned, at least in part, on the type of insurance a person has and where he or she receives health care, future reforms to the health care system are needed that provide a stronger overhaul of health care quality and must be better at addressing the effects of patients’ prior experiences with health care. In particular, because patients with several different public insurance coverage options experienced a higher burden of discrimination, not addressing these problems will disproportionally affect populations that are poorer and experience worse social determinants of health (eg, Medicaid enrollees). Furthermore, while perceived discrimination has a negative effect on health care utilization, our study suggests that the health care system needs to improve its ability to address certain types of discrimination to promote better population health.

https://www.jabfm.org…

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Comment:

By Don McCanne, M.D.

The Medicaid program works well from the standpoint that the benefits are comprehensive and the out-of-pocket exposure is minimal, providing relatively good financial protection in the event of medical need.

However, Medicaid is a welfare program and, as such, faces certain stigmas. People on the program are certainly aware of that and thus may be on guard for fear that they may be considered by others to somehow be less worthy, which could show up in the quality of care they receive or the enthusiasm with which it is rendered. In fact, the majority are now enrolled in Medicaid managed care programs which have reputations for stinting on care because of the low reimbursement rates they receive. For those receiving care outside of managed care organizations, it is generally known that reimbursement rates are very low and it may be difficult to know if providers are truly altruistic or if they are accepting Medicaid patients by default. At any rate, there is little political support for funding Medicaid at rates comparable to the private sector.

This uncertainty may cause patients to be on the watch for discrimination in their care. This may be particularly true for individuals who are already accustomed to discrimination because of their racial or ethnic backgrounds.

Unfortunately, this study adds to previous studies that confirm that racial and ethnic minorities indeed do perceive discrimination in the care they receive under the Medicaid program.

If we were to replace all current sources of health care funding with a single payer model of an improved Medicare for All, we would automatically eliminate discrimination that is based on the financing source, such as we see with Medicaid. Certainly other sources of discrimination would continue to require further remedies, but Medicare for All would provide a giant step forward toward social solidarity by virtue of an egalitarian health care financing system.

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By Susan Jaffe
MedPage Today, July 15, 2020

A House committee unanimously approved legislation Wednesday that would make changes for the first time in 50 years to the complex rules for enrolling in Medicare’s Part B, which covers doctor visits and other outpatient care.

Currently, seniors who don’t get Part B when they first become eligible for Medicare pay permanent, recurring late enrollment penalties and can only sign up during the first 3 months of the year for coverage that begins July 1, unless they qualify for an exception. To make matters worse, they cannot buy other health insurance during their months-long wait.

Patients often find out they need Part B only after their provider or insurance company sends them a bill for services. That’s because only Social Security beneficiaries currently receive a notice when they become eligible for Medicare.

If the measure, known as the “BENES” Act (Beneficiary Enrollment Notification and Eligibility Simplification Act), becomes law, the Centers for Medicare & Medicaid Services (CMS) and the Social Security Administration would be required to notify people before they turn 63, 64, and 65 that they may be eligible for Medicare at age 65. It would eliminate the waiting period by ensuring that coverage begins on the first of the month after they sign up.

Currently, far too many people make honest mistakes when trying to understand and navigate this confusing system. The consequences of such missteps are significant — including late enrollment penalties, higher out-of-pocket health care costs, gaps in coverage, and barriers to accessing needed service. In 2019, 764,000 Medicare beneficiaries paid a penalty for late Part B enrollment, increasing their monthly premiums by an average 28%, according to a May report by the Congressional Research Service.

The House of Representatives is expected to pass the bill sometime this year but its prospects in the Senate are still uncertain.

https://www.medpagetoday.com…

BENES Act:
https://www.aging.senate.gov…

Medicare Part A and B Eligibility and Enrollment:
https://www.cms.gov…

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Comment:

By Don McCanne, M.D.

The eligibility, processes and rules for enrolling in Medicare are relatively complex and vary for Part A – hospital, Part B – physician and outpatient, Part C – private Medicare Advantage, Part D – drug, and Medigap – private supplemental coverage. Original Medicare is Part A and Part B, but enrollment is such that individuals may end up with gaps in coverage or paying significant penalties if the enrollment process for Part B is not followed carefully. The BENES Act would reduce this risk, though not eliminate it.

If you read the CMS eligibility and enrollment instructions for Part A and Part B (link above), you will see that they are unreasonably complex for a program that should be (but is not) automatic for everyone. Although the BENES Act would help, some complexities would remain, not to mention the problems with Part C, Part D, and especially with the Medigap plans. Medigap is particularly important for those who want to remain in the Original Medicare program, but the rules are such that enrollment may have underwriting penalties or coverage can be refused if the initial enrollment period was missed. In the push to privatize Medicare, they have made enrollment in the Medicare Advantage plans easier, but there are still rules to be followed, not to mention that you are limited to the insurers’ provider networks and you lose your almost unlimited choice of providers in the Original Medicare program.

Compare this to single payer improved Medicare for All. Every resident is eligible and is automatically enrolled, forever. Benefits are comprehensive, including drugs, and since care is free at the time of service, there is no reason to have separate private or supplemental plans. There is no Part A, Part B, Part C, Part D, nor Medigap; there is only Medicare for All.

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By HwaJung Choi, Ph.D.; Andrew Steptoe, D.Sc.; Michele Heisler, M.D., M.P.H.; Philippa Clarke, Ph.D.; Robert F. Schoeni, Ph.D.; Stephen Jivraj, Ph.D.; Tsai-Chin Cho, M.Sc.; Kenneth M. Langa, M.D., Ph.D.
JAMA Internal Medicine, July 13, 2020

Key Points

Question: What is the difference in health status between high- and low-income individuals in the US vs England?

Findings: In this cross-sectional study including 18 572 persons (46 887 person-years of observations), the health gap between the bottom 20% and top 20% of income distribution was significantly greater for US adults aged 55 to 64 years than their English peers on 13 of 16 health measures. In addition, for most measures, the health of US adults appeared to be poorer than that of their peers in England, especially those from the lower end of the income distribution.

Meaning: The findings of this study suggest that the income-health gradient is greater among US middle-aged adults than among their peers in England, with poor health especially pronounced among those with lower income in the US.

From the Introduction

This study compared the health of US adults aged 55 to 64 years with the health of their peers in England. The US and England have a relatively similar culture, language, and economic system, yet have substantially different health care and social welfare systems. The US provides limited public health insurance for those younger than 65 years, but England provides publicly funded health care free at the time of service for all individuals under the National Health Service. About 17% of US adults aged 55 to 64 years had only public health insurance coverage, and 13% had no health insurance coverage in 2012-2013. The greater level of income inequality with limited public safety net in the US compared with England raises the question of whether those with low income in the US are at greater risk for poor health outcomes than low-income adults in England.

From the Discussion

Using data on adults aged 55 to 64 years from comparable nationally representative surveys of the US and England, this study provides evidence on disparities in health across income groups in the US vs England. Analyses of 16 health outcomes found substantial income differences in each country and for all outcomes except cancer in both countries and measured high blood pressure in England. Moreover, the disparity in health between low-income and high-income adults was significantly greater in US adults for 6 of the 8 self-assessed or directly measured outcomes, and 7 of the 8 self-reported physician diagnosis outcomes.

Cross-country differences in health were in favor of England for all health outcomes except ADL limitations, depression, and measured blood pressure, which were not significantly different between countries. The US and England disparities were pronounced among lower-income adults.

From the Conclusions

The findings of this study suggest that the gap in health between lower-income vs higher-income adults is substantial and significantly larger in the US than England for most health outcomes that we examined. In addition, lower-income adults in the US appear to have poorer health compared with lower-income adults in England.

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

The United States and England have similar cultures but different health care financing systems. This study looked at health care outcomes in both countries in the top and bottom income quintiles of those 55 to 64 – the last decade before most U.S. citizens become eligible for our government Medicare program.

The health gap between the top and bottom quintiles is significantly greater in the United States than it is in England. Further, the health of U.S. adults is poorer than their peers in England, especially for those with lower incomes.

Also income inequality is greater in the United States than it is in England. Everyone in England receives care free at the time of service through their national health service, whereas the health care financing system in the United States is fragmented with a limited public safety net.

What is more remarkable is that England has better outcomes even though its per capita health expenditures are half that of the United States.

We have the money, and we’re already spending it – $4 trillion this year. But we sure could do a lot better on how we spend it. A single payer improved Medicare for All would work just fine. And about that income inequality, we could take a major step forward by using more equitable tax policies to fund a $4 trillion universal risk pool.

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