PNHP

Why the current COVID-19 crisis necessitates a focus on U.S. healthcare reform

Why the current COVID-19 crisis necessitates a focus on U.S. healthcare reform

By Simrun K. Bal, M.D.
New Hampshire Union Leader, June 15, 2020

As an internal medicine resident (a doctor undergoing advanced training and working under supervision), the current medical and economic crisis related to COVID-19 has weighed heavily on my mind. Even before the pandemic, we residents often cared for patients experiencing the systemic inequities of our current health care system.

We serve uninsured and under-insured patients who may not be able to afford, for example, the $200 out-of-pocket cost for a vial of much-needed insulin for diabetes management.

In our primary care clinics, some patients save up over months to afford a needed diagnostic test. Now, with COVID-19, we serve patients who face even greater obstacles. Losing a job, losing health insurance, and getting sick is a deadly combination that reveals underlying vulnerabilities in our health care system.

Can we utilize the current crisis as an opportunity to focus on achieving access for everyone to health care that is affordable, universal, and equitable?

In the United States, our health care system is based on employer-based coverage, for up to half of all Americans. The main origins of this practice began around World War II when wages were frozen temporarily due to inflation. Individual companies were not allowed to raise pay, so they instead attempted to distinguish themselves from other businesses by offering health insurance as a key benefit to workers.

Although it may seem that employer-based coverage was functioning well prior to the pandemic, there are clear signs that it was not. Research in 2019 demonstrated that even with employer-based health coverage, more than half of Americans still delayed or postponed suggested treatments due to cost. Furthermore, as noted in the American Journal of Public Health in 2019, the majority of Americans who file for bankruptcy due to medical debt actually have health insurance.

Now, in another historic crisis, the COVID-19 pandemic has caused millions of individuals to lose their jobs. As of early May, at least 170,000 individuals in New Hampshire — about 12% of the state’s population — have filed for unemployment. This meant that many were suddenly and shockingly removed from their health insurance plan, finding themselves without coverage or being unable to afford coverage. Our patients describe feeling as though “someone has pulled the rug out from under [their] feet.”

Congress has taken temporary measures that appear reassuring, such as providing assistance through the CARES Act as well as the Families First Coronavirus Response Act. In New Hampshire, workers who have lost their jobs in the past 60 days or who anticipate job loss over the next 60 days can apply to enroll in the ACA marketplace. Unfortunately, those unemployed workers can often only afford the least expensive “Bronze” plans, with high deductibles. Fortunately, telemedicine services are also expanding, allowing providers to reach patients in rural areas of New Hampshire who might be unable to be present for in-person care.

Although I am grateful for these tentative signs of progress, I feel concerned that the vulnerabilities of our current health care system limit the possibilities of what we can achieve with these temporary measures. Access to health care coverage shouldn’t be a benefit given by an employer only during times of prosperity.

The health of all of us depends on the health of each of us. The public good depends on protecting individuals, particularly those who are most at risk. It is for this reason that we must carefully investigate alternatives to our current health care system. This choice will be a key component of the 2020 election. Different options include a public-option healthcare plan or single-payer health care (Medicare-for-All).

With a public-option plan, Americans would have a choice between private coverage and a public option (which could be purchased by employers). Unfortunately, people would still be at risk for changes in coverage due to job loss. About 10 million Americans would also still remain uninsured, and the same complexity in payments would still be present. In contrast, Medicare-for-All would provide universal, streamlined coverage. By eliminating private insurers and lowering the cost of prescription drugs, it would actually reduce spending on health care and allow us to begin improving the quality of care. These two options represent ways in which we can challenge the health care status quo and respond to the inequalities revealed by this pandemic.

Within each challenge is an opportunity. With the challenges posed by the current pandemic, we are learning many painful lessons about the vulnerabilities in our health care system.

I encourage citizens in New Hampshire to continue to educate themselves about the U.S. health care system and proposed reforms, to pay attention to temporary policy changes, to participate in making these changes permanent, and to consider involvement in groups advocating for change.

These opinions are my own and do not necessarily reflect those of my employer.

Dr. Simrun K. Bal is an internal medicine resident physician at Dartmouth-Hitchcock Medical Center in New Hampshire. She lives in Hanover.

https://www.unionleader.com…

Medicare for All Explained Podcast: Episode 36

Interview with Prof. Daniel Skinner

June 14, 2020

Health policy professor Daniel Skinner argues for a thorough reform of American health care that includes, but is not limited to, single-payer Medicare for All. Points of discussion include the “structural dynamic of inequality” that affects the health of Black Americans, people of color, and people with low incomes; and a recent op-ed by Skinner that called for a conversation on the nationalization of hospitals.

Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

SQ 802 would be a step forward for Oklahoma

By Daniel Pham
The Oklahoman, June 14, 2020

At my white coat ceremony almost a year ago, I pledged to “do no harm” in the pursuit of a medical career. However, one does not need to graduate from medical school to see that our fragmented health care coverage in Oklahoma harms patients and communities, yielding poorer health outcomes than the national average.

Patients share stories of being denied care because of inadequate coverage or paying unbelievably expensive out-of-pocket costs. Even as a first-year medical student, I hear these stories and even learn how to “manage” a patient who cannot afford their care.

In the United States, life expectancy increases linearly by income level, and Oklahoma is no different. Almost 200,000 Oklahomans do not have health care coverage and many more are underinsured. Often, they rely on free or low-cost clinics, where medical students volunteer and practice the clinical skills we learn. However, this system has become overwhelmed due to increasing demand and limited resources.

Expanding Medicaid would strengthen the financial situation of rural hospitals, which have struggled to keep their doors open. Additionally, studies have shown that states that expanded Medicaid produce net savings because of the reduction of spending on uncompensated care.

However, the economic arguments mean little to me because as a future health care professional, I do not want to practice in a system that fails to meet the health needs of our most vulnerable. The COVID-19 pandemic magnified the fact that individual health is connected to the health of an entire community. We are only as strong as our weakest link. For those with adequate and comprehensive health coverage, it is imperative that we collectively ensure everyone around us has access to the care they need.

In medical school, I learn to examine the social determinants of health and believe that one of the biggest developments the state could make would be to give every Oklahoman access to high-quality health care and guarantee it as a human right. There is work to be done toward providing everyone the care they deserve, and voting for State Question 802, Medicaid expansion, is the first step in that direction.

Daniel Pham, an Oklahoma City native, attends medical school at the University of Oklahoma Health Sciences Center. SQ 802 is on the ballot June 30.

https://oklahoman.com…

COVID-19 crisis comes with financial toxicity

18.2 Million Individuals at Increased Risk of Severe COVID-19 Illness Are Un- or Underinsured

By Adam W. Gaffney MD, MPH, Laura Hawks MD, David H. Bor MD, Steffie Woolhandler MD, MPH, David U. Himmelstein MD & Danny McCormick MD
Journal of General Internal Medicine, June 10, 2020

We analyzed a nationally representative survey to identify individuals at elevated risk for severe COVID-19 and, among these, those at high risk of financial toxicity from care at the start of the epidemic.

Discussion

At the start of the outbreak, 18 million adults at increased risk of severe COVID-19 were inadequately insured and hence at risk of delay in seeking care because of cost concerns and of financial toxicity if hospitalized. Traditionally disadvantaged groups—racial minorities, low-income persons, and rural residents—were more likely to be at risk of severe COVID-19 (consistent with the experience of previous viral respiratory epidemics) and of financial harm. Those living in states that failed to expand Medicaid or issue a stay-at-home order were also at greater risk of severe disease and inadequate coverage.

Gaps in insurance coverage, and states’ decisions to reject Medicaid expansion and defer prevention measures, may hence exacerbate the damage wrought by the COVID-19 epidemic, as well as health disparities. Rising unemployment after the onset of the epidemic in the USA will likely translate into health coverage losses that could further widen these gaps; our estimates of uninsurance and underinsurance are likely underestimates. These findings provide support for steps taken to address inadequacies in coverage for the diagnosis and treatment of COVID-19 and for the consideration of additional policies that could expand coverage during the economic downturn.

https://link.springer.com…

‘Lethal Inequality’: New Study Shows Millions at High Risk of Covid-19 in US Lack Adequate Health Insurance

By Jake Johnson
Common Dreams, June 10, 2020

Dr. Adam Gaffney, a critical care physician and lead author of the study, said the coronavirus pandemic “is laying bare the lethal inequality of American society and American healthcare.”

“Our ICU has been flooded with poor and minority patients; having Covid-19 is scary enough without worrying that you’ll be bankrupted by medical bills,” said Gaffney, who works at the Cambridge Health Alliance and Harvard Medical School and serves as president Physicians for a National Health Program (PNHP).

“These promises of new protections for patients with Covid-19 are full of holes,” said Dr. Danny McCormick, a primary care physician and senior author of the study. “Covid-19 threatens the health of people everywhere, but only in the U.S. will it also ruin patients financially. When people avoid testing and care because they fear the costs, it fuels the epidemic’s spread.”

Dr. Steffie Woolhandler, distinguished professor of Public Health at CUNY’s Hunter College and another of the study’s authors, said the new research bolsters the case for both an emergency expansion of Medicare to the uninsured—as proposed by Sen. Bernie Sanders (I-Vt.) Rep. Pramila Jayapal (D-Wash.)—and an eventual transition to Medicare for All.

“It’s not just Covid care that’s unaffordable,” said Woolhandler, co-founder of PNHP. “Patients with heart disease, asthma, and diabetes need protection too. Medicare for All is the long-term answer.”

https://www.commondreams.org…

Comment:

By Don McCanne, M.D.

As Steffie Woolhandler states, “Medicare for All is the long-term answer.”

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

Debating Beshear’s plan on health insurance for black Kentuckians

By Kay Tillow
Lexington (Ky.) Herald-Leader, Letters, June 11, 2020

Kentuckians are fortunate to have a governor who has responded to the pandemic with intelligence and humanity. His restrictions have saved lives. Now Gov. Andy Beshear looks at the unequal impact of COVID-19 on African Americans and, with compassion, declares that all African Americans in Kentucky should have health insurance. Yes. That would be an excellent beginning.

Now, governor, say its name. The only system that will cover every African American, letting no one fall through the cracks, is a national, not-for-profit, single payer plan — an improved Medicare for All. Such a plan, as set forth by Physicians for a National Health Program, would automatically enroll everyone, make care free at the point of service, yet save us money by removing the parasitic, for-profit insurance industry from our system.

Single payer would save rural hospitals by assuring funds through global budgeting and would cover dental work, eyeglasses, hearing aids, and drugs. It would cover nursing home care, banning the impoverishment now required for eligibility.

The plan would cover the rest of us as well. Please say its name, governor. National single payer health care — improved Medicare for All — publicly funded with the profit makers removed.

Diagnosing and treating systemic racism

By Michele K. Evans, M.D., Lisa Rosenbaum, M.D., Debra Malina, Ph.D., Stephen Morrissey, Ph.D., and Eric J. Rubin, M.D., Ph.D.
The New England Journal of Medicine, June 10, 2020

The role of the physician in times of social injustice and societal distress is difficult to navigate. Since the importation of enslaved Africans as chattel to provide the labor that built this country began, Americans have functioned within the intricate injustices that are the vestiges of that institution. Slavery has produced a legacy of racism, injustice, and brutality that runs from 1619 to the present, and that legacy infects medicine as it does all social institutions.

In an effort to engender trust in what they would like to see as a “postracial” society, some U.S. clinicians proclaim that they ”don’t see color.” But color must be seen. By looking through a racially impervious lens, clinicians neglect the life experiences and historical inequities that shape patients and disease processes. They may inadvertently feed the robust structural racism that influences access to care, quality of care, and resultant health disparities.

In the review of systems, we query patients about exposure to toxicants, but we never ask about one of the most dangerous toxicants: racism. The work of David Williams details the morbidity and risk of death related to perceived discrimination. Discrimination and racism as social determinants of health act through biologic transduction pathways to promote subclinical cerebrovascular disease, accelerate aging, and impede vascular and renal function, producing disproportionate burdens of disease on black Americans and other minority populations.

Even as the social contract between the government and the American people has frayed in the complex struggle over the pandemic, racial injustice, and police brutality, physicians must reflect on the condition of medicine’s own contract with society. Our society expects physicians to live up to standards of professionalism, deliver state-of-the-art, timely care with competence and integrity, and promote the public good. To carry out these duties, physician-citizens must recognize the harm inflicted by discrimination and racism and consider this environmental agent of disease as a vital sign — alongside blood pressure, pulse, weight, and temperature — that provides important information about a patient’s condition. Medical skill has allowed us to respond rapidly to a novel virus to save lives; we must also use our expertise to address racism and injustice and to protect vulnerable people from harm.

Now, amid an acute public health crisis that is transforming medicine, perhaps we have an opportunity to reset our priorities to face this deeper, more chronic crisis as well. It is time to reimagine the medical interaction and the doctor–patient relationship, recommitting ourselves to the quiet work of doctoring and building trust with individual patients. We can become more conscious of our biases when we care for minority patients and push ourselves to go the extra mile.

As the vulnerability and inadequacy of our health care system are once again exposed, it is also time to reconceive that system, including the development of its workforce.

Direct action to eliminate persistent health disparities obliges us to redouble our demands for a system that recognizes health care as a human right, providing an avenue to health equity for all.

Although effecting such fundamental transformation may feel impossible, the energy, idealism, and visions of young people have long fueled movements for change. Martin Luther King, Jr., was 26 when he led the Montgomery bus boycott and 34 when he delivered his powerful “I have a dream” oration. If we blend our voices with those of the newest members of our profession to advocate for the most vulnerable and to reinvigorate every aspect of their care, perhaps we can use our current public health crisis as a catalyst to, as Reverend Al Sharpton put it, “turn this moment into a movement.”

The full article can be accessed for free at this link:
https://www.nejm.org…

Comment:

By Don McCanne, M.D.

We’ve heard these phrases before:

  • “society expects physicians to promote the public good”
  • “As the vulnerability and inadequacy of our health care system are once again exposed, it is time to reconceive that system”
  • “a system that recognizes health care as a human right”
  • “health equity for all”
  • “turn this moment into a movement”

Nowhere in this article did the authors mention a universal, accessible, equitable, and efficiently-administered national health program – a single payer model of an improved Medicare for All – but that would provide a tremendous start and major contribution to a strong foundation for treating systemic racism. It’s doable and affordable.

Let’s turn this moment into a movement.

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

COVID-19 and Health Financing: Perils and Possibilities

By Adam Gaffney, David U. Himmelstein, Steffie Woolhandler
International Journal of Health Services, June 9, 2020

Abstract

While the COVID-19 pandemic presents every nation with challenges, the United States’ underfunded public health infrastructure, fragmented medical care system, and inadequate social protections impose particular impediments to mitigating and managing the outbreak. Years of inadequate funding of the nation’s federal, state, and local public health agencies, together with mismanagement by the Trump administration, hampered the early response to the epidemic. Meanwhile, barriers to care faced by uninsured and underinsured individuals in the United States could deter COVID-19 care and hamper containment efforts, and lead to adverse medical and financial outcomes for infected individuals and their families, particularly those from disadvantaged groups. While the United States has a relatively generous supply of Intensive Care Unit beds and most other health care infrastructure, such medical resources are often unevenly distributed or deployed, leaving some areas ill-prepared for a severe respiratory epidemic. These deficiencies and shortfalls have stimulated a debate about policy solutions. Recent legislation, for instance, expanded coverage for testing for COVID-19 for the uninsured and underinsured, and additional reforms have been proposed. However comprehensive health care reform – for example, via national health insurance – is needed to provide full protection to American families during the COVID-19 outbreak and in its aftermath.

From “Potential Policy Solutions”

(At the link below, there is a convenient table that can be converted into a high-resolution PDF that lists various legislative proposals, their policy mechanisms, current status, and potential advantages and disadvantages.)

While many of these proposals, especially the emergency Medicare expansions, could provide some aid to those affected by COVID-19, full protection, in the long-term, would require systemic reform. Addressing financing dysfunctions on a disease-by-disease basis, after all, is neither efficient nor fair. The COVID-19 outbreak hence serves as a reminder of the benefits of a unified, national health program. A Medicare for All reform, much discussed in Democratic presidential primary debates, would achieve universal coverage and address the problem of underinsurance. Such a reform might have additional advantages specific to an outbreak of an infectious disease. For instance, it could provide public health authorities with novel tools to combat epidemics, such as Taiwan’s use of its national health insurance database for case finding early in the epidemic. A well-structured national health insurance reform would also facilitate moving to a more rational and equitable allocation of ICUs and other healthcare resources through health planning and the public-financing of hospital capital expansion. This could help ensure an adequate supply and distribution of resources in the face of future epidemics. At the same time, the nation needs to dramatically increase funding of its public health agencies. A doubling of funding — from around 2.5% of national health expenditures to 5.0% — will not end the current epidemic, but it could help ensure readiness for the next one.

The outbreak has already exposed the multifold inadequacies of the US’ uniquely unequal, privatized and fragmented health financing system. It also illuminates other inequities — including exclusionary policies that deter immigrants from using social assistance programs, lack of universal paid sick leave, and inadequate protections for workers — that weaken our social fabric and endanger the public’s health. As of this writing, it is unclear how severe the COVID-19 outbreak will ultimately prove to be in the US, although the rapidly climbing death toll is already a tragedy. Whatever the future holds, however, the transformation of the nation’s healthcare system and social safety-net is urgently needed.

https://pnhp.org…

Comment:

By Don McCanne, M.D.

Although we have the most expensive health care system in the world, the COVID-19 pandemic provides stark evidence that our health care financing system is highly dysfunctional, wasting tremendous resources while impairing health care access for far too many individuals and families and failing to prevent the financial hardship that should never occur with a high performance system.

Temporary patches have been proposed, but comprehensive reform is absolutely essential. We would be much better off starting with that right now.

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

Millions at high risk of severe COVID-19 outcomes lack coverage to cover costs

By Steven Ross Johnson
Modern Healthcare, June 10, 2020

More than 18 million people who were most at risk of experiencing severe outcomes from COVID-19 at the start of the outbreak had the least access to healthcare because they were either uninsured or underinsured, according to a new study.

Researchers found some of the most vulnerable populations—including African Americans, Native Americans, lower-income individuals, those residing in rural areas and in states that have not expanded Medicaid—were both more likely to be at high risk of severe COVID-19 illness and lack adequate healthcare coverage to get care if they did get sick, according the study, published Wednesday in the Journal of General Internal Medicine.

African Americans were 42% and Native Americans 90% more likely to be at risk for severe COVID-19 compared to whites. High-risk persons from those racial groups were 51% and 53% more likely to have inadequate healthcare coverage compared to whites at high risk. Hispanics at high medical risk were more than twice as likely as whites to have inadequate coverage.

Researchers say the findings point to a critical need for policymakers to provide more robust support for testing and treating COVID-19 as rising unemployment causes more people to lose their insurance and states seek to re-open businesses, increasing the risk for more cases.

“In a way lower-income people and racial minorities are in double jeopardy because of the way our healthcare system is financed,” said lead study author Dr. Adam Gaffney, a pulmonary specialist at the Cambridge Health Alliance in Boston. “

Gaffney said being uninsured or underinsured meant it was more likely those who got sick would delay seeking treatment because of cost concerns. Results of a Gallup survey released last December found a quarter of those polled reported they or a family member had postponed treatment for a serious medical condition over the past year because of the cost. That percentage increased from 19% in 2018.

Since the start of the outbreak lawmakers have taken a number of actions to provide funding to help cover the costs related to getting tested and treated for COVID-19. Such measures have provided hospitals with nearly $300 billion in relief aid to reimburse providers for expenses and lost revenues incurred during the pandemic.

Passage of the Families First Coronavirus Response Act in March mandated that insurers cover costs related to COVID-19 testing with no out-of-pockets expenses to consumers. The cost of treatment for COVID-19 has no such cost-sharing protections.

Most healthcare insurers have offered to waive copays and deductibles for the treatment of COVID-19. But a report released last month by the patient advocacy organization Public Citizen found at least 15 of the 23 fee waivers being offered are set to expire by July 1.

That report found only two of the 25 largest insurers offering fee waivers offer to cover costs for both in-network and out-of-network care. Up to 60% of people in private insurance plans may not be eligible for fee waivers at all since they exclude those in self-insured plans unless an employer underwrites for those plans to opt-in for that coverage.

Gaffney said more support was needed to address the rising level of need. An estimated 36 million people have lost their jobs since the beginning of the outbreak with as many as 25 million expected to lose their employer-based health insurance as a result.

“The protection is inadequate,” Gaffney said. “I think we need to take further steps as this epidemic continues to ensure full coverage not just for COVID testing but for COVID treatment as well.”

https://www.modernhealthcare.com…

18 Million Americans Lack Adequate Health Insurance While Facing Greater Risk of Severe Coronavirus, Study Finds

By Jason Lemon
Newsweek, June

More than 18 million Americans, most of whom are minorities and low-income individuals, are uninsured or underinsured while also being at increased risk of developing severe cases of COVID-19, a new study by researchers at Harvard Medical School and CUNY’s Hunter College has shown.

“Our study shows that minority communities face double jeopardy from COVID: on the one hand, they are at higher risk of severe complications from coronavirus, and on the other hand, they are more likely to be uninsured and underinsured, and hence to avoid care or to face potentially ruinous medical bills,” Dr. Adam Gaffney, the study’s lead author who is a pulmonary and critical care physician at the Cambridge Health Alliance and Harvard Medical School, told Newsweek.

“Our dysfunctional health care financing is one important contributing factor behind pernicious racial health inequities in American society,” Gaffney said.

The study, which was published Wednesday in the Journal of General Internal Medicine, used data compiled by the Centers for Disease Control and Prevention regarding age, race and health risks. It looked specifically at health issues—such as asthma, diabetes, kidney disease, heart disease and severe obesity—that increase the risk of an individual developing a severe case of COVID-19. The researchers then analyzed this data in connection to whether the individuals had adequate insurance.

When the data was reviewed, the results showed that minorities, with the exception of Asians, and low income individuals were more likely to have underlying health issues that can increase the severity of a new coronavirus infection. Additionally, this higher-risk group, which is estimated to be about 18.2 million people, was more likely to be uninsured or underinsured.

These issues were compounded further in states that have not permitted Medicaid expansion under the Affordable Care Act, which would allow more people to access government-run health insurance. The research showed that black Americans were 42 percent more likely to be at risk for severe COVID-19 while they were also 51 percent more likely to have inadequate health care coverage than high-risk non-Hispanic whites. With Native Americans, the disparity was even greater, as they were 90 percent more likely to be at high risk for severe COVID-19, and 53 percent more likely to have inadequate health care coverage.

Gaffney acknowledged that steps have been taken by the government and insurance companies to address some of the problems with inadequate insurance coverage amid the coronavirus pandemic. However, he said this was not enough, while pointing out that the large uninsured and underinsured population creates an additional public health risk.

“To control this pandemic on an ongoing basis, people have to be unafraid to obtain care when they need it, whether for testing or treatment. But a Gallup poll in May found that 14 percent of Americans would avoid health care because of costs even if they had symptoms consistent with COVID. If people stay home with symptoms because they’re afraid of a giant bill, they put their own health at risk,” the doctor said.

“This also could impede efforts to reduce viral spread. This pandemic is laying bare the weaknesses, the gaps, and the inequities of the U.S. health care system,” he said.

The study used data that was compiled prior to millions of Americans losing their jobs due to the economic fallout caused by the pandemic. Gaffney noted that many more people have now lost their employer-sponsored health insurance as millions have filed for unemployment.

“These trends will only exacerbate the inequities we identified in our study,” he said.

Dr. Steffie Woolhandler, a co-author of the study who is a distinguished professor of public health at CUNY’s Hunter College and a lecturer in medicine at Harvard Medical School, said that the issue with health care coverage goes beyond the coronavirus pandemic.

“It’s not just COVID care that’s unaffordable,” Woolhandler said in a statement emailed to Newsweek. “Patients with heart disease, asthma and diabetes need protection too. Medicare for All is the long-term answer,” she said.

Although data has not been fully collected and compiled, numerous reports across the country have revealed that minority and low-income communities have been disproportionately affected by the pandemic. Experts have pointed to economic inequalities as well as a higher prevalence of some pre-existing health conditions, which aligns with new Harvard/CUNY study.

Minorities are also disproportionately represented in many professions deemed essential as stay-at-home orders were implemented across the country. This means they were more likely to continue going to work and interact with a wider range of individuals during lockdowns, potentially exposing them to a greater risk of contracting the virus.

https://www.newsweek.com…

18.2 million at increased risk of severe COVID-19 are uninsured or underinsured: Harvard study 

Racial minorities who are most likely to be inadequately insured against the costs of illness among those at increased risk of severe complications from coronavirus

FOR IMMEDIATE RELEASE, June 10, 2020

Contact: Clare Fauke, communications specialist, Physicians for a National Health Program, clare@pnhp.org, 312-782-6006
Dr. Adam Gaffney, Physicians for a National Health Program, agaffney@cha.harvard.edu

Even before soaring unemployment caused millions of Americans to lose their health insurance, 18.2 million individuals at increased risk of severe COVID-19 were either uninsured or underinsured, according to a new study published today in the Journal of General Internal Medicine by researchers at Harvard Medical School and CUNY’s Hunter College. Although most of those at high medical and financial risk were white, racial minorities were overrepresented.

Researchers determined who was at risk of severe COVID-19 based on age and medical risk factors such as diabetes. They found that Blacks, Native Americans, lower-income individuals of all races/ethnicities, and those residing in rural areas or in states that had not expanded Medicaid were doubly disadvantaged: they were both more likely to be at high risk of severe COVID-19 and to lack adequate coverage. For instance, compared to non-Hispanic whites, Blacks were 42% and Native Americans 90% more likely to be at risk for severe COVID-19, and high-risk persons from those racial groups were 51% and 53% more likely to have inadequate coverage compared to high-risk whites. Persons in states that failed to expand Medicaid were 6% more likely to be high risk, and 52% more likely to have inadequate coverage compared to those in states that accepted the ACA’s Medicaid expansion. Hispanics at high medical risk were more than twice as likely as non-Hispanic whites to have inadequate coverage.

“The pandemic is laying bare the lethal inequality of American society and American health care,” said lead author Dr. Adam Gaffney, a pulmonary and critical care physician at the Cambridge Health Alliance and Harvard Medical School. “Our ICU has been flooded with poor and minority patients; having COVID-19 is scary enough without worrying that you’ll be bankrupted by medical bills,” he added.

Despite recent federal actions to help fund COVID-19 care, and some insurers’ promises to upgrade coverage for the disease, many American still lack protection from COVID-19’s costs.  The Families First Coronavirus Response Act mandated full coverage for COVID-19 testing, but not for treatment, and the CARES Act provided some funding for hospitals treating uninsured patients, but the protection is far from adequate. While some private insurers have promised to waive copays and deductibles for treatment as well as testing, this promise doesn’t apply to out-of-network care, or to the majority of privately-insured workers whose employers are self-insured. Moreover, most of these waivers will expire by July 1. A Gallup poll found that many remain fearful of treatment costs, with 14% of Americans saying they would avoid care because of costs even if they develop symptoms of COVID-19.   

“These promises of new protections for patients with COVID-19 are full of holes,” noted senior author Dr. Danny McCormick, a primary care physician and associate professor at Harvard Medical School. “COVID-19 threatens the health of people everywhere, but only in the U.S. will it also ruin patients financially. When people avoid testing and care because they fear the costs, it fuels the epidemic’s spread,” he added. 

The investigators also noted that the new federal legislation and insurers’ promises won’t help patients with COVID-19-like symptoms who are found to have a different diagnosis. “It’s not just COVID care that’s unaffordable,” said co-author Dr. Steffie Woolhandler, Distinguished Professor of Public Health at CUNY’s Hunter College and a Lecturer in Medicine at Harvard Medical School. “Patients with heart disease, asthma, and diabetes need protection too. Medicare for All is the long-term answer. But in the meantime, passage of the stopgap Medicare expansion bills introduced by Sen. Bernie Sanders and Rep. Pramila Jayapal would ensure that patients can get the care they need during the crisis, regardless of their diagnosis.”

“18.2 Million Individuals at Increased Risk of Severe COVID-19 Illness Are Un- or Underinsured,” Adam W. Gaffney, M.D., M.P.H., Laura Hawks, M.D., David H. Bor, M.D., Steffie Woolhandler, M.D., M.P.H., David U. Himmelstein, M.D., Danny McCormick, M.D., Journal of General Internal Medicine, published online ahead of print June 10, 2020. DOI: 10.1007/s11606-020-05899-8

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization whose more than 23,000 members support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.

COVID-19 and Health Financing: Perils and Possibilities

This study, authored by PNHP president Adam Gaffney, M.D., M.P.H. and PNHP co-founders Steffie Woolhandler, M.D., M.P.H. and David Himmelstein, M.D. was published online in the International Journal of Health Services on June 9, 2020. Click HERE to read the study on the SAGE Journals website.

Abstract

While the COVID-19 pandemic presents every nation with challenges, the United States’ underfunded public health infrastructure, fragmented medical care system, and inadequate social protections impose particular impediments to mitigating and managing the outbreak. Years of inadequate funding of the nation’s federal, state, and local public health agencies, together with mismanagement by the Trump administration, hampered the early response to the epidemic. Meanwhile, barriers to care faced by uninsured and underinsured individuals in the US could deter COVID-19 care and hamper containment efforts, and lead to adverse medical and financial outcomes for infected individuals and their families, particularly for those from disadvantaged groups. While the US has a relatively generous supply of ICU beds and most other health care infrastructure, such medical resources are often unevenly distributed or deployed, leaving some areas ill-prepared for a severe respiratory epidemic. These deficiencies and shortfalls have stimulated a debate about policy solutions. Recent legislation, for instance, expanded coverage for testing for COVID-19 for the uninsured and underinsured, and additional reforms have been proposed. However comprehensive healthcare reform, e.g. via national health insurance, is needed to provide full protection to American families during the COVID-19 outbreak, and in its aftermath.

As of this writing, the United States is experiencing the world’s largest COVID-19 outbreak.1 Deaths are continuing to rise, and the hospital infrastructure of some cities has been severely strained. While every country faces unique challenges responding to this serious public health threat,2,3 the US’ underfunded public health infrastructure, fragmented medical care system, and paltry social protections have imposed particular impediments to control and mitigation of the epidemic.

As US policymakers contend with the widespread dissemination of COVID-19, addressing the structural weaknesses of the US public health and healthcare financing system — particularly for disadvantaged groups — must be a priority, both for this epidemic and the next. In this article, we explore how underfunding of the nation’s public health agencies impaired the early response to the epidemic; how financial barriers that obstruct care for many in the US healthcare system could hamper efforts to contain it moving forward; the adverse financial ramifications for patients from the outbreak; and potential policies to ameliorate health financing deficiencies in the months and years ahead.

1. Underfunded Public Health

Federal, state and local public health agencies are the frontline defense against novel epidemics. Years of inadequate funding of these agencies, however, has hampered the nation’s response to the outbreak.

Despite nominal increases in public health spending over the past decade, there has been a progressive decline in such funding as a proportion of total health spending4 (Figure 1).5 Certain agencies and spending areas have seen particularly notable cuts. The budget of the Centers for Disease Control and Prevention (CDC), for instance, fell by about 10% (accounting for inflation) between 2010 and 2019, while CDC spending on state/local emergency preparedness fell by about a third from 2003 to 2019.6 The Prevention and Public Health Fund, a pool of public health funds established by the Affordable Care Act to help support state and local public health agencies, has seen multiple cuts since its creation.6 As budgets’ have grown tighter, state and local public health agencies have experienced a major decline in staffing, shedding some 50,000 personnel since 2008.7

Steps taken by the Trump administration further undercut the nation’s infectious disease readiness, including leaving some 700 staff position at the CDC unfulfilled during the 2017 hiring freeze8 and disbanding the office focused on federal pandemic preparedness.9 While the full story of the disastrous rollout of diagnostic testing has not yet been fully told, chronic underfunding of public health agencies appears to have left the nation ill-prepared for the arrival of the epidemic. For instance, case and contact tracing — measures that have been successfully deployed in nations such as Taiwan, South Korea, and Singapore,2,10 and that controlled the 2002-03 SARDS outbreak11-13 — were quickly abandoned in the US, as local health agencies became overwhelmed.14 Efforts to renew such efforts are currently underway in certain states, notably Massachusetts, but these are exceptions to the rule.

2. COVID-19 and Healthcare Affordability: Implications for Disease Control, Health, and Family Finances

In March 2020, as widespread dissemination of the novel coronavirus became obvious, case identification and contact tracing rapidly gave way to broad social distancing measures, including stay-at-home orders and closures of non-essential businesses, aimed at “flattening the epidemic curve.”3,15 Even if ultimately effective, epidemiologists predict that the outbreak will recrudesce once social distancing measures are eased, an eventuality that might be ameliorated or prevented through ramped up testing, case finding, and contact tracing. Such an intervention, however, requires a high-performing, and readily accessible, health system.2

Yet 30 million Americans, 9% of the population, had no health coverage before the epidemic,16 while 44 million more were underinsured — i.e. had coverage that required high copays, deductibles, or other out-of-pocket expenses.17 Overall, about a quarter of non-elderly adults were either uninsured, or avoided seeing a doctor in a given year because of costs, with (as shown in Figure 2) especially high rates in some states, such as Texas and Florida. As the economy spirals and millions of individuals are thrown out of work, the number of Americans uninsured or otherwise unable to afford care for COVID-19 will soar. News outlets carried stories early in the outbreak about patients with suspected coronavirus infections hit by “surprise” bills from hospitals, adding up to thousands of dollars.18-21 Although the widespread inaccessibility of coronavirus testing has thus far been the major bottleneck in the US, fear of costs could keep many infected patients from care in the future, hampering the case identification efforts needed to contain an outbreak. To address this likelihood, Congress passed the Families First Coronavirus Response Act, signed into law by President Trump on March 18. The law expands coverage of testing (and associated visits) both for the uninsured and those with copays and deductibles, which could alleviate such fears for some.

This measure, however, only covers the cost of testing — not treatment. As described in greater depth below, the Trump administration has also promised to use bailout funds to compensate hospitals for the costs of treated uninsured individuals with COVID-19. Such protection, however, is likely to be inadequate, and some individuals will no doubt still be deterred from obtaining medical care. Indeed, a poll conducted in early April found that 14% of Americans said they would avoid medical care due to cost if they developed symptoms consistent with COVID-19; the proportion was even higher among ethnic minorities and those with low incomes.22 Those who remain undiagnosed because they fear the financial consequences of a trip to the hospital may continue to go to work, attend school, or use public transportation, furthering spread. Lack of federally-mandated paid sick-leave is also likely to impede disease mitigations efforts. In 2019, about a quarter of civilian workers lacked paid sick leave, and the rate is substantially higher among those in service occupations.23 Staying home may not be financially tenable for some such individuals. As will be discussed later, new legislation expanded sick pay benefits for some American workers — but left millions out.

High healthcare costs could also threaten the health of patients infected with COVID-19. Fear of incurring out-of-pocket costs frequently deters patients from seeking urgently needed healthcare, even for “high-severity” conditions like acute asthma24 and myocardial infarction.25 Uninsured patients presenting to US emergency rooms with pneumonia or exacerbations of obstructive lung disease (potential COVID-19 symptoms) are more likely than those with insurance to be discharged home instead of admitted to hospital, likely reflecting patients’ desire to avoid ruinous bills and hospitals’ reticence to bear the costs of care.26 It is plausible that individuals with severe COVID-19 who nevertheless avoid medical care could suffer cardiopulmonary arrest in their homes. A surge in the number of patients found dead in their homes by paramedics in New York City during the outbreak suggests that many individuals with COVID-19 are dying before arriving to the hospital.27 However, it is unknown whether lack of healthcare access could have been a contributing factor in some or any of these deaths.

Yet even if inadequate coverage causes no physical harm, however, it can still inflict “financial toxicity.”28 For those with employer-sponsored insurance, the average cost of a hospitalization for pneumonia for patients with complications and co-morbidities was $20,292 in 2018, some of which may have to be paid out-of-pocket in the form of a deductible.29 Elderly patients with Medicare coverage, many on low fixed incomes, also face deductibles exceeding a $1,000 for a pneumonia hospitalization.30 Those facing severe protracted critical illness, however, may face even higher costs. A recent study found that out-of-pocket costs in the last year of life for the uninsured requiring ICU care averaged more than $26,000.31 Even for the insured these costs are often substantial, averaging $10,022 for those with private coverage.31 Such sums could be ruinous to the 4 in 10 US adults who are unable to cover even a $400 expense in the event of an emergency.32 Those unable to pay can face lawsuits, home foreclosure, and bankruptcy proceedings when hospitals seek to recover unpaid medical debts.33,34 And many individuals exposed to financial pressures from COVID-19-related medical costs may be forced to skimp on other important household expenses, such as rent or food, risking downstream deleterious health effects. For many, the financial harms of medical bills will be compounded by lost wages due to job loss, illness, or self-quarantine.

Epidemics tend also to have a disproportionate impact on oppressed populations.35 The H1N1 epidemic, for instance, led to higher hospitalization rates among racial/ethnic minorities relative to white populations,36,37 and a disproportionately high death rate among Hispanic children.37 Clear evidence is already mounting that Black and Hispanic are bearing the heaviest burden of severe COVID-19 disease and death as well.38,39 Yet Black and Hispanic Americans — and those with low-incomes more generally — are less likely to be insured,16 and have fewer household resources on average to cover the cost of copays and deductibles. At the same time, the Trump administration’s harsh anti-immigrant policies — including a recent rule change that deems immigrants to be “public charges” if they use public health programs, and hence potentially ineligible for upgrades in their immigration status — have sown fear in immigrant communities. These policies deter enrollment in health programs and could dissuade millions of immigrants from seeking care, including for COVID-19,40 despite the existence of an exemption for the care and treatment of communicable diseases.41 A 2018 survey, for instance, found that 13.7% of adults in immigrant families are avoiding participation in government benefit programs because they fear the consequences for their immigration status.42

Overall, the confluence of xenophobic policies, rising uninsurance, mass unemployment, and a major epidemic seems destined to exacerbate existing deep inequalities in health and healthcare.

3. COVID-19 and the Seriously Ill: Hospital Infrastructure and Affordability

The fragmented and privatized US healthcare financing system also has distinct implications for those who develop severe illness from COVID-19. While the US is unique among high-income nations in its lack of universal coverage, it is less of an outlier with respect to its healthcare infrastructure. Figure 3 displays hospital and ICU bed supply in 8 nations in North America and Europe. On the one hand, the US is towards the lower end of peer nations with respect to bed supply. It has similar beds per capita as four of the nations in this sample (the United Kingdom, Canada, the Netherlands, and Spain), but substantially less than three (France, Belgium, and Germany). On the other hand, the US has a relatively generous supply of ICUs, with more ICU beds per capita than every nation in the sample except Germany. US ICU density — about 25 beds per 100,000 population depending on how it is counted — is more than twice that of France and Canada, and many-fold higher than the United Kingdom’s.43-47 Patients in US ICUs have, historically, been on average less severely ill than those in other nations as a consequence of this more generous supply,44,45 suggesting more surge capacity.48

Such aggregate statistics, however, obscure three potential problems. First, a large epidemic (with a rapid peak) could overwhelm (or severely strain) the hospital and ICU infrastructure of any nation49 — as in Italy50, New York, and potentially other US cities in coming weeks. Second, while the US’ laissez-faire approach to financing healthcare infrastructure has led to marked growth in ICU infrastructure51.52, it has also led to arbitrary regional imbalances in supply. There is a six-fold difference in ICU beds per capita between the hospital referral region with the highest and the lowest bed density in the US.43 As Carr, Addyson, and Kahn note, geographic variation in ICU density in the US means that a pandemic “could quickly exceed critical care capacity in some areas while leaving resources idle in others,” a reality that “reflects the limitations of a private health system in which planning occurs primarily from the hospital perspective.”43 This distributive problem reflects larger imbalances in the availability of healthcare infrastructure that stem from a profit-driven financing system, exemplified by ongoing hospital expansion in healthcare-dense areas, and the simultaneous closure of hospitals in rural and poorer areas. Consequently, while supply may be ample in some areas, it is inadequate in others in the face of an epidemic. Moreover, there are no mechanisms to redeploy resources to where they are needed, or to shift patients to less-stressed areas.

A lack of health planning, in other words, has left the nation’s healthcare system ill-prepared for an emergency, whether with respect to the distribution of infrastructure, or the stockpiling of ventilators or personal protective equipment for healthcare workers. And with no unified governance, federal, state, and local governments continue to compete with hospitals for supplies.

4. Potential policy solutions

The challenge posed by COVID-19 in the context of these deficiencies in healthcare financing has prompted a range of reform proposals. The Table summarizes achieved and proposed reforms, as well as their benefits and limitations.

The Families First Coronavirus Response Act, signed into law by President Trump in March, provides coverage for the costs of diagnostic testing and related healthcare visits for the uninsured, as earlier noted.53 While this may encourage testing for such individuals, the law didn’t address the problem of high treatment costs (for instance, for those admitted to the hospital for COVID-19 pneumonia). The Act also required that all public and private insurers cover testing and related visits without cost-sharing,53 but, like the coverage of testing for the uninsured, does nothing to lower the far-higher out-of-pocket costs for treatment of COVID-19. Moreover, it’s unlikely to allay immigrants’ fears about enrolling in public health programs or seeking care.

Another initiative to cover the uninsured would allow uninsured individuals to purchase private plans outside of the typical “open enrollment” period, a step taken thus far by several states,54 although not yet by the federal government. Such a move might modestly increase insurance uptake, although coverage would remain unaffordable for many, including the millions of Americans rapidly joining the ranks of the uninsured.

A plan announced April 3 by the Trump administration would allocate a portion of the $100 billion in hospital relief provided by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, passed in late March, to cover costs of COVID-19 treatment for the uninsured.55 However, this program offers incomplete protection to patients: coverage is contingent both on the availability of funds and the participation of providers.56

Other provisions have been aimed at reducing medical costs for those with insurance. An announcement from the Internal Revenue Service that some plans with high-deductibles will be permitted (but not required) to exempt COVID-19-related care from the plan deductible57 might reduce out-of-pocket costs for some, but will likely have a limited effect. Additionally, some, but not all insurers, have announced plans to eliminate cost-sharing for COVID-19 related treatment, but many individuals will remain exposed to such costs absent federal action. Moreover, neither of these reforms does anything to address the problem of medical costs for other conditions, which will be increasingly unaffordable as workers lose jobs, income, and insurance benefits as recession deepens.

Addressing the lack of paid sick leave is also a policy priority. The Families First Coronavirus Response Act requires employers to provide workers with about 10 days of emergency sick leave, but it exempts the largest employers from the requirement, allows small employers to apply for exemptions, applies only to COVID-19 affected individuals, and expires at the end of 2020.58,59 Due to the exemptions, it might cover as few as 20% of American workers.58,59

A variety of other health financing reforms have been achieved or proposed to deal with the COVID-19 crisis. In early March, for instance, President Trump signed into law an $8.3 billion bill that increases funding for state and local health departments, vaccine and treatment development, medical supply purchases, and community health centers (CHC), clinics that provide care for substantial numbers of uninsured individuals.60 While the additional research and development funds will be useful — and might speed the development of useful therapeutics — the law did little to guarantee the affordability of treatments that emerge from the publicly-funded research.60 The new law also allows Medicare to pay providers for “telehealth” services, enabling remote electronic health visits from doctors that might unburden emergency rooms and reduce the risk of nosocomial coronavirus transmission. (Private insurers are also expanding coverage for telehealth services).61 But the effects of this provision are likely to be modest, particularly for poor patients, many of whom lack adequate internet access.62 Moreover, telehealth does little to allay patients’ cost concerns. Indeed, as phone conversation with physicians are increasingly re-classified as telehealth visits, some patients are finding that they face copays or deductibles for what may have been a previously free telephone call.63

Meanwhile, mounting job losses instigated by the epidemic and the ongoing public health measures taken to control it look likely to lead to enormous losses in health coverage: an estimated 7.3 million workers could become uninsured by June 1 if predicted unemployment increases come to fruition.64 In response, lawmakers have proposed additional reforms to expand coverage to this population. A bill introduced by House Democrats in April 2020, for instance, would provide full subsidization of COBRA plans, which would allow many individuals to maintain their employer-sponsored health benefits after job loss. Such a reform, however, would exclude many of the uninsured, while doing nothing to protect out-of-work individuals form the high copays and deductibles imposed by many employer-sponsored private plans.

Others have proposed using the Medicare program to expand coverage during the crisis. In April, Representative Pramila Jayapal and Senator Bernie Sanders introduced the Health Care Emergency Guarantee Act, which would expand Medicare coverage to all the uninsured, and simultaneously provide wrap-around coverage of copays and deductibles for the insured. Later that month, Jayapal joined Massachusetts Representative Joseph Kennedy in introducing the Medicare Crisis program, a more limited bill that would provide Medicare coverage to the unemployed, bolster state Medicaid programs, and cover all COVID-19 related care costs. Both proposals, particularly the more comprehensive Health Care Emergency Guarantee Act, would realize major expansions of coverage, protecting millions of Americans from burdensome healthcare costs for the duration of the crisis.

While many of these proposals, especially the emergency Medicare expansions, could provide some aid to those affected by COVID-19, full protection, in the long-term, would require would systemic reform. Addressing financing dysfunctions on a disease-by-disease basis, after all, is neither efficient nor fair. The COVID-19 outbreak hence serves as a reminder of the benefits of a unified, national health program. A Medicare for All reform, much discussed in Democratic presidential primary debates, would achieve universal coverage and address the problem of underinsurance. Such a reform might have additional advantages specific to an outbreak of an infectious disease. For instance, it could provide public health authorities with novel tools to combat epidemics, such as Taiwan’s use of its national health insurance database for case finding early in the epidemic.10 A well-structured national health insurance reform would also facilitate moving to a more rational and equitable allocation of ICUs and other healthcare resources65 through health planning and the public-financing of hospital capital expansion. This could help ensure an adequate supply and distribution of resources in the face of future epidemics. At the same time, the nation needs to dramatically increase funding of its public health agencies. A doubling of funding — from around 2.5% of national health expenditures to 5.0% — will not end the current epidemic, but it could help ensure readiness for the next one.66

“Epidemics,” wrote the German pathologist Rudolf Virchow, “are like large sign-posts from which statesman of stature can read that a disturbance has occurred in the development of his [sic] nation.”67 (pp. 22) COVID-19 is such a sign-post. The outbreak has already exposed the multifold inadequacies of the US’ uniquely unequal, privatized and fragmented health financing system. It also illuminates other inequities — including exclusionary policies that deter immigrants from using social assistance programs, lack of universal paid sick leave, and inadequate protections for workers — that weaken our social fabric and endanger the public’s health. As of this writing, it is unclear how severe the COVID-19 outbreak will ultimately prove to be in the US, although the rapidly climbing death toll is already a tragedy. Whatever the future holds, however, the transformation of the nation’s healthcare system and social safety-net is urgently needed.

Table: Legislation, policies, and proposals to address health financing challenges related to COVID-19

Click HERE to view a high-res PDF of this table.

Figure 1: Public Health Spending as a Percent of National Health Expenditures: 2009 – 2018

Source of data: National Health Expenditures Accounts, 2009-2018.5

Figure 2: Inadequately insured non-elderly adults by state (%)

Source: Author’s analysis of the 2018 Behavioral Risk Factor Surveillance System. Inadequately insured include those who are uninsured, or those who are insured but failed to see a doctor when needed due to cost. Includes adults 18 – 64 years in age. Map created with Microsoft Excel. Inadequate insurance rate for states not shown: Hawaii – 14%; New Hampshire – 18%; Massachusetts — 16%; Connecticut – 17%; Rhode Island – 19%; New Jersey – 22%; Delaware – 22%; Maryland – 19%; District of Columbia – 13%.

Figure 3: Hospital and ICU Bed Supply in 8 Nations

Notes: Hospital beds / 10,000 population are from OECD74 (2016 for the US and 2017 for other nations). ICU beds for the United States is drawn from Wallace et al.47, who reported 77,809 beds in 2009; total population denominator for that year (306,771,529) is drawn from the US Census. ICU beds for Canada is for 2009-10 and is drawn from Fowler et al.; these beds only include those with capacity for mechanical ventilation.46 ICU beds for European nations are drawn from Rhodes et al., and reflect years 2010-11; they include “intermediate care beds” and hence may overstate capacity relative to the US and Canada.75 Of note, the ICU bed supply in these 8 nations were also studied by Wunsch et al., who found roughly similar figures for most nations in 2005 (albeit with a substantial increase over time in the UK);44 we selected these same nations for presentation here for consistency.

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Health policy trade-offs: keep good, dump bad

Cutting through the Jargon: Health Care Reform Design Issues and Trade-Offs Facing Us Today

By Linda J. Blumberg
Urban Institute, June 2020

Exploring the Five Core Questions Necessary to Evaluate the Trade-Offs Inherent in a Health Reform Proposal

Evaluating the trade-offs inherent in the answers to each of the five core questions below is critical to understanding the philosophical underpinnings and general implications of health reform proposals.

  1. How broadly should the costs of the sick be shared with the healthy?
  2. How important is reaching true universal coverage? How many US residents must be insured?
  3. How generous should federally financed subsidies of premiums and cost sharing be?
  4. How should reform options be financed?
  5. Should there be regulations limiting the prices paid to health care providers of different types (i.e., hospitals, physicians, prescription drug manufacturers, medical device manufacturers), and if so, how broadly should those regulations apply, and how should prices be set?

Answers to These Five Central Questions Frame Policy Proposals

To illustrate how this five-decision framework clarifies the reforms most frequently discussed, I use three policy examples:

  • Full repeal of the ACA
  • Build upon the ACA with additional financial assistance and a public option
  • Replace the current system with an enhanced single-payer program

(Pages 10-14 provide the author’s answers to each of the five questions for each of the three models listed. Use the link to access the report.)

From the Conclusion

Advocates of various health care reform proposals are quick to extoll the virtues of their preferred reforms. But advocates should acknowledge the trade-offs inherent in their respective approaches. An educated consumer of public policy ideas should be aware that there is no perfect solution. All reforms will yield advantages and disadvantages, gains and losses. The challenge is finding a policy that represents a broadly accepted set of trade-offs. Any one person’s preferred trade-offs will hinge on their individual values and preferences. This brief is designed to help people understand the inherent consequences of different options so readers can make more informed choices about the types of reforms they support.

https://www.urban.org…

Comment:

By Don McCanne, M.D.

Linda Blumberg is right when she says that we should understand the trade-offs with various health reform policies. But the policies are not neutral from a health care justice perspective. There are beneficial policies and detrimental policies, and we should not grant detrimental policies an equal status just because some individuals place self-interests above the rest of us. Let’s look briefly at the three models of reform she discusses.

Full Repeal of the ACA

  1. Sharing health care costs of the sick with the healthy
    • It would increase health care costs for the sick
  2. True universal coverage
    • Millions more would be uninsured
  3. Generosity of federal subsidies of premiums and cost sharing
    • Insurance costs would increase for individuals and families
  4. Financing this reform option
    • Federal support would be reduced
  5. Price regulation
    • Reduction of government price oversight

Build upon the ACA with Additional Financial Assistance and a Public Option

  1. Sharing health care costs of the sick with the healthy
    • Many of the sick would still face significant costs
  2. True universal coverage
    • Many immigrants would still remain uninsured, and others underinsured
  3. Generosity of federal subsidies of premiums and cost sharing
    • Subsidies would be expanded but many will still face significant costs
  4. Financing this reform option
    • More federal support but inequitable private spending would persist
  5. Price regulation
    • Public option would be regulated, but not employer-based plans

Replace the Current System with an Enhanced Single-Payer Program

  1. Sharing health care costs of the sick with the healthy
    • All costs care shared equitably through a universal risk pool
  2. True universal coverage:
    • All residents are covered regardless of immigration status
  3. Generosity of federal subsidies of premiums and cost sharing
    • Financial barriers to health care would be removed
  4. Financing this reform option
    • Fully funded through equitable progressive taxes
  5. Price regulation
    • Fair prices would be paid through rate negotiation and global budgeting

So let’s accept good policies while rejecting the bad. It’s long past time that we replace the I/me/mine selfish, uncaring policies with we/us/ours egalitarianism so that all of us can have accessible, affordable health care whenever we need it.

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