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NASI report on expanding Medicare eligibility

NASI report on expanding Medicare eligibility

The Final Report of the Academy’s Study Panel on Medicare Eligibility

Examining Approaches to Expand Medicare Eligibility: Key Design Options and Implications

National Academy of Social Insurance, March 2020

From the Executive Summary

Improving access to affordable, high-quality health coverage and care and constraining health care spending remain formidable policy challenges for the United States. In response, candidates, state and federal officeholders, academics, and a variety of stakeholders are presenting a wide range of proposals, including proposals to change Medicare eligibility. The Study Panel examined three approaches to changing Medicare eligibility and assessed how variants of these approaches could be designed to address key policy objectives, including expanding coverage, improving the affordability of access and care, and containing health care costs. The three approaches considered were:

  • lowering the eligibility age by just a few years to age 62 or to as low as age 50
  • extending Medicare coverage to all
  • creating a Medicare buy-in under which some or all of the population or employers would be eligible to purchase Medicare or Medicare-like coverage

Proposals to adapt Medicare to extend coverage to new beneficiary populations present a significant set of technical and program design considerations. This report attempts to identify the options for changing Medicare eligibility, or creating a Medicare-like program, and to provide an assessment of the issues that would need to be addressed. Such considerations include:

  • eligibility criteria
  • benefit structure, including covered services and cost sharing
  • premium structure and whether subsidies are available for newly eligible populations
  • provider payment rates and any regulations concerning provider participation
  • the roles of Medicare Advantage and private supplemental coverage
  • financing mechanisms
  • the rules regulating interactions with other public and private insurance
  • rules governing the transition to a new or modified program

Summary of Findings

These three approaches address the goals of increasing coverage, improving affordability and access to care, and controlling system-wide health care costs, but each one presents different orders of magnitude. A Medicare-for-all program, the most ambitious, aims for near-universal coverage and would likely have the greatest impact on access and affordability for the entire population. Although Medicare-for-all could have the greatest impact of the three options on system-wide cost containment, the impact depends on the level of provider payment rates, prescription drug pricing, and level of administrative savings. It would also require the greatest amount of additional federal revenue and resources while potentially lowering net costs for some individuals or other payers.

Lowering the age of Medicare eligibility and offering a Medicare buy-in program would target specific portions of the population, and the impacts on policy goals are by design more limited. The impact of lowering the age of Medicare eligibility would be similar in direction to Medicare-for-all, but it would have a much smaller scope, even if the eligibility age were lowered to 50. The Study Panel’s analysis finds that the impact of a Medicare buy-in is most difficult to determine. It would be highly dependent on underlying design decisions and the complicated relationships that would be created with existing coverage options. The buy-in approach may have a limited impact on increasing overall coverage rates and controlling system-wide health care costs, but it would improve affordability and access to care for participating individuals. Although often suggested as a simple add-on to improve the ACA, in practice a Medicare buy-in would greatly increase the complexity of the current health care system.

Closing Comments

Improving access to affordable, high-quality health coverage and care and constraining health care spending remain formidable policy challenges for the United States. When there is widespread public perception that coverage and access problems are significant enough to require action, a window for reform opens.

Evidence that the nation has reached such a point includes polls indicating that health care is a top issue for voters heading into the 2020 presidential election, as it was in the 2018 midterm elections. Significant problems in the health care system do not necessarily point to particular paths for reform, but they do create demand for change.

Because it would make use of an existing and popular coverage platform, extending Medicare to a broader population may seem to be a straightforward way to address the challenges of affordability, coverage, and cost containment. Although positive impacts on coverage and access to care would result from extending Medicare to more Americans, such a change also involves substantial challenges in program design and implementation. Policymakers need to acknowledge that Medicare is a complicated program, one that some believe is also in need of reform; that the health care sector is a large, profitable share of the U.S. economy; and that any significant change in Medicare eligibility is likely to help individuals who qualify for coverage while potentially disadvantaging other stakeholders.

https://www.nasi.org…

Examining Approaches to Expand Medicare Eligibility: Key Design Options and Implications (full report, 180 pages):
https://www.nasi.org…

Comment:

By Don McCanne, M.D.

This is an important and timely paper. There is currently an overwhelming public consensus that we need to improve access to health care while making it affordable for all. Although there is considerable political rhetoric about protecting the private insurance industry, it is ever more clear that the private sector continues to drive up costs without meeting goals of providing access to everyone. Inevitably, discussion has centered around expansion of our revered Medicare program as a means of providing affordable health care to all.

How would we do that? Three major options include lowering the eligibility age for Medicare, establishing a Medicare buy-in or a Medicare-like public option, or extending Medicare to cover everyone. This report discusses the various design options and implications of each.

Students and advocates of the single payer model of Medicare for All will immediately recognize that the Medicare for Some models (lowering eligibility age, Medicare buy-in, public option) fall far short of the reform that we need. But this paper is still highly recommended because, by understanding the implications of the lesser models of Medicare expansion, you can explain to others why it is essential that we move forward with the uncompromised single payer model of an improved Medicare for All.

Even there, it is essential that this report be read critically. As an example, they present two models of extending Medicare coverage to all: one with and the other without including the option of private Medicare Advantage (MA) plans. Of course, including MA plans not only perpetuates the profound inefficiencies of a multi-payer system, it also perpetuates a model based on business principles with profits for passive investors rather than being dedicated solely to the altruistic mission of patient service.

Anyway, it’s a great report that will be useful to you in educating those who do not understand why perpetuating a system with private insurers is such a bad idea, though it likely will not be very helpful for lay audiences who do not have a foundation of knowledge about beneficial versus detrimental health policy.

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Health Affairs on ACA at 10: A celebration of cruel mediocrity

The Affordable Care Act Turns 10

How Have ACA Insurance Expansions Affected Health Outcomes? Findings From The Literature

Health Affairs, March 2020

A growing body of literature examining the effects of the Affordable Care Act (ACA) on nonelderly adults provides promising evidence of improvements in health outcomes through insurance expansions.

However, not all studies reported a significant positive relationship between ACA provisions that expanded insurance coverage and health status.

https://www.healthaffairs.org…

Did The ACA Lower Americans’ Financial Barriers To Health Care?

We found that the Affordable Care Act generated substantial, widespread improvements in protecting Americans against the financial risks of illness. The coverage expansions reduced uninsurance rates, especially relative to earlier forecasts; improved access to care; and lowered out-of-pocket spending.

But subsequent court decisions and congressional and executive branch actions have left millions uninsured and allowed the risk of inadequate insurance to resurface.

https://www.healthaffairs.org…

Women’s Coverage, Utilization, Affordability, And Health After The ACA: A Review Of The Literature

This literature review summarizes evidence on the law’s effects on women’s health care and health and finds improvements in overall coverage, access to health care, affordability, preventive care use, mental health care, use of contraceptives, and perinatal outcomes.

Despite major progress after the Affordable Care Act’s implementation, barriers to coverage, access, and affordability remain, and serious threats to women’s health still exist.

https://www.healthaffairs.org…

The ACA’s Impact On Racial And Ethnic Disparities In Health Insurance Coverage And Access To Care

In the years since the law went into effect, insurance coverage has increased significantly for all racial/ethnic groups.

Despite these improvements, a large number of adults remain uninsured, and the uninsurance rate among blacks and Hispanics is substantially higher than the rate among whites.

https://www.healthaffairs.org…

How The ACA Dented The Cost Curve

Numerous provisions of the Affordable Care Act (ACA) were designed to make health care more affordable…

yet the act’s cumulative effects on health care costs are still debated.

https://www.healthaffairs.org…

Transforming Medicare’s Payment Systems: Progress Shaped By The ACA

We conducted a narrative review of these payment reforms, finding that several programs generated modest savings while maintaining or improving the quality of care, but they had high dropout rates.

In general, evidence for other APMs is less conclusive, and whether the reforms spurred similar changes in the private sector remains anecdotal.

https://www.healthaffairs.org…

The Changing Landscape Of Primary Care: Effects Of The ACA And Other Efforts Over The Past Decade

Considerable progress has been made in understanding how to implement and support different approaches to improving primary care delivery in that decade…

though evaluations showed little progress in spending or quality outcomes.

https://www.healthaffairs.org…

The ACA’s Individual Mandate In Retrospect: What Did It Do, And Where Do We Go From Here?

This article reviews recent research on the mandate’s effects, concluding that the mandate meaningfully increased insurance coverage, but likely by less than was projected before implementation.

These coverage gains are likely to erode as mandate repeal takes hold.

https://www.healthaffairs.org…

The ACA’s Effect On The Individual Insurance Market

The vision of the Affordable Care Act (ACA) for a reformed individual health insurance market included requirements and incentives for insurers to manage risk instead of avoiding it, minimum standards for coverage adequacy, income-related subsidies, managed competition through health insurance Marketplaces, and new programs to promote insurer competition.

However, in the wake of a political backlash against the law and unstinting opposition from many federal and state policy makers, the administration of President Barack Obama and Congress made several decisions that weakened the law’s foundations. The law’s opponents further undermined market stability through legal challenges that created uncertainty about the future of the law.

https://www.healthaffairs.org…

How The ACA Reframed The Prescription Drug Market And Set The Stage For Current Reform Efforts

Looking back a decade after the Affordable Care Act became law, we found that new drug approvals have accelerated and the therapeutic advances embodied in some novel medicines are substantial—as are the prices that companies are charging for them.

The lack of affordability of prescription drugs has become an increasing challenge for American patients and payers, particularly those with limited budgets.

https://www.healthaffairs.org…

The Ten Years’ War: Politics, Partisanship, And The ACA

After decades of failed efforts to overhaul American health care, the Affordable Care Act’s 2010 enactment was the most important health reform achievement since Medicare and Medicaid’s passage.

But ten years later, ACA politics are more tenuous than triumphal, and the ACA has not escaped the controversy that surrounded its enactment.

https://www.healthaffairs.org…

The ACA And The Courts: Litigation’s Effects On The Law’s Implementation And Beyond

Litigation over the law began on the day of its enactment and has been a constant in the decade since.

Although the law has survived these challenges, its effectiveness has been hobbled.

https://www.healthaffairs.org…

Health Insurance Coverage: What Comes After The ACA?

By Benjamin D. Sommers

The Affordable Care Act (ACA) led to the largest expansion of health insurance in the US in fifty years, bringing the uninsurance rate to its lowest recorded level in 2016.

But even at that point, nearly thirty million people lacked health insurance, and millions more still struggled to afford needed medical care. Recent studies also indicate a partial erosion of the ACA’s coverage gains since 2017.

POLICY REMEDIES FOR REDUCING UNDERINSURANCE

There is no obvious market-based remedy for the increasing financial burden experienced by many people with private insurance.

FUNDAMENTAL HEALTH SYSTEM REFORM

Finally, no discussion of coverage and access to care would be complete without considering more dramatic proposals to overhaul the US health insurance system. Under the broad rubric of “single payer” or “Medicare for All,” 2020 presidential candidates have floated a variety of approaches ranging from Medicare buy-in with a gradual transition to universal coverage, to the elimination of all private insurance in the US. A full assessment of the political and economic considerations of such proposals is well beyond the scope of this article, but these considerations warrant extensive debate. To vastly oversimplify matters, a publicly financed single-payer system would offer important advantages in terms of its universality, administrative efficiency, and potential for wringing price concessions from providers, hospitals, and drug and device makers that would get the US closer to its peers in terms of health care costs. But it would also involve enormous political and logistical challenges—particularly if it entailed eliminating private coverage for the over 150 million Americans currently insured through their employers—as well as shifting trillions of dollars in health care spending from the private sector to the federal government.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

The March issue of Health Affairs is a special edition that looks at the impact of the Affordable Care Act as it turns 10. Most of the articles are listed above with a short paragraph on a policy goal and a second short paragraph on the progress towards that goal. Although the policy gains are celebrated, it is difficult to see how anyone could celebrate the progress when many of the results are cruelly mediocre at best, and collectively should represent a profound disappointment for the policy community.

There is a glimmer of hope in the discussion of Benjamin Sommers on what comes after the ACA. For those who say that we must preserve and protect our private insurance plans, Sommers states, “There is no obvious market-based remedy for the increasing financial burden experienced by many people with private insurance.” You private insurance supporters, listen up!

Sommers also writes, “a publicly financed single-payer system would offer important advantages in terms of its universality, administrative efficiency, and potential for wringing price concessions from providers, hospitals, and drug and device makers that would get the US closer to its peers in terms of health care costs,” though he concedes that there are “enormous political and logistical challenges.”

Over a decade ago, as the politics were aligning behind what became the Patient Protection and Affordable Care Act, many of us were sounding the alarm that the policies supported were quite unsatisfactory, and that proceeding down that path would delay by another decade effective reforms that we desperately needed. What has happened since then is that far too many of us have experienced financial hardship, including personal bankruptcy, physical suffering and even death because of a system design that significantly impairs access to essential health care, even though we were already spending enough money to meet the goals of health care justice for all.

On June 11, 2009, I gave the keynote address at the annual meeting of the Health Care Council of Orange County – a group that was well informed on health policy.

I opened with the following questions directed to the audience:

How many here believe that it is probable – not certain, but probable – that Congress will pass health care reform and President Obama will sign it this year?
(Most individuals raised a hand)

How many believe that the legislation will provide insurance coverage to everyone or almost everyone?
(Not one hand went up)

How many believe that the legislation will be effective in slowing the rate of health care cost increases?
(Not one hand went up)

Following is an excerpt from a Quote of the Day that I wrote shortly after that meeting:

Everyone agrees that it is critical that we do something now to slow the rate of increases in health care costs. While addressing costs, most of us also agree that we must bring everyone in under the umbrella of financial security when facing health care needs. Since neglect of these issues has created the crisis we face, you would think that Congress and the administration would be busy attempting to fix these problems.

Congress is busy all right. But no one at the Health Care Council has been fooled. We are going to end up with legislation that will be labeled “health reform,” but the twin crises of rising costs and inadequate insurance will still be with us. Congress and the President will walk away, pretending that they did something, and it will take years or decades of more suffering and hardship before our leaders revisit the problems and finally do the right thing.

Sheer madness!

https://pnhp.org…

Let’s not allow the neoliberals to waste another decade continuing to take us down that path that is studded with financial hardship, physical suffering, and even death. Single payer Medicare for All. Now!

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

Single-payer is a practical solution

By Zach Thomas
The Charlotte Observer, March 3, 2020

Regarding “Single-payer care may work out for these restaurateurs,” (March 1):

Yes, single-payer health insurance would be beneficial in many ways. Restaurant owners will more likely be able to keep employees long term. Workers could take “sick days” to see a doctor and not face financial harm. The public benefits, too. Who wants to eat at restaurants where servers show up sick to avoid huge insurance deductibles?

A single-payer plan would cost less than the patchwork system we now endure. This article is a good example of how subsidized coverage like Medicare for All can offer practical and healthy solutions.

ACA still leaves many exposed to catastrophic health expenditures

Association of the US Affordable Care Act With Out-of-Pocket Spending and Catastrophic Health Expenditures Among Adult Patients With Traumatic Injury

By Charles Liu, MD, MS; Yusuke Tsugawa, MD, PhD; Thomas G. Weiser, MD, MPH; John W. Scott, MD, MPH; David A. Spain, MD; Melinda Maggard-Gibbons, MD, MSHS
JAMA Network Open, February 28, 2020

Abstract

Importance: Trauma is an expensive and unpredictable source of out-of-pocket spending for American families. The Patient Protection and Affordable Care Act (ACA) sought to improve financial protection by expanding health insurance coverage, but its association with health care spending for patients with traumatic injury remains largely unknown.

Objective: To evaluate the association of ACA implementation with out-of-pocket spending, premiums, and catastrophic health expenditures (CHE) among adult patients with traumatic injury.

Design, Setting, and Participants: Data from a nationally representative sample of US adults aged 19 to 64 years who had a hospital stay or emergency department visit for a traumatic injury from January 2010 to December 2017 were analyzed using the Medical Expenditure Panel Survey. Multivariable generalized linear models were used to evaluate changes in spending after ACA implementation. Additionally, 4 income subgroups were evaluated based on ACA thresholds for program eligibility: lowest-income patients (earning 138% or less of the federal poverty level [FPL]), low-income patients (earning 139% to 250% of the FPL), middle-income patients (earning 251% to 400% of the FPL), and high-income patients (earning more than 400% of the FPL). Data were analyzed from February to December 2019.

Exposures: Implementation of the ACA, beginning January 1, 2014.

Main Outcomes and Measures: Out-of-pocket spending, premium spending, out-of-pocket plus premium spending, and likelihood of experiencing CHE, defined as out-of-pocket plus premium spending exceeding 19.5% of family income.

Results: Of the 6288 included patients, 2995 (weighted percentage, 51.3%) were male, and the mean (SD) age was 41.4 (12.8) years. Implementation of the ACA was associated with 31% lower odds of CHE (adjusted odds ratio, 0.69; 95% CI, 0.54 to 0.87; P = .002). Changes were greatest in lowest-income patients, who experienced 30% lower out-of-pocket spending (adjusted percentage change, −30.4%; 95% CI, −46.6% to −9.4%; P = .01), 26% lower out-of-pocket plus premium spending (adjusted percentage change, −26.3%; 95% CI, −41.0% to −8.1%; P = .01), and 39% lower odds of CHE (adjusted odds ratio, 0.61; 95% CI, 0.44 to 0.84; P = .002). Low-income patients experienced decreased out-of-pocket spending and out-of-pocket plus premium spending but no changes in CHE, while middle-income and high-income patients experienced no significant changes in any spending outcome. In the post-ACA period, 1 in 11 of all patients with traumatic injury and 1 in 5 with the lowest incomes continued to experience CHE each year.

Conclusions and Relevance: Implementation of the ACA was associated with improved financial protection for US adults with traumatic injury, especially lowest-income individuals targeted by the law’s Medicaid expansions. Despite these gains, injured patients remain at risk of financial strain.

From the Discussion

Using nationally representative data, we found that implementation of the ACA in January 2014 was associated with decreased out-of-pocket spending among low-income US adults with traumatic injuries who were eligible for the policy’s Medicaid expansions and Marketplace subsidies. Implementation of the ACA was also associated with decreased odds of experiencing CHE, especially for the lowest-income patients earning 138% or less of the FPL. The decreases in spending were substantial in magnitude, ranging from an 18% decrease in out-of-pocket plus premium spending among low-income patients to a 30% decrease in out-of-pocket spending among lowest-income patients. Notably, these improvements in financial protection were not seen in middle-income adults eligible only for premium subsidies or high-income individuals ineligible for subsidies. Furthermore, our findings illustrate that strikingly high rates of CHE persist among patients with traumatic injury in the post-ACA period.

We did not observe decreases in CHE among low-income and middle-income patients despite their eligibility for ACA Marketplace subsidies, which may be because of several reasons. First, these groups had higher rates of insurance coverage before implementation of the ACA than the lowest-income subgroup, so gains in insurance coverage following ACA implementation were correspondingly smaller. Second, Marketplace (and private non-Marketplace) insurance plans have higher copayments and deductibles than Medicaid, and states are permitted to charge premiums to Medicaid beneficiaries earning more than 150% of the FPL, so the types of coverage gained by these subgroups did not lower spending as much. Third, because of lower ACA subsidies and higher income, middle-income individuals in particular may have tended to purchase less generous Marketplace plans, exposing them to higher out-of-pocket costs in the event of trauma. For example, during the 2018 Marketplace open enrollment period, individuals earning 100% to 250% of the FPL selected silver-tier or gold-tier plans over bronze-tier plans 82% to 18%, while those earning 251% to 400% of the FPL selected bronze-tier plans over silver-tier or gold-tier plans 51% to 49%. (Platinum and catastrophic plan enrollment was not released in these data.) Fourth, low-income and middle-income patients in our study had employer-sponsored insurance more often (40% and 66%, respectively) than the lowest-income patients (9%). Underinsurance has grown substantially among Americans with employer-sponsored insurance over the past 15 years, possibly blunting gains in financial protection from ACA-related increases in Medicaid and Marketplace coverage.

Finally, we found that even after ACA implementation, nearly 1 in 11 of all US patients with trauma and 1 in 5 with incomes of 138% or less of the FPL continued to experience catastrophic health care spending. Among patients experiencing CHE in the post-ACA period, one-fifth remained residually uninsured, and nearly three-fourths were insured (half with private insurance and one-quarter with Medicaid) but continued to experience CHE, indicating that they are underinsured. This may be because of variable implementation of the ACA in different states, lack of awareness of program eligibility, or plan-specific factors, such as out-of-network billing. There remains a critical need for policy solutions to address this crisis of affordability among low-income patients struggling with the dual misfortunes of traumatic injury and high-burden health care costs.

https://jamanetwork.com…

Comment:

By Don McCanne, M.D.

Although this study confirmed that “Implementation of the ACA was associated with improved financial protection for US adults with traumatic injury, especially lowest-income individuals targeted by the law’s Medicaid expansions,” the authors also found that “these improvements in financial protection were not seen in middle-income adults eligible only for premium subsidies or high-income individuals ineligible for subsidies. Furthermore, our findings illustrate that strikingly high rates of CHE (catastrophic health expenditures) persist among patients with traumatic injury in the post-ACA period.”

Further, “Among patients experiencing CHE in the post-ACA period, one-fifth remained residually uninsured, and nearly three-fourths were insured (half with private insurance and one-quarter with Medicaid) but continued to experience CHE, indicating that they are underinsured.”

Single payer Medicare for All would eliminate uninsurance and underinsurance. Yet many politicians reject this model of reform in preference for us being allowed to keep the insurance we have in spite of the fact that tweaking the current system and adding a public option will increase health care spending while still falling far short on the goals of reform. In contrast, single payer Medicare for All would reduce total health care spending while meeting the goals of universality, comprehensiveness, affordability, accessibility, and choice of health care professionals in a system that is equitable for all.

It’s past time to quit celebrating an overpriced system that isn’t working for far too many of us and get to work establishing what would be the premier system in all the world – the single payer model of an improved Medicare for All.

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Americans need ‘Medicare for All’

By Matthew Downing
Chicago Tribune, Letters, March 2, 2020

We, over 75 future doctors and nurses at Rush University Medical Center, demand that U.S. Sen. Dick Durbin co-sponsor S.1129, the Medicare for All Act of 2019.

The health care system we are about to enter is no longer sustainable. Medical bills are the leading cause of personal bankruptcy in the United States, despite three-quarters of those bankrupted having health insurance when they got sick. As costs continue to rise well above any industrialized nation in the world, our patients are rationing their insulin.

“Medicare for All” will save an estimated $450 billion a year on administrative costs. It is the only bill that guarantees health care as a human right by providing universal coverage and would save over 65,000 lives each year. Patients will be able see any doctor without copays, deductibles or premiums, and 95% of taxpayers will pay less for their health care.

It is our job to advocate for our patients. It is Sen. Durbin’s job to advocate for the people of Illinois. Americans should not lose their health care because they lost their jobs. Americans should not lose their health care because their insurance denied a specialist’s treatment. Americans should not lose their health care because their medications costs more than their rent. If the senator truly believes health care is a human right for all, then he must support S.1129.

Matthew Downing is the vice president of the Rush University chapter of Students for a National Health Program.

https://www.chicagotribune.com…

A fix for racial health care inequities

By Jacqueline Marshall
The Charlotte Observer, March 2, 2020

It’s time to think about a major sickness plaguing our health system — racial inequities.

Black Americans are much more likely to be uninsured. They have lower life expectancies and are more likely to die from diabetes and heart disease. Black mothers are 320% more likely to die from pregnancy-related complications.

Comprehensive universal coverage can close most of these racial disparities. Black men in the VA have a 24% lower death rate than whites. And once Americans enroll in Medicare, racial health disparities shrink or disappear. We can replicate the successes of the VA and Medicare with Medicare for All — the only policy that will provide equal protection to everybody.

Universal health care the cure for medical billing disorders

By Eric Naumburg, M.D., M.P.H.
The Baltimore Sun, Letters, March 2, 2020

Our country’s failure to enact a universal health care system — often called Improved Medicare for All or Single-Payer Health care — causes many hardships. Not-for-profit hospitals suing patients is one sad result (“As Maryland hospitals continue to sue patients, state lawmakers call for ‘guardrails,’” Feb. 28). This behavior is immoral because it leads to homelessness, hunger, delaying needed health care, personal bankruptcy, disrupting families, etc.

Increased numbers of people have health insurance under the Affordable Care Act, yet national polling shows that more people (26%) report going without needed care than before passage of the ACA. Why is this? Employer sponsored health insurance plans have become skimpier and skimpier with employees paying high premiums, deductibles and co-pays for less coverage. Employers struggle to provide adequate employee health insurance while healthcare prices rise faster than wages and these forces have overwhelmed the positive benefits of the ACA.

A thoughtfully executed National Improved Medicare for All health system would cover everybody with no co-pays or deductibles. In fact, there would be no medical bills to decipher. Only the national health insurance system would be able to cover necessary care so all providers, hospitals, and doctors would be in the system. You would have choice of any doctor and hospital, no limited networks of providers, no surprise medical bills. You get to keep your own doctor.

The national health system would control prices because it could negotiate payment rates and drug costs. Hospitals would negotiate one annual budget with the national health system based on the community’s needs and demand for services. Savings from such a system would be dramatic as the complex medical billing system would be eliminated.

Dr. Eric Naumburg is co-chair of Maryland Physicians for a National Health Program.

https://www.baltimoresun.com…

The Biggest Lies Ever Told About a Single-Payer System for Healthcare

By John Caccavale, Ph.D. A.B.M.P.
National Alliance of Professional Psychological Providers, The Clinical Practitioner, March 2020

This election year sees healthcare reform as the major issue confronting the American elective. While political issues wax and wane over election cycles, healthcare reform consistently remains as the top issue among a majority of Americans. However, most elected politicians and media pundits do little to provide any satisfactory answers that are based upon the objective data about what we know and what we don’t know about which, if any, reform policy could resolve the continuing crisis in healthcare.

As for the major political parties, the Democratic Party supports bolstering the Affordable Care Act that was passed in 2010. The Republican Party is intent on destroying ACA, and has offered no plan to replace it. What this does is leave the American people in a holding position because the two political parties are recommending that we either accept the Democratic position that is totally inadequate and flawed or the Republican position that essentially means more illness and death. People need healthcare and the Republican position is unacceptable. Likewise, although the ACA has provides care to many millions of people who formerly did not have coverage, a significant number of people remain uninsured.

While some of my statements above may be seen as political, it is not my intent or motivation to advocate whether the ACA or Republican No should be adopted. My intent, as a clinician, is to talk about why I think a single payer system or, “Medicare For All” as many call it, is the best choice both for patients and providers. I don’t think any advocacy for MFA can be made unless we have the objective facts about it. Chief among any discussion of MFA is the cost. Almost everyone who opposes MFA points to the “excessive” cost to provide healthcare to everyone is the USA. So I think it natural to start with the facts that we have to evaluate the costs for universal coverage under MFA.

What The Data Show About the Cost for Universal Coverage Under MFA

Although advocates and those who oppose MFA throw out numbers galore about the cost of MFA while not citing any objective data to support their claims, at the low end we hear that it would cost about $35 trillion dollars over a 10-year period. At the high end, opponents cite closer to $50 trillion dollars. According to a recent study 1 published by CMS, the official administrator for the Medicare, program, total expenditures for healthcare in 2018 was $3.5 trillion dollars. They project that national healthcare expenditures will grow at an average rate of 5.5 percent per year and will reach nearly $6.0 trillion by the year 2027.

The chief proponent for MFA is Senator Bernie Sanders who is currently is running for president. His campaign website and previous statements puts the cost at $35 trillion dollars for his MFA program over a 10-year period. Some of his competitors and some in the media cite a $50 trillion price tag. The data clearly supports Senator Sanders’ position in two major ways. Firstly, his $3.5 trillion dollars annually for the cost is in line with CMS’s cost projections. Secondly, Sanders and other proponents cite significant costs savings under the MFA system. A very recent study 2 calculates that MFA will save more than 13% annually in healthcare expenditures. This amounts to $455 billion dollars, which more than offsets the 5.5% annual increase that CMS cites. This is similar to the estimates that other studies cite. So, clearly, if we look at the available data from the agency that administers the most efficient healthcare system, MFA will not only provide coverage to everyone but will also provide significant savings over the current system.

My experience as a clinician, who is also a trained healthcare policy analyst, the typical savings cited for MFA may be on the low side. For example, a few years ago NAPPP sent me to meet with several members of the Congressional Mental Health Caucus in Washington, DC. We provided them data showing how savings of $220 billion dollars over a 10-year period could be had simply by controlling the over prescribing of four classes of psychotropic medications. There are many other ways to reduce expenditures including the low administrative costs associated with MFA and the relationship of predatory pharmaceutical practices to cost and by the elimination of third-party insurers who contribute not a single penny of value to the system.

In a 2020 study, Hammelstein, et al 3 cites that the administrative costs for healthcare, comparing the single-payer system of Canada to the US system, was about 16% in Canada but was 34% for the US. Their study was based on 2017 data, but is much higher for 2020 going forward. CMS reports that their administrative costs average only 2%, annually. Objectively there is no comparison. I suggest that the data
should be our guide and not political or industry posturing.

Taxes Will Go Up Under MFA?

Yes, the Medicare tax currently paid and deducted from paychecks will increase. Overall costs to consumers, however, will significantly decrease. The average cost of healthcare insurance for a family is about $12,000 per year. The average increase for MFA is estimated to be about $4,000 per year per family. This means that a family would gain $8,000 per year in actual dollars. The overall cost to consumers far exceeds any increase in Medicare tax. Employers will also see a significant decrease in their healthcare costs as there will be a shift into MFA. Employees may be able to get higher wages as employer costs essentially are eliminated. The beware of tax increase argument simply is not valid if the increase in taxes for healthcare is offset by the average annual cost under the present system.

MFA Is Socialism and Americans Do Not Accept Socialism?

If socialism is defined as a government run or funded function than Americans do not only accept socialism but actually may love it. Ask anyone if they could provide or pay for the healthcare needs of their elderly parents if Medicare did not exist. I’m sure they are not against this type of socialism. We already have government run and funded healthcare through Medicare, Medicaid, and a host of other healthcare related programs for all ages of Americans. The ACA itself is mostly government run and funded. The twist is that taxpayers are subsidizing private corporate healthcare insurers who are receiving the largest share of government largess.

Aside form healthcare, government funded tax breaks for corporations far outstrip the costs for any of the government’s expenditures for healthcare. Subsidized payments to farmers is pure socialism. Government run utilities that are run by cities and states is socialism. No private utility company can compare with these entities. I can go on and on, but I think the point is clear: there are a multitude of socialistic program in the US and whether or not people recognize them as such does not change the fact that they are. Moreover, despite some issues about efficiency that many opponents cite, government is not a business. Business exits to make a profit. Government exists to provide services to its people. Perhaps this is what has been lost. Healthcare is much
too important to leave in private hands and the current system continues to provide proof that it cannot serve the needs of the majority.

It’s Important to Keep A Private Based Insurer System?

I’m not sure why this is the case and if there are any significant arguments to support a private based system. By any accounts a private based insurer system is responsible to shareholders and not patients, the primary stakeholders. When profit becomes more important than life and death issues, profit has no justification to prevail. Prior to the late 1970s, healthcare insurers were not publicly traded companies. By law they were non-profits. At that time, the system functioned fairly well. People who did not have employer-paid insurance had access to government hospitals and clinics. Hospitals didn’t gouge patients and medication costs were relatively low.

When the law was changed to allow healthcare companies to become publicly traded companies, the emphasis changed to profit making. Costs at all levels increased and have continued to do so. As profits soar so do costs, and because these companies must show a profit every three months to satisfy their shareholders and Wall Street fund managers, there is a neverending upward spiral. Providers supply profits by low reimbursement. Patients supply profits by paying high premiums, high deductibles, phantom panels that decrease access, and the uninsured with death and decease.

I might be cynical, but after many years of being a practitioner I do not see the importance of a private based system that is the primary provider of a healthcare system to one that is centered on patient care. There is, however, a role for a private insurer market. The sale of optional secondary insurance where people can purchase insurance for services not covered by MFA may be warranted such as insurance
for cosmetic surgery that is not medically necessary. I’m sure there are other examples, but the point is that these companies should not be the primary provider for healthcare.

Providers Cannot Be Treated Fairly Under MFA?

As a clinician I understand that many providers have not fared as well as others under Medicare and similar programs. However, low reimbursements are more a function of the private based system than on Medicare. A little history: prior to the implementation of Medicare in 1964, organized medicine and the Republican Party fought to defeat President Johnson’s signature social policy. However, when it became
clear that Medicare would pass the Congress, the very night before the passage of the bill, physicians, as a whole, increased their rates for services. Why? Because they knew that rates after passage would be the starting point for negotiation. Now, all these years after the passage of Medicare, few physicians and other healthcare-related practices can exist without Medicare.

Psychologists, in particular, have fared worse under Medicare for several reasons. When Medicare was implemented, the APA refused to have psychologists included as physicians in the bill. APA academics, under the presidency of Jerome Bruner, were against psychologists becoming paid therapists and rebutted the efforts of Dr. Nicholas Cummings to include psychologists as independent practitioners under Medicare. Hopefully, we will not make the same mistakes. The way things are going, however, with APA transforming psychology from a doctoral-level to a masters-level profession, I fear clinicians who are not politically active may further set us back if MFA becomes a reality, which I think will come sooner or later.

Another major reason that psychologists have not fared well over the past decades is precisely due to the privatization of healthcare. It is the healthcare companies that have skewed reimbursements downward. Industry practices to increase profit and
decrease costs are major factors. CEO pay is another major factor. If anything, some of the savings from MFA can be pointed to higher reimbursement rates.

All providers will benefit with MFA, but psychologists will benefit more than others will. Increased access to mental healthcare will substantially increase practice. Decreased bureaucracy, reporting, billing, and deductibles under the Sanders’ plan will translate into higher practice revenues. More important is the fact that psychology is a healthcare profession and this means we are advocates for greater and quality patient
care. These goals and values are not attainable under a privately-based insurance system.

With millions of people who have no insurance and millions more who are under insured, people are being denied mental health coverage as well as other important services. MFA is a patient-centered and provider-centered solution to a major national crisis. This is why I urge psychologists and other healthcare professionals to support MFA. The data shows this is the right thing to do.

http://www.nappp.org…

References

  1. Under current law, national health spending is projected to grow at an average rate of 5.5 percent per year for 2018-27 and to reach nearly $6.0 trillion by
    2027. https://www.cms.gov…
  2. Galvani AP, et al. Published: February 15, 2020. doi: https://doi.org/10.1016/S0140-6736(19)33019-3
  3. Himmelstein DU, Campbell T, Woolhandler S. Health Care Administrative Costs in the United States and Canada, 2017. Ann Intern Med. 2020;172:134–142. [Epub ahead of print 7 January 2020]. doi: https://doi.org/10.7326/M19-2818

Medicare for All Explained Podcast: Episode 29

Interview with Martha Gaines

March 1, 2020

Prior authorization requirements are bad enough, but what happens when insurance companies authorize a procedure only to go back on their word? Legal advocate Martha Gaines describes the troubling trend of “retrospective denials.”

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

https://medicareforallexplained.podbean.com

Medicare for All saves money; Medicare for some doesn’t

22 studies agree: 'Medicare for All' saves money

By Diane Archer
The Hill, February 24, 2020

The evidence abounds: A “Medicare for All” single-payer system would guarantee comprehensive coverage to everyone in America and save money.

Christopher Cai and colleagues at three University of California campuses examined 22 studies on the projected cost impact for single-payer health insurance in the United States and reported their findings in a recent paper in PLOS Medicine. Every single study predicted that it would yield net savings over several years. In fact, it’s the only way to rein in health care spending significantly in the U.S.

All of the studies, regardless of ideological orientation, showed that long-term cost savings were likely. Even the Mercatus Center, a right-wing think tank, recently found about $2 trillion in net savings over 10 years from a single-payer Medicare for All system. Most importantly, everyone in America would have high-quality health care coverage.

Medicare for All is far less costly than our current system largely because it reduces administrative costs. With one public plan negotiating rates with health care providers, billing becomes quite simple. We do away with three-quarters of the estimated $812 billion the U.S. now spends on health care administration.

Administrative costs are so high because thousands of insurance companies individually negotiate benefit rules and rates with thousands of hospitals and doctors. On top of that, they rely on different billing procedures — and this puts a costly burden on providers.

Administrative savings from Medicare for All would be about $600 billion a year. Savings on prescription drugs would be between $200 billion and $300 billion a year, if we paid about the same price as other wealthy countries pay for their drugs. A Medicare for All system would save still more with implementation of global health care spending budgets.

Even more savings are possible in a Medicare for All system because, like every other wealthy country, we would have a uniform electronic health records system. Such a system generates additional savings because system problems would be easier to detect and correct. A uniform claims data system helps reduce health care spending for fraudulent services. In 2018, total U.S. health care costs were $3.6 trillion, representing 17.7 percent of GDP.

Savings are in part a function of the benefits Medicare for All covers. The Mercatus report and others projected savings, even with the elimination of deductibles and out-of-pocket costs. Under both Sen. Bernie Sanders’s (I-Vt.) Medicare for All bill and Rep. Pramila Jayapal’s (D-Wash.) Medicare for All bill, patients would not pay deductibles or coinsurance when they receive medical care. Their bills also provide for vision, hearing and dental care, as well as long-term services and supports, such as home care and nursing home care.

No matter how you design a single-payer public health insurance system, it would have lower overall health care costs, so long as for-profit private health insurers no longer exist to drive up health care costs. Yes, it’s true that some other wealthy countries rely on “private insurers” to provide benefits and spend far less than we do on care. But, these insurers do not operate in any way like health insurers in the U.S.

Other wealthy countries dictate virtually every element of the health insurance people receive, including what’s covered, what’s paid, and people’s out-of-pocket costs — all identical for everyone. The insurers operate like claims processors or bill payers. They follow the coverage and payment rules set by the government, nothing like the private health insurers in the U.S. which revel in product diversity (read: complexity and confusion).

And, if you’re thinking that having the federal government guarantee coverage to all Americans is a big deal, it’s actually not. The government already pays for about two-thirds of health care costs. Among other things, it pays for Medicare, Medicaid, VA, TriCare and a wide range of state and local health care programs, along with private insurance for government employees and tax subsidies for private insurance.

Whether you call it single-payer or Medicare for All, it isn’t some socialist pipe dream. It’s a sensible, efficient, and effective way to guarantee excellent health insurance to everyone.

Diane Archer is a senior adviser at Social Security Works.

https://thehill.com…

PLOS Medicine, “Projected costs of single-payer healthcare financing in the United States: A systematic review of economic analyses” by Christopher Cai, Jackson Runte, Isabel Ostrer, Kacey Berry, Ninez Ponce, Michael Rodriguez, Stefano Bertozzi, Justin S. White, James G. Kahn

PDF version can also be downloaded at this link: https://doi.org…

Comment:

By Don McCanne, M.D.

We continue to hear that single payer Medicare for All costs too much, and we cannot afford it. Although the PLOS study mentioned above was covered in a previous Quote of the Day, the link is provided again since it is a highly credible summary of prior single payer analyses that shows that single payer actually saves money after the initial transition from our current system.

The article above by Diane Archer is useful because it explains the model in terms that most audiences can understand. Although the PLOS article is technical, it is also useful for those who need to understand in greater detail how the conclusion of savings was reached.

It is particularly important to understand that analyses that were omitted used various assumptions or model variations that disqualified them as bona fide single payer models for the United States. S1 Appendix lists the studies excluded and the reasons for that. This should refute the claim of those who say that these studies were cherry-picked to obtain a desired result.

Those supporting the addition of a Medicare-like public option are the most outspoken in claiming that single payer Medicare for All costs too much. Yet it is their model that leaves in place our overpriced system while adding the costs and administrative complexity of yet another plan – the public option (for those who want it). Do not let them dismiss single payer with the glib comment that we don’t know how to pay for it. We do; we would pay for it with progressive taxes which would make it affordable for absolutely everyone and at a total cost that the nation can afford – a total cost lower than what they propose by merely tweaking our current system and adding a public option.

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“Medicare for All” offers Americans the real choices we all need

By Ian O’Connor
The (Charleston, S.C.) Post and Courier, February 27, 2020

In medical school I am seeing the tragic results of a profit-driven corporate health insurance system. It’s worse than I thought, but there is an obvious way to fix it.

The private health insurance industry restricts Americans’ choice, dictating which doctors we can and can’t see, which hospitals we can and can’t go to, and which treatments or prescription drugs we can access. That’s what you get if you are fortunate enough to have insurance; too many of us do not.

Despite major gains under the Affordable Care Act, 10% of South Carolinians remain uninsured. Our state ranks 36th in the country for health care, 36th for access to care and 40th for public health.

At least four rural hospitals in South Carolina have closed over the past 10 years, and the state’s Medicaid agency is trying its best to help struggling hospitals stay afloat.

Medical school has helped me further realize that “Medicare for All” is our best solution.

With Medicare for All, Americans would finally be provided total choice of doctors and hospitals.

With Medicare for All, virtually every physician would be in-network, allowing us to choose doctors and hospitals for ourselves without worrying about out-of-network prices or surprise bills. This comprehensive coverage would be free at the point-of-care, with no premiums, deductibles or any other form of unpredictable out-of-pocket costs. No more need to declare bankruptcy because you got sick or were in an accident.

The economy would love Medicare for All, too.

Employers would be freed of the albatross of paying for employee health insurance, and every American would be free to change jobs without needing to change (or lose) insurance and find a new doctor.

Hospitals would fare better financially.

Today, most private insurers pay hospitals on a fee-for-service basis, encouraging them to provide increasingly expensive technological care while neglecting their community’s needs for more primary care, obstetrics, mental health and the treatment of addictions. Hospitals that manage to provide care for people without insurance are financially penalized for helping their community. That’s just not the right way to set up a health care system.

With Medicare for All, there would be no more uncompensated care. By partnering with the government to develop budgets, hospitals would be paid based on the health needs of their communities, ensuring that vital hospitals wouldn’t be improperly forced to close. Special reserves would be set aside for unanticipated public health crises.

And providers would be freed up to spend more time focused on patients instead of fighting insurance companies — whose business model is denying care.

For any American family, private insurance is, at best, an unacceptably risky bet. Even the supposedly solid private insurance plans, for example those Culinary Union plans recently at the center of heated debate in Nevada, are subject to the whims of these companies and do not guarantee coverage for medical necessities. Medicare for All would guarantee comprehensive coverage.

We cannot afford any more of the scam that is this cruel corporate multi-payer maze masquerading as a health insurance system. It is a malevolent bureaucratic nightmare that skims 34% off the top of our national health care spending. And for what? Marketing and outlandish salaries and bonuses for executives, of course, but also unnecessary paperwork for us providers and the sham administrative costs inherent to such a parasitic system. It is inexorably inefficient (and “Medicare for All Who Want It” maintains the same inefficiencies that make our health care system so expensive).

Meanwhile, Medicare’s administrative overhead is less than 3%.

South Carolina, and America, needs single-payer Medicare for All. Everything else is more expensive, wasteful and will continue to take away our health care choices.

Ian O’Connor is a medical student at the Medical University of South Carolina and founder and president of the MUSC chapter of Students for a National Health Program.

https://www.postandcourier.com…

Health insurers are abruptly terminating anesthesiology contracts

Health insurers are abruptly terminating physician contracts

By Jeff Lagasse
Healthcare Finance, February 27, 2020

Physician anesthesiologists are being forced out of network as insurance companies terminate their contracts, often with little or no notice, according to a new national survey from the American Society of Anesthesiologists.

Initial results find 42% of respondents had contracts terminated in the last six months, while 43% of respondents experienced dramatic payment cuts from insurers — both mid-contract and at renewal — in some cases by as much as 60%. Some of the impacted contracts were signed less than six months ago.

The informal, non-scientific survey, which was distributed earlier this month, received responses from 76 practice groups in 33 states. It confirms anecdotal complaints that proposed surprise medical bill legislation has coincided with a significant number of insurance contract terminations and unilateral lower payment adjustments by health insurance companies.

While the timing alone suggests insurance companies are motivated by factors related to anticipated legislative changes on surprise medical bills, some survey respondents reported they were specifically told by insurers this was the case.

The responses also indicated that UnitedHealthcare was noted as the insurer most associated with these changes, but Aetna, Cigna and Blue Cross Blue Shield also were mentioned.

https://www.healthcarefinancenews.com…

Comment:

By Don McCanne, M.D.

Patients who have been diligent in making sure that their hospitals and surgeons are in their insurers’ provider networks, often they find that the anesthesiologist is not and thus they may be exposed to surprise medical bills.

According to this survey from the American Society of Anesthesiologists there has been a relatively abrupt move on the part of private insurers to either demand payment cuts of up to 60% or force anesthesiologists out of the insurers’ provider networks. This certainly does not benefit the anesthesiologists, and it potentially exposes patients to surprise medical bills. So who does benefit? It is likely that the legislative proposals to end surprise billing that are being considered by Congress will primarily benefit the insurers. The government will control fees without need for the insurers to negotiate contracts with the providers.

This will work particularly well for the insurers if the legislation protects the patients from the surprise bills and the principle is established that the government can control fees in the private sector and not just in government programs such as Medicare and Medicaid. The insurer gets the equivalent of contracted rates without having to negotiate contracts. Arbitration has been proposed but it is administratively burdensome and costly and may result in higher fees, so the insurers do not want that. Congress has been very friendly to the insurance industry, and it is likely that this abrupt trend in contract cancellations signals the fact that the final surprise bill legislation will be written by the insurance lobbyists.

Can those politicians who keep telling us that we want to keep our private insurance plans explain to us why we would? Maybe we could find out their true motivations by checking out OpenSecrets.org.

Yes, fees would be controlled under single payer Medicare for All, but they would be determined through negotiations with representatives of the physicians, ensuring that they are fair for the physicians and fair for the taxpayers who fund the system. As it is now, we may soon find that our urgent care centers are staffed by former anesthesiologists who now work by the clock.

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