Fordham University, April 29, 2020

Despite apparent gaps in the United States’ healthcare system during the coronavirus outbreak, Americans are generally satisfied with the healthcare system’s performance, according to a new poll from Fordham University. The crisis may, however, be driving more Americans to support a government-run healthcare system. At this point, Americans also express support for guaranteed quality healthcare for all Americans, those infected with the coronavirus, and other groups, regardless of party affiliation. Support for access to quality care regardless of citizenship status is also widespread.

The poll, conducted by NORC at the University of Chicago, took place from April 16 through 20, 2020, among 1,003 respondents nationwide. It has a margin of sampling error of 4.33 percentage points. The poll is a product of the Fordham Graduate School of Arts and Sciences’ Advanced Certificate in Public Opinion and Survey Research and its M.A. in Elections and Campaign Management.

Support for Single-Payer Healthcare during the Pandemic

The coronavirus pandemic may be influencing Americans’ support for a single-payer healthcare system. When asked to choose between a single-payer system and a system based mostly on private insurance, a slim 53% majority of Americans now choose a single-payer system with 44% preferring insurance-based. Five months ago, pre-coronavirus, when Gallup asked a similar question the numbers were the reverse – 42% and 54% respectively.

Not surprisingly there are large partisan differences on this issue. Majorities of Democrats (68%) and independents (57%) would prefer a single-payer system in the midst of the pandemic, but nearly three-quarters (72%) of Republicans would rather have a system based primarily on private insurance.

Q: If you had to choose which of the following two approaches for providing healthcare in the midst of the coronavirus pandemic in the United States would you prefer–a government-run healthcare system, or a system based mostly on private health insurance?

Government run system:

• 53% – Total
• 68% – Democrat
• 57% – Ind/Other
• 27% – Republican

System based on private insurance:

• 44% – Total
• 26% – Democrat
• 41% – Ind/Other
• 72% – Republican

Perceptions of Government’s Healthcare Responsibilities

We asked Americans about the federal government’s responsibility to provide quality healthcare to various groups of Americans: the poor, senior citizens, veterans, those infected with the coronavirus, and all Americans. Majorities of all partisan affiliations agreed it was the federal government’s responsibility to provide healthcare to each of the groups.

Those who agree it is the federal government’s responsibility to provide quality healthcare for all Americans:

• 87% – Democrat
• 80% – Independent/Other
• 59% – Republican

For most of the target groups, the majority support for guaranteed quality healthcare is sizable. Only for guaranteeing healthcare to all Americans does a deep partisan divide develop – a smaller majority of Republicans – 59% – support guaranteed quality care for all, compared to seven-in-ten or more of Republicans that support the same for each of the other target groups. (Full results at link below)

Healthcare Coverage for Non-Citizens

Americans are also supportive of providing healthcare to non-citizens when it comes to the coronavirus outbreak. Nearly eight-in-ten respondents believe people should have access to quality medical care regardless of citizenship status, with half of all Americans strongly believing so. Here again, majorities of all parties are supportive of such access.

https://www.globenewswire.com…

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Comment:

By Don McCanne, M.D.

So this is yet one more poll that shows that a majority of Americans would prefer a “government run system,” though the number is not quite as high as other polls since 72% of Republicans preferred the option of a “system based on private insurance.”

The more significant finding in this poll is that a strong majority, including 59% of Republicans, agree that “it is the federal government’s responsibility to provide quality healthcare for all Americans.” Also, almost all agree, including 66% of Republicans, that during the coronavirus attack “people should have access to quality medical care, regardless of citizenship status.”

It is reassuring to see that there is strong agreement that the government needs to be involved in providing health care for all. We just have to do a better job in explaining to Republicans why an improved version of Medicare would be better than relying on private insurers.

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

By Susannah Luthi
POLITICO, April 28, 2020

Big businesses and powerful Democrats are aligning around a proposal to bail out employer health plans in the wake of staggering losses to the insurance industry, as some worry that a surge in uninsured Americans could give new life to a stalled push for “Medicare for All.”

The business and labor interests, who have strong economic motives to keep the current system of employer-based care, are rallying behind a Democratic effort to subsidize temporary extensions of newly unemployed Americans’ workplace health plans in Congress’ next coronavirus rescue package.

But to some progressives who cheered Bernie Sanders’ (I-Vt.) Medicare for All plan, the crisis has exposed what they see as the folly of tying employment to health coverage. Sanders, who’s advocating for an emergency version of his health plan during the pandemic, ripped the idea of propping up an expensive employer system in a POLITICO op-ed Tuesday.

“Not only would health insurance corporations make massive profits off the plan—profits that come at the cost of the American taxpayers—but it would still leave tens of millions uninsured or underinsured,” the former Democratic presidential candidate wrote. “And during this pandemic, a lack of insurance means more Covid-19 transmissions and more deaths.”

Employers, health care groups and unions badly want the employer system to emerge from the health crisis unscathed, believing it would ward off any new expansion of government health care. Joe Biden’s rise to becoming the presumptive Democratic nominee was a relief to the health care industry, which has spent the past two years attacking Medicare for All.

“This crisis will be over — not soon enough, but it will be over — and we need to fundamentally keep that highway back to jobs and job-provided health care open,” said Ilyse Schuman, senior vice president of health policy for the American Benefits Council, which represents major employers.

While the health industry and Democrats still want to bolster Obamacare, an unusual bloc is pressuring Congress to fully subsidize workplace premiums for the uninsured. Corporations would benefit because the employer-based system supplies a big tax break for benefits they can use as a recruiting tool. Unions would keep the generous coverage they have negotiated with corporations. And hospitals and doctors could maintain the big payouts from private insurance, which are far higher than the Medicare and Medicaid rates paid by government.

Unions, major insurers, hospitals and the consumer advocacy group Families USA have banded together through a group called the Alliance to Fight for Health Care, and are lobbying Congress to subsidize COBRA through the next stimulus package.

Supporters said COBRA aid would provide a backstop to hospitals and physicians, whose finances have been hurt by the cancellation of elective procedures during the crisis.

“Hospitals and providers are seeing tremendous expense and increase in uncompensated care and uninsured individuals coming in, while also seeing drops in elective procedures, so I think it’s money well spent in protecting employees in a time of crisis,” said Katie Mahoney, vice president of health policy for the U.S. Chamber of Commerce.

House Speaker Nancy Pelosi first pitched COBRA subsidies a month ago in a proposed alternative to the $2.2 trillion CARES Act that was ultimately approved by Congress.

Support from unions puts pressure on progressive Democrats, the driving force behind Medicare for All, to back the policy.

Unite Here, representing mostly service workers, said Congress must subsidize workplace plans. The union’s international president, D. Taylor, estimates 95 percent of its members are unemployed during the crisis.

Moreover, experts note, COBRA subsidies come with a huge price tag and ultimately help the middle- and higher-income people, rather than lower-income people more likely to work retail and service jobs affected by shutdowns.

“Almost no matter the employment outlook or time horizon, COBRA subsidies are unlikely to be the most cost-effective way of expanding coverage or relieving financial hardship,” said Matt Fiedler, former chief economist of the Council of Economic Advisers under the Obama administration. “They’re just not targeted on the right people.”

https://www.politico.com…

Alliance to Fight for Health Care: Supporting the employer-provided health care system
https://www.fightforhealthcare.com

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Here’s How to Cover Uninsured Americans During the Pandemic

By Sen. Bernie Sanders
POLITICO, April 28, 2020

As the coronavirus continues to spread, and the United States climbs closer to 1 million cases and nearly 60,000 deaths, we face an unprecedented economic and health care crisis that demands an unprecedented response. While we work toward an economic solution that keeps people on the payroll, Washington is also in the midst of a crucial argument over how to help cover the costs of testing, treatment and all other essential care for the millions of people who are now uninsured or soon will be as the country faces record levels of job loss.

Last week, the White House said it would give an unspecified amount of federal aid directly to hospitals to cover the costs of treating uninsured Covid-19 patients, but details have not been released, and the proposal leaves out all non-Covid-19—but still crucial—medical care. The week before, a handful of Democrats proposed spending hundreds of billions of dollars on expanding subsidies for COBRA—the program that allows those who have lost their jobs to continue, on a temporary basis, paying out-of-pocket for the health insurance coverage they received from their previous employer.

But there’s another, better way to guarantee that everyone in America gets all the health care they need, without cost, for the duration of the pandemic: Empower Medicare to pay all of the health care costs for the uninsured, as well as all out-of-pocket expenses for those with existing public or private insurance, for as long as this pandemic continues. Our Health Care Emergency Guarantee Act is more comprehensive than Trump’s vague proposal and less expensive than the Democrats’ COBRA expansion.

While almost all Democrats understand the severity of the crisis and the need to act, too many of them are proposing a totally inadequate response that would simply lock in place the dysfunction and waste of our current health care system.

Subsidizing COBRA, as they have suggested, would be both expensive and ineffective: Not only would health insurance corporations make massive profits off the plan—profits that come at the cost of the American taxpayer—but it would still leave tens of millions uninsured or underinsured. And during this pandemic, a lack of insurance means more Covid-19 transmissions and more deaths.

Expanding COBRA during the pandemic would do nothing to cover those who already lacked insurance. It also won’t help the many Americans who continue to receive employer-provided health care but are still prevented from going to the doctor by massive deductibles and co-pays. In fact, the average family with employer-provided insurance faces $4,700 in out-of-pocket costs every year. The deductible alone for the average low-income worker is $2,600 a year. Maintaining the status quo does nothing to address these extraordinary costs, made worse during the pandemic economy.

Further, COBRA subsidies will only cement the inequities of our current health insurance system. Right now, low-wage workers are, on average, enrolled in plans with low premiums but higher deductibles. On the other hand, higher-wage employees, often professionals, have platinum plans with much higher premiums and far superior coverage. Expanding COBRA, which subsidizes only premiums, would treat high-income workers who lose their jobs far better than low-wage workers who do, even though the latter have suffered the brunt of the economic damage wrought by the pandemic.

The Health Care Emergency Guarantee Act would treat all people equally. For the duration of this crisis, under the act, Medicare will cover all medically necessary health care, including prescription drugs, for the uninsured, whether those who have recently lost their jobs or those who have been long without insurance. It is simply irresponsible and dangerous to the public to allow millions of people in this country to go without health coverage as a pandemic rips through our communities.

The American people deserve a health care response to the pandemic that’s simple, easy to understand and doesn’t require them to fill out complicated forms or deal with an already stressed bureaucracy in order to receive care. Under this proposal, everyone in the United States, regardless of insurance coverage or immigration status, would be able to walk into a doctor’s office to receive the care they need without worrying about the cost.

https://www.politico.com…

Health Care Emergency Guarantee Act:
https://www.sanders.senate.gov…

Summary of Emergency Guarantee Act:
https://www.sanders.senate.gov…

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Comment:

By Don McCanne, M.D.

One of the painful lessons of the tragic Covid-19 pandemic is that we see how terrible the functioning of our health care financing system is, as if it weren’t already obvious before the pandemic arrived. We knew that the current system was overpriced and underperforming, resulting in unacceptable levels of financial hardship, physical suffering and even death, but the severity of the deficiencies have been compounded by the impact of the pandemic.

The Affordable Care Act was a misguided effort to reform the system since the deficiencies in the model were well recognized before it was enacted and implemented. Now the pandemic has brought these deficiencies into sharper focus as the hardship and suffering increase. A model that would have been less expensive and vastly more effective is the single payer model of Medicare for All. As far as financing the increased health care services required during this pandemic, Medicare for All would have been much more effective had it been in place. Medicare for All along with reinforcement of our public health services would have reduced the severity of the detrimental medical and economic impacts of Cobvid-19.

Now it is obvious that we should promptly move forward with Medicare for All, and it is also very obvious to the various vested interests that currently fare well under our fragmented, dysfunctional system. These opponents of Medicare for All have aligned themselves in yet another organization to fight Medicare for All: the Alliance to Fight for Health Care. They have decided to support a temporary expansion of COBRA to fill in some of the void caused by the pandemic, a logical choice for them since COBRA is already a temporary insurance program designed to provide coverage during intervals of unemployment. This would provide the least disruption to our current financing system, allowing them to eventually pick up where they were before the onset of the pandemic.

Bernie Sanders has a much better idea. He proposes filling in the void with Medicare. It would be much more effective and less expensive than the COBRA expansion. So as an urgent measure his Health Care Emergency Guarantee Act would be far better. Everyone would get the health care they need, and it would be affordable.

Better yet, when the public sees how effective Medicare can be, it doesn’t take much imagination to see substantial reinforcement of the support that the Medicare for All proposal already has. At the end of the pandemic, the public would be nearly unanimous in their support for Better Medicare for All. Yet some Congressional Democrats, unions such as UNITE, and Families USA are joining big business on the COBRA bandwagon. We are at risk of losing the battle if we don’t take greater measures to overcome our inertia. This is the opening we’ve been looking for, and we should take it.

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

By Gabriela Schulte
The Hill, April 24, 2020

Q: Would you support or oppose providing Medicare to every American?

• 69% – Net support
• 37% – Strongly support
• 32% – Somewhat support
• 31% – Net oppose
• 18% – Strongly oppose
• 14% – Somewhat oppose

Support for Medicare for All has remained consistently strong over the past two years, according to a new Hill-HarrisX poll.

Sixty-nine percent of registered voters in the April 19-20 survey support providing Medicare to every American, just down 1 percentage point from an Oct. 19-20, 2018 poll, and within the poll’s margin of error.

Popularity for Medicare for All grew slightly among Democratic voters, with a 2 percentage point increase from 2018.

Support among independent voters was steady at 68 percent.

However, support among Republican voters declined 6 percentage points over the course of two years, from 52 percent support in 2018 to 46 percent in 2020.

Progressive lawmakers have been pointing to the coronavirus crisis to make a case for the need for Medicare for All as millions of Americans are kicked off their employee-based health insurance due to the economic fallout of the pandemic.

“Crises are moments of opportunity for policy change,” Robert Griffin, Research Director of the Democracy Fund Voter Study Group, told Hill.TV.

“But it’s not a sure thing, it’s not going to happen automatically. It does require leadership at the end of the day,” he added.

President and CEO of the Roosevelt Institute, Felicia Wong, believes support for Medicare for All will only grow amid the coronavirus crisis.

“These progressive policies have been popular for a long time. I think COVID-19 will make them more popular as it becomes clear just how fragile our American political economy really is,” Wong told Hill.TV.

https://thehill.com…

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Public Opinion on Single-Payer, National Health Plans, and Expanding Access to Medicare Coverage

KFF, April 3, 2020

Historically, our polls have shown support for the federal government doing more to help provide health insurance for more Americans, though support among Republicans has decreased over time. But this never translated into majority support for a national health plan in which all Americans would get their insurance from a single government plan until 2016.

As Medicare-for-all becomes a staple in national conversations around health care and people become aware of the details of any plan or hear arguments on either side, it is unclear how attitudes towards such a proposal may shift. KFF polling finds public support for Medicare-for-all shifts significantly when people hear arguments about potential tax increases or delays in medical tests and treatment. KFF polling found that when such a plan is described in terms of the trade-offs (higher taxes but lower out-of-pocket costs), the public is almost equally split in their support. KFF polling also shows many people falsely assume they would be able to keep their current health insurance under a single-payer plan, suggesting another potential area for decreased support especially since most supporters (67 percent) of such a proposal think they would be able to keep their current health insurance coverage.

KFF polling finds more Democrats and Democratic-leaning independents would prefer voting for a candidate who wants to build on the ACA in order to expand coverage and reduce costs rather than replace the ACA with a national Medicare-for-all plan. Additionally, KFF polling has found broader public support for more incremental changes to expand the public health insurance program in this country including proposals that expand the role of public programs like Medicare and Medicaid. And while partisans are divided on a Medicare-for-all national health plan, there is robust support among Democrats, and even support among over four in ten Republicans, for a government-run health plan, sometimes called a public option. Notably, the public does not perceive major differences in how a public option or a Medicare-for-all plan would impact taxes and personal health care costs. However, there are some differences in perceptions of how the proposals would impact those with private health insurance coverage. KFF polling in early April 2020 finds about half of Americans support both a Medicare-for-all plan and a public option. So while the general idea of a national health plan (whether accomplished through an expansion of Medicare or some other way) may enjoy fairly broad support in the abstract, it remains unclear how this issue will play out in the 2020 election and beyond.

https://www.kff.org…

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Comment:

By Don McCanne, M.D.

Two-thirds voter support of Medicare for All sounds quite good. Most politicians would consider two-thirds support to be a clear voter mandate. But Kaiser Foundation polling has found that when you qualify the question on Medicare for All, the support can shift depending on whether the qualification is perceived as favorable or unfavorable. Also, when single payer is presented as a ballot issue, simple rhetorical sound bites by opponents have been effective in defeating such proposals by wide margins.

It would be great if one of the pollsters finally asked a question that would better define the will of the nation:

Which would you prefer?

1. One single comprehensive health care program, that you would have for your entire life, that is guaranteed by our government, that covers all essential health care services, that would allow you to choose your physicians and other health care professionals and your hospitals and clinics, and that would always be affordable for you because it would be paid through taxes that are based on your ability to pay.

2. An unstable series of different forms of health care coverage throughout your life dependent on your employment (with ever-changing private plans, if coverage is even provided), poverty status (Medicaid, if qualified), age (Medicare for seniors), chronic disability or chronic renal disease (Medicare), ACA exchange plans (may qualify for government subsidies based on income), available health plans in the individual market (if premiums and cost sharing are affordable), military status (Military Health System), veteran status (VA Health Care, if qualified), Native American status (Indian Health Service, if qualified), incarceration (prison health care), child (CHIP or Medicaid, depending on family income), temporary coverage between jobs (COBRA, if premiums are affordable), health savings account (if funded), retiree health plan (if provided in whole or in part by a prior employer), uninsured (full personal risk-bearing), charity (perhaps nominal fees in a community health center), or self funded (if adequate personal wealth); with coverage that is highly variable dependent on the program in which you may be enrolled, in which your choice of physicians and hospitals is limited by provider networks selected by the insurers, or providers employed by various private or government programs (such as those listed), and affordability would be dependent on premiums, deductibles, copayments, coinsurance, concierge fees, and income levels that establish eligibility for various programs; with no assurance that any particular program will be there for you when you need it.

3. “Healthcare Reform to Make America Great Again.” Proposed reforms include repealing the Affordable Care Act, allowing individuals to deduct the full amount of premiums for individual health plans from their federal tax returns, providing block grants to finance state Medicaid programs, and allowing insurers to sell insurance across state lines.

https://www.commonwealthfund.org…

4. Leave the system as it is (select #2).

It is difficult for individuals to grasp: 1) the simplicity, effectiveness, efficiency, ethics and affordability of the single payer model of Medicare for All, 2) the complexity and injustices of the system that we have, and 3) the gross inadequacies of the Republican rhetorical proposal. It is sad that when the dialogue on reform is reduced to buzzwords, the nation tends to line up on the political polarization scale, perpetuating inertia, and then we all suffer, except the wealthy.

Can’t we just take #1, and go with it?

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

By Ed Silverman
STAT, April 24, 2020

Led by the World Health Organization, a long list of countries, industry groups, and nongovernmental organizations committed to joining a project for developing and producing new drugs, vaccines, and tests for Covid-19 — and ensure worldwide access to the products.

The orchestrated move, which is being called the Access to COVID-19 Tools Accelerator, comes as the pandemic has infected more than 2.7 million people and claimed approximately 191,000 lives, sparking urgent calls for global cooperation in devising a medical response.

As part of the effort, a key goal is to level the global playing field so that any products will be available to rich and poor populations alike, a contentious issue that for many years has often pitted low-income countries against the pharmaceutical industry, in particular.

“The world needs these tools, and it needs them fast,” remarked WHO Director-General Tedros Adhanom Ghebreyesus during a 90-minute presentation. “Past experience has taught us that even when tools are available, they have not been equally available to all. We cannot allow that to happen. … Our shared commitment is to ensure all people have access to all the tools to defeat Covid-19.”

Among those involved are France; Germany; the U.K.; Saudi Arabia; South Africa; Italy; Norway; Spain; Malaysia; the World Bank; the United Nations; the Bill and Melinda Gates Foundation; Unitaid; Wellcome Trust; the Global Fund to Fight AIDS, Tuberculosis and Malaria; Gavi, the Vaccine Alliance; Coalition for Epidemic Preparedness Innovations; and the International Federation of Pharmaceutical Manufacturers.

Two economic powers, however, were notably absent from the proceedings: the U.S. and China. The Trump administration recently announced plans to end its funding to the WHO over allegations that the global health agency was too close to China.

It remains unclear about the extent to which the project will include a so-called voluntary pool to collect patent rights, regulatory test data, and other information that could be shared for developing drugs, vaccines, and diagnostics.

Such a pool is likely to be regarded warily by the pharmaceutical industry, given questions that may arise about the structure of the pool.

This is not the only effort to attempt to harness the abilities of the pharmaceutical industry to come to the rescue. Last week, the National Institutes of Health on Friday announced it would launch a sweeping public-private partnership between federal researchers and 16 drug makers, aimed at coordinating and accelerating the development of Covid-19 treatments and vaccines.

To be sure, the pharmaceutical industry is facing increased pressure. More than three dozen asset managers, pension funds, and insurers are urging the pharmaceutical industry to cooperate in the fight against Covid-19 by sharing research data and providing affordable worldwide access to medicines, diagnostics, and vaccines.

Although reactions to the accelerator project were largely positive, skepticism remains. For instance, Frederick Abbott, a professor of international law at Florida State University and a WHO consultant, believes the effort holds potential, but questions over patent rights, marketing exclusivity, and compensation for innovative work need to be addressed for the concept to succeed.

“A high-level framework is important,” according to Brook Baker, a professor at Northeastern University School of Law, “but the call for global solidarity must actually trump commercial prerogatives, nationalism, and demagogic egos.”

https://www.statnews.com…

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U.S. says will not take part in WHO global drugs, vaccine initiative launch

By Stephanie Nebehay
Reuters, April 25, 2020

The United States will not take part in the launching of a global initiative on Friday to speed the development, production and distribution of drugs and vaccines against COVID-19, a spokesman for the U.S. mission in Geneva told Reuters.

“There will be no U.S. official participation”, he said in an email reply to a query.

U.S. President Donald Trump has announced a suspension of funding to the World Health Organization (WHO), where it is the largest donor. French President Emmanuel Macron and German Chancellor Angela Merkel helped launch the global initiative on Friday, the U.N. agency said.

https://uk.reuters.com…

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Comment:

By Don McCanne, M.D.

Talk about a time that we need to join together in international cooperation; we have a pandemic that has already caused over 200,000 deaths and economic disruption throughout the world. Shouldn’t the United States be stepping up to help out? At least some of us would think so. No. Instead, we walk, exercising “commercial prerogatives” and assuaging “demagogic egos.”

What kind of people have we become that we tolerate this?

It’s almost May 1.

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

The Americanization of Italian health care plays a part in the country’s disastrous coronavirus outbreak.

By Vale Disamistade
The Nation, April 14, 2020

Democratic and Republican pundits have no shortage of bogus talking points to discredit calls for Medicare for All.

A memorable recent incarnation of this effort came when Democratic nominee Joe Biden weaponized the Italian health care system—which has been besieged by one of the world’s most lethal outbreaks of Covid-19—against universal health care during the March 15 Democratic presidential debate. “With all due respect to Medicare for All,” he said, “you have a single-payer system in Italy. It doesn’t work there.”

There’s really nothing a European like me enjoys more than listening to US politicians rant about the mythic “endless lines” and inadequate levels of care we face in our single-payer systems.

Before moving to the United States, I had never once worried about accessing the health care I needed. As for our waiting lines, nothing compares to the struggle to find an American doctor that will simultaneously take new patients and accept my insurance, or the endless process of disputing inflated bills and going back and forth with the web of insurance companies and private-sector middlemen that are somehow involved at every stage of even a simple procedure.

Here’s what Biden’s comments completely elide: When Covid-19 reached Italian shores, it found a country in the midst of a private-sector transformation that has been turning the country’s single-payer health care system into an Italian version of Biden’s beloved “public option”—and putting millions of people at risk in the process.

The callous slashing of public funding undertaken by all Italian administrations since the 1990s and the parallel proliferation of private clinics have left the country with fewer health care personnel and hospital beds, and longer wait times.

To be sure, Italian authorities’ mistakes were legion. But these failures have very little to do with the public nature of the health care system, and very much to do with the fatal ingredient in the cocktail of tardy responsiveness and at-risk demographics: a decade of austerity policies. Since the turn of the century, and more aggressively after the global recession of 2008, the Servizio Sanitario Nazionale (SSN), Italy’s universal health care system, has undergone continuous spending cuts and rounds of privatization.

The “Americanization” of the SSN has been ongoing since the 1990s, when Italy joined the European Union. But the 2008 global financial crisis acted as an accelerator, and when the recession really hit the country in 2011.

The Piani di rientro, policies aimed at containing health care expenditure across the country, became the fundamental instrument through which the then-decentralized network of regional health care services could be re-centralized under the unifying agenda of austerity. These financial recovery plans put regions with high deficits under the scrutiny of the Ministry of Health and, for the first time, the Ministry of Finance—turning the delivery of health care into an issue of financial stability.

In concrete figures, these plans have amounted to the cutting of €37 billion from the SNN since 2010. Between 2008 and 2017, a hiring freeze led to a decrease of 42,800 health care personnel—particularly doctors and nurses.

A study published as recently as last month shows how between 2004 and 2014 these policies worked really well at reducing costs. They also had the “inadvertent” consequence of increasing the rate of “avoidable deaths” by 3 percent.

If there is anything to blame for this catastrophe other than the virus itself, ask an Italian. Many of us have been saying it all along: Austerity kills.

https://www.thenation.com…

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Comment:

By Don McCanne, M.D.

Italy’s lesson? Austerity kills.

Joe Biden says that Italy shows us that Medicare for All won’t work, yet freeing up a half trillion dollars in administrative waste by enacting and implementing single payer Medicare for All would go a very long way toward forestalling austerity in our health care system. Medicare for All will work.

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

By Peter V. Lee, Elliott S. Fisher, Kelly Green
Health Affairs Blog, April 20-21, 2020

One of the underlying principles of the Affordable Care Act of 2010 (ACA) is that public health is a public good. The landmark legislation dramatically changed how we view health care in the United States and brought meaningful health insurance coverage within reach of millions of Americans.

The nation made historic progress in reducing the number of uninsured Americans through sweeping reforms to Medicare, dramatic expansion of Medicaid, establishment of Marketplaces and subsidies in the individual market, and landmark health insurance market reforms. These were important achievements representing the biggest changes to coverage since the launch of Medicare and Medicaid more than 50 years ago. Serious challenges, however, remain. Concerns about health care affordability and access to needed services and health insurance coverage in the face of the COVID-19 pandemic are top of mind to consumers and voters across the nation. In addition, recent federal actions threaten to unravel some of the progress made, and there has been a resurgence of uninsurance in many states.

The experience of Covered California—California’s state-based Marketplace—shows that when the tools of the ACA are used effectively, progress is possible in coverage, affordability, quality, and delivery system improvement.

In a two-part blog post, we are highlighting the achievements, challenges, and lessons learned from California’s coverage expansion efforts and its Marketplace, Covered California. We believe these lessons are particularly relevant not only to the federal government and states, but to employers who are not effectively meeting the needs of many of the nearly 160 million Americans with employer-based coverage.

Lessons For Employer-Based Coverage

• Premium contributions and cost sharing should be adjusted based on employee income.
• Employers should promote benefit designs that are standardized and patient-centered.
• Employers should enable employees to shop for value.
• Employers should push for changes in underlying care delivery that will lower costs over the long term.

Looking Ahead

The Affordable Care Act enabled the nation to make great progress in expanding coverage. But, we cannot accept the progress made in California and other states as an end point. There is much more work to be done to enable millions more Americans to see their health care lives improve in the future. There are still 1.1 million uninsured Californians who are eligible to enroll through the Marketplace, Medi-Cal, or their employer—but are not now insured, whether by choice or due to lack of knowledge of what is available. Rising health care costs are a serious threat, and the affordability of health coverage and care remains a problem to many with and without coverage. Widespread racial and ethnic disparities remain largely unaddressed, as do marked variations in quality performance across plans and providers. On the delivery reform front, far too many enrollees continue to receive care in fragmented delivery models, subjecting them to lower quality and higher costs. These challenges are not unique to California and demonstrate intrinsic issues that states, the federal government, and employers need to work to resolve.

The current coronavirus epidemic poses perhaps the greatest threat to US health care in modern times, making predictions about future policy directions more challenging than ever. However, when policy makers consider the next round of health care reforms, we could well face a choice between a single-payer system that radically transforms the financing, coverage, organization, and delivery of care or more modest reforms that build on the current employer-based system. For the latter path to succeed, it will be important to take the lessons from the ACA and apply them to the employer sector. Otherwise, the next 10 years are likely to be marked by continued erosion in coverage and availability of care for the vast majority of Americans. In any future, however, dramatic changes will be necessary, so that all Americans can receive more financial help, have good benefits that bring value and quality, and experience a high-quality, cost-efficient care delivery system.

Part 1:
https://www.healthaffairs.org…

Part 2:
https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

California’s implementation of the Affordable Care Act was spectacularly successful, considering what they had to work with. Yet, because of the limitations of ACA, it has been a dismal failure when measured by the numbers who remain uninsured, by the lack of affordability of care for many of those who are insured, and by the perpetuation of the dysfunctions of the traditional American health care financing system.

As it turns out, the sector of health care coverage that supposedly was working so well – employer-sponsored health plans – frequently has not provided the protection that employees need. The authors do provide some suggestions for change, but they would have little impact since they are mere tweaks in a system that has fundamental design defects.

Buried in this two part analysis of California’s five year experiment with ACA is one sentence that says it all: “However, when policy makers consider the next round of health care reforms, we could well face a choice between a single-payer system that radically transforms the financing, coverage, organization, and delivery of care or more modest reforms that build on the current employer-based system.”

Modest reforms of the highly flawed employer-based system does not cut it, whereas enactment of a single payer improved Medicare for All is precisely what we need. Just read that one sentence and you can skip the rest. See, it really is simple.

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By Rachel Fehr and Cynthia Cox
KFF, April 17, 2020

The Medical Loss Ratio (or MLR) requirement of the Affordable Care Act (ACA) limits the portion of premium dollars health insurers may use for administration, marketing, and profits. Under the ACA, health insurers must publicly report the portion of premium dollars spent on health care and quality improvement and other activities in each state in which they operate.

The Medical Loss Ratio provision requires insurance companies that cover individuals and small businesses to spend at least 80% of their premium income on health care claims and quality improvement, leaving the remaining 20% for administration, marketing, and profit. The MLR threshold is higher for large group insured plans, which must spend at least 85% of premium dollars on health care and quality improvement. Insurers failing to meet the applicable MLR standard have been required to pay rebates to consumers since 2012 (based on their 2011 experience). Currently, MLR rebates are based on a 3-year average, meaning that 2020 rebates are calculated using insurers’ financial data in 2017, 2018, and 2019. Insurers may either issue rebates in the form of a premium credit or a check payment and, in the case of people with employer coverage, the rebate may be shared between the employer and the employee. Insurers will begin issuing rebates later this fall.

Using preliminary data reported by insurers to state regulators and compiled by Market Farrah Associates, we estimate insurers will be issuing a total of about $2.7 billion across all markets – nearly doubling the previous record high of $1.4 billion last year. The amount varies by market, with insurers reporting about $2 billion in the individual market, $348 million in the small group market, and $341 million in the large group market. These amounts are preliminary estimates, and final rebate data will be available later this year.

Insurers in the individual market in 2018 and 2019 are driving this record-high year of MLR rebates in 2020. Rebates issued in 2020 are based on 2017, 2018, and 2019 financial performance. As our previous analysis of insurer financial performance found, in 2017 financial performance in the market had begun to stabilize as premiums rose. Insurers in 2018 were highly profitable and arguably overpriced. In 2019, despite the absence of the individual mandate penalty and premiums dropping a bit on average, insurers continued to perform strongly. On average, insurer loss ratios (the share of premium income paid out as claims) in the individual market in 2019 were 79%. (This is a simple loss ratio; the ACA allows insurers to make some adjustments to this ratio when calculating rebates).

Rebates in the small and large group markets are more similar to past years.

As more people are expected to move into the individual market this year after losing job-based coverage, it is worth considering the possibility of future rebates based on the 2020 calendar year. The cost to insurers for covering coronavirus treatment are still unknown, but could be tens if not hundreds of billions of dollars. That said, hospitals and outpatient offices are canceling elective procedures and individuals are delaying or forgoing other care due to lessened access from social distancing measures and concerns over contracting the virus. Even if individual market insurers experience losses in 2020, it is entirely possible they will owe rebates in 2021 because those rebates will be based on 2018 and 2019 experience as well.

These high rebate estimates come at a time when insurers are working on submissions to regulators for proposed premiums for 2021, in the midst of significant uncertainty about how the coronavirus pandemic will affect health care costs. For 2021 premiums, key factors will include how many people are expected to become infected and severely ill next year, as well as how much pent up demand there may be for care delayed this year. Enrollment in individual market plans is expected to increase as millions of people lose their jobs and health insurance and qualify for a special enrollment period, but these new enrollees will not qualify for rebates when they are paid out in 2020 unless they were also enrolled at some point in 2019.

https://www.kff.org…

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Comment:

By Don McCanne, M.D.

At the time that the Affordable Care Act was crafted, it was realized that, since private insurance coverage would be mandated for a large sector of the population, the private insurers would have essentially a blank check to gouge as much as the traffic would bear. Thus it was decided that a minimum medical loss ratio would need to be established; that is, the insurers would be required to pay out at least 80 percent of their premium revenues in the form of medical benefits for those enrolled in their individual or small group plans and 85 percent for their large group plans. (They were also allowed to count “quality improvement” programs as a medical loss, though some of us feel that they should really be considered administrative and advertising expenses, but we won’t cover that here.)

The point is that private insurers are allowed to keep 15 to 20 percent of premium revenues to be used to cover administrative services (the actual product that they are selling us) and profits. This has made the private for-profit insurers the darlings of Wall Street considering their high profit margins plus the increased market value of their stocks.

If the insurers end up paying out less in benefits than the required amount, then they have to refund the difference. But that is not such a bad deal for them. That way they can be sure that they received the maximum profit allowable, whereas if they paid out more in benefits than required, they would draw down their profit margins. Also, with extra funds under their control, they have more which they can use to work the float (invest the excess funds in order to increase their profits). Granting premium refunds with extra funds is certainly better for them than absorbing greater losses.

Under the ACA medical loss ratios of 80 to 85 percent, the private insurers can spend 15 to 20 percent on overhead and profits. Under Medicare, administrative costs are about 2 percent and profits are not a category in the Medicare budget. That means that Medicare has what would be a medical loss ratio of about 98 percent. That is desirable since that means the funds are being spent on patient care.

Another point. Insurers usually report their profits as a percentage of their entire premium revenues. If you consider that most of their premium revenues are our funds that they are merely holding in trust to pay out future health benefits, then the real product they are selling us is their administrative services. If you count the profits they retain as a percentage of their administrative services, then they have an egregiously outrageous profit margin. (Bank investors are much more concerned about their return on equity than their return on assets – other peoples’ money that they hold in trust.)

The medical loss ratio game is simply one more reason that we should reject private insurers and replace our current dysfunctional health care financing system with a single payer program of Medicare for All. We would each be paying in our equitable contribution based on what we could afford, and the funds would be going where they should be going – taking care of our health. What gall it takes to keep in place an industry that thinks it is a loss to invest in our health.

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