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Surprise medical bills, coronavirus and bad insurance: 3 arguments for Medicare for All

Surprise medical bills, coronavirus and bad insurance: 3 arguments for Medicare for All

Americans aren't just worried about contracting the coronavirus. They're worried about how they'd pay for it and other unexpected health expenses.

By Philip A. Verhoef, M.D.
USA Today, March 9, 2020

Congress is grappling with the problem of surprise medical bills, but will its Band-Aid approaches make a difference? As a physician, I’m trained to look beyond superficial symptoms to diagnose the underlying ailment. When patients pay thousands of dollars each year for “good” private insurance, how does a health care system allow them to walk away from a single hospital visit with debilitating medical debt? These concerns have become even more pressing with the spread of the new coronavirus and the costs associated with prevention, testing and treatment.

Most Americans assume that a commercial insurance card in their wallet protects them from unexpected medical bills. They pay their premiums and deductibles, scour the pages of insurance fine print and keep up with the revolving door of “in-network” doctors and hospitals.

However, going to the “in-network” hospital is no guarantee that the emergency room doctor, radiologist or anesthesiologist will be “in-network.” Today, many hospitals no longer directly employ physicians but instead contract with physician staffing firms such as TeamHealth, which employs more than 16,000 clinicians at 3,300 medical facilities.

Caught unaware in a medical crisis

These agencies are extremely profitable, which is why private equity firms are so hungry to buy them. Contract physicians operate outside of insurance coverage agreements — they’re not part of any “network” — and can act like free agents, billing patients directly for services not covered by insurance, called “balance billing.”

What does this mean for patients? Imagine you’re having a heart attack and call 911. Paramedics transport you to the nearest emergency room, which may or may not be in your insurer’s network. And because that hospital — or the ER doctor on duty —  does not have a contractual relationship with your insurer, they can essentially name their price and “balance bill” you for the amount the insurance company won’t cover.

Here in Hawaii, many critically ill patients must use air ambulances for transportation from their home island to one that can provide emergency specialty services. For one of my patients, an air ambulance was a life-or-death necessity but deemed “out of network” by their insurance. Weeks later, the family received a balance bill for more than $25,000. They were forced to file bankruptcy and then enroll in Medicaid to cover subsequent health care costs — all with an insurance card in their wallet.

If this hasn’t happened to you, it’s just a matter of time. Over 40% of privately insured patients face surprise medical bills after visiting emergency rooms or getting admitted to hospitals. These bills punch a major hole in most family budgets: The average surprise hospital bill is $628 for emergency care and $2,040 for inpatient admission. That’s on top of the more than $20,000families pay in premiums and deductibles each year just for the insurance policy.

If faced with a surprise $500 medical bill, half of Americans would either have to borrow money, go into debt or wouldn’t be able to pay it at all. Medical bills are a key contributor in two-thirds of personal bankruptcies, and yet the vast majority of households filing for medical bankruptcy have insurance.

Medicare for All is the only solution

What is the value of commercial insurance if it can’t protect us from financial ruin?

Lawmakers are considering a number of policies that would prohibit balance billing, cap the amount patients pay at out-of-network facilities and implement baseball-style arbitration when providers and insurance companies can’t agree on a payment. But surprise bills are not the real problem — they are merely one symptom of a dysfunctional system based on private insurance. And insurance companies only turn a profit by restricting patient choice, denying claims and passing costs onto enrollees.

The only policy that can end this scourge for good is single-payer Medicare for All, which would cover everyone in the nation for all medically necessary care. Medicare for All would eliminate out-of-network bills, because every doctor and hospital would be covered. Patients would never see a medical bill again, because Medicare for All would pay doctors and hospitals directly, with no deductibles, co-pays or insurance paperwork to get in the way.

Right now the current Medicare system is covering the costs of coronavirus testing, protecting patients just as it was designed to do. This health emergency is another argument for expanding such protections to all Americans.

Working in various hospitals across the country, I have met so many patients who delay or avoid needed care for fear of surprise bills and financial catastrophe. That’s risky for them and, in the face of a threat like coronavirus, for all of us. It doesn’t have to be this way. As a doctor, I prescribe Medicare for All.

Dr. Philip A. Verhoef is an intensive care unit physician in Honolulu, Hawaii. Follow him on Twitter: @DrPhilipVerhoef.

https://www.usatoday.com…

Cost realities of the health care status quo

By Elizabeth Andes, M.D.
The Kansas City Star, Letters, March 8, 2020

Voters have an opportunity to cast votes for presidential candidates with very different solutions to the American health care crisis. Poll after poll show that most voters’ top priority in this election is the cost of health care. This makes sense, given that American health care costs twice that of nations with universal care, while health insurance, pharmaceutical and hospital companies reap huge profits.

The Affordable Care Act included many important improvements, but sidestepped the fundamental drivers of our crisis. Prescription drug coverage through Medicare Part D has been a bonanza for Big Pharma, but it included no provisions for reining in costs and profits.

At a time when 68,000 American lives are lost every year from a lack of health care, we can no longer support outrageous corporate profits over people. Opponents of “Medicare for all” ask how we can afford it. A recent study in The Lancet revealed that such a program would reduce costs by 13%.

We can’t afford our current wasteful system of overhead, profit and greed. Only universal coverage can ensure that the United States doesn’t continue to rank dead last among 17 industrialized nations in life expectancy and other health outcomes.

Dr. Elizabeth Andes is the chair of the Kansas City Metro Chapter of Physicians for a National Health Program.

Canadians are happy with their single-payer system

By Jay D. Brock, M.D.
The Free Lance-Star (Fredericksburg, Va.), March 7, 2020

There’s a reason why Canadians love their Single Payer Health Insurance System more than hockey, while our health insurance industry is about as popular as the telemarketing industry.

We all see the costs increase beyond our control, and wonder where and how it will end. We all hear or worry about the denials of care. Or seethe when our health insurance company takes away our choice of physician.

What’s going on?

Blame the health insurance industry upon which our health insurance system is based. Its business model is to take in as many of our healthcare dollars as possible, but spend as few of them on our healthcare as it can get away with—the classic definition of a wasteful middleman. This is a system built with the health of the insurance industry— not our health—in mind.

No wonder Single Payer Medicare for All, gaining in popularity, has health insurance CEO’s so worried.

Especially since “Waste” should be our system’s middle name. Our healthcare costs become increasingly unaffordable because the system manages to spend hundreds of billions of our healthcare dollars on administrative and other costs that have nothing to do with our health and everything to do with building a bigger medical bureaucracy.

The waste is staggering indeed—a top medical journal, “The Lancet”, just published a major article revealing that a Single Payer Medicare for All would not only cover everyone and do it without any additional out of pocket costs for us, it would also save $450 billion and 68,000 lives a year—lives now lost because too many of us cannot afford timely medical care.

Critics who complain that the Canadian system, like any system,  has its problems, ignore that it spends much less than we do. Sadly, these critics neglect to mention that when we switch to a Single Payer, money now wasted on those administrative costs would go to our healthcare, and there would then be enough money to cover everyone’s care—and do it without any additional out of pocket costs— while covering some aspects of care Canadians can only dream about, including medications and even nursing home care.

Please note that Single Payer Medicare for All doesn’t change our healthcare delivery system—rightly the envy of the world—it changes how we fund and pay for it. So increased wait times for getting appointments, especially elective procedures, largely a function of how much money is in the system, and not the system itself, should not be a problem. (If some of the hundreds of billions saved with M4A is spent on educating more doctors and nurses, wait times for all should even improve compared to now.)

Despite what critics claim, the average American will see their take-home pay go up—and their healthcare costs go down. Economists have told us that the vast majority of Americans, perhaps as many as 95% of us, would come out ahead.

Can the country afford M4A?

Absolutely.

We already put enough money into healthcare to pay for it, but with all the waste we just don’t spend it wisely.

What we can cannot afford is the current system, with its waste of money—and lives—that should be an affront to the family values of every American.

As every other modern nation spends half of what we spend while providing robust insurance to their entire country it offends my sense of pride in the United States to hear someone throw up their hands, abandon the American Dream, and claim that we are not able to do at least as well as they can. And our proof point is Medicare. For more than 50 years, Medicare has rescued American seniors from poverty, extended their lives, and provided them with access to nearly every physician and hospital.

Medicare for All seeks to improve Medicare, make it truly affordable, and extend it to all.

In the end, the decision will be about what’s more important—maintaining our family’s health with a truly fair and affordable Single Payer Medicare for All, or maintaining the current system.

I choose my family.

I hope you do too.

Dr. Jay D. Brock, a family medicine physician, lives in Fredericksburg.

https://www.fredericksburg.com…

Doctors and dark money: A bad prescription for health care reform

By Augie W. Lindmark, M.D., Micah A. Johnson, and Alec M. Feuerbach
Medscape, March 6, 2020

As Democratic presidential candidates continue to debate health reform, a multi-million dollar advertising campaign aims to sway voters against any expansion of Medicare. Behind that campaign is a coalition of 115 health care industry groups including insurers, hospitals, drug companies – and physicians.

The ads that have run during Democratic debates are paid for by the Partnership for America’s Health Care Future, a group formed in 2018 with a seemingly benign goal: “improve what’s working in health care and fix what’s not.” Leaked documents, however, reveal the Partnership is focused on the more specific goal of blocking Medicare for All, Medicare Buy-In, and public option plans.

The American Medical Association was a notable founding member of the Partnership, and as physicians and medical students, we were troubled that medicine’s largest professional body would join a dark money lobbying group. Others in the profession shared our concern and organized protests at the AMA annual meeting last summer in Chicago. After mounting pressure—and just two months after the summer protests—the AMA did the right thing: it quit the Partnership. Doctors, we hoped, would play an honest and constructive role in the next wave of health reform debates.

Unfortunately, the AMA was not the only physician group in the Partnership. Other members listed on the group’s website include the American College of Radiology, the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, and the Virginia Orthopaedic Society. We believe these organizations should follow the AMA and exit the Partnership—and all doctors’ groups should avoid such deceptive efforts in the future.

It is inevitable that doctors will hold diverse views about health care reform, but physicians should adhere to professional standards such as disclosing financial conflicts of interest and presenting evidence truthfully. Simply put, we believe the tactics of the Partnership for America’s Health Care Future are incompatible with these standards.

To understand the problem of the Partnership, it helps to examine both their interests and actions. To block Medicare expansion, the group has launched a multi-year strategy (containing at least 17 initiatives) aimed at influencing the national health reform debate, including their deep-pocketed advertising campaign.

One ad aired during the South Carolina Democratic debate showed a mother at her child’s basketball practice warning about “new government-controlled health insurance.” Another ad warns that a “one-size-fits-all” government health insurance program could force 55% of rural hospitals to close.

When the public hears a message denouncing the expansion of public health insurance, they deserve to know that a private insurance trade group sponsors that message. But from Facebook ads to YouTube videos to television ads, the Partnership relies on its nondescript name and does not disclose the identity of its member groups. This provides a convenient avenue for industry groups to simultaneously influence public opinion and obscure their own financial interests.

This was evident when the group spent nearly $300,000 in South Carolina in advance of that state’s primary, and more than $900,000 in Virginia leading up to Super Tuesday on March 3. Last summer, the Partnership bought half of all political advertising in Iowa—re-upping their investment to $1.2 million before the Iowa caucuses. As a dark money organization the Partnership does not disclose its funding sources, but its member groups are clearly big spenders: they spent $143 million lobbying Congress in 2018.

And it’s not just advertisements. In December, the Washington Post reported a series of email exchanges that suggest lobbyists affiliated with the Partnership had drafted significant portions of op-eds published by state lawmakers attacking proposals to expand Medicare. Upon publication, there was no mention of the Partnership, leaving readers unaware of the industry role in crafting these messages.

The Partnership also actively promotes misinformation. For instance, one advertisement states that “Medicare for All, Medicare Buy-In, and a public option all mean the same thing: you’d pay more to wait longer for worse care.”

This message is misleading in numerous ways. First, a public option is vastly different from Medicare for All: one proposal could add a public plan to the Affordable Care Act Marketplace while leaving the rest of the insurance system intact and the other would transition all Americans into a version of Medicare.

Furthermore, the Partnership’s claim that Americans would “pay more” under these reforms is contradicted by Congressional Budget Office (CBO) findings that a public option would have lower premiums than private insurance. Similarly, when asked about Medicare for All during a Congressional hearing, the Deputy Director of the CBO indicated that many middle- and low-income people could pay less for Medicare for All than they currently pay for their employer-sponsored insurance, largely because a public insurance system can be financed progressively.

Instead of pouring money into such campaigns of misinformation, doctors should present evidence truthfully. But the American College of Radiology “has committed extensive resources to the Partnership’s goal,” including a $300,000 grant to the Partnership around the time of its inception. Supporting misinformation campaigns seems to violate not only an established norm of the medical profession, but also the ACR’s own bylaws that state: “Members should not publicize themselves through any medium or forum of public communication in an untruthful, misleading, or deceptive manner.”

Physicians should play an honest and constructive role in the health reform debate, and uphold the values of the medical profession when entering the public arena. Physician groups should not participate in a dark-money lobbying organization that promotes misleading information and obscures significant conflicts of interest. The Partnership for America’s Health Care Future is a bad prescription for health reform, and doctors should stay away.

https://www.medscape.com…

HHS’s zero tolerance for children (er, something like that)

Communication and Management Challenges Impeded HHS's Response to the Zero-Tolerance Policy

U.S. Department of Health and Human Services, Office of Inspector General, March 2020

Why we did this study

In spring 2018, the Department of Justice and Department of Homeland Security (DHS) adopted a zero-tolerance policy under which large numbers of families entering the United States without authorization were separated by DHS. Typically, adults were held in Federal detention while their children were placed in Department of Health and Human Services (HHS) custody and provided care through the Unaccompanied Alien Children (UAC) Program. A Federal district court subsequently ordered the Federal Government to reunify separated families who met certain criteria. Given the impact of the zero-tolerance policy on vulnerable children and families, OIG conducted this review to examine challenges that HHS faced in responding to the zero-tolerance policy and carrying out the reunification effort.

How we did this study

This report synthesizes information from interviews with, and written responses from, senior HHS officials and HHS staff; interviews with staff at 45 HHS-funded care provider facilities under the UAC Program; case reviews for a purposive sample of separated children; and more than 5,000 documents obtained through requests to the Department, from facility staff, and from interview respondents. We analyzed interview and documentary data to identify significant challenges that HHS and facilities faced in responding to the zero-tolerance policy and reunifying separated children, as well as factors that contributed to those challenges.

What we found

Interagency channels for coordinating immigration policy across Federal departments were not used to notify HHS of the zero-tolerance policy in advance. Meanwhile, key senior HHS officials did not act on staff’s repeated warnings that family separations were occurring and might increase. HHS’s lack of planning for the possibility of larger-scale family separation left the Department unable to provide prompt and appropriate care for separated children when the zero-tolerance policy was implemented. Further, because no procedures or systems had been established to track separated families across HHS and DHS for later reunification, HHS struggled to identify separated children. Additionally, care provider facilities faced significant operational challenges at every stage of the reunification process, complicated by poorly-communicated guidance from HHS. Finally, HHS has taken steps to improve tracking of separated children, but the procedures include manual processes that are vulnerable to error.

What we recommend

HHS should take steps to ensure that children’s interests are prioritized and represented in decisions affecting the UAC Program, both internally and when engaging with interagency partners. HHS should also modify or pursue formal agreements with DHS and DOJ to ensure that it is receiving information that supports its operation of and ability to provide care for children in the UAC Program. Additionally, HHS should improve communication to care provider facilities regarding interim guidance, operational directives, and other instructions that are not immediately available in published policy documents. Finally, HHS should further improve its ability to identify and track separated children by reducing reliance on manual processes.

https://oig.hhs.gov…

Complete report (70 pages):
https://oig.hhs.gov…

HHS was unprepared for Trump family separation policy, watchdog says

By Nathaniel Weixel
The Hill, March 5, 2020

Poor communication and internal management decisions left the Department of Health and Human Services (HHS) ill-prepared to respond to the Trump administration’s “zero tolerance” policy of family separations, according to an internal watchdog report released Thursday.

The report from HHS’s Office of Inspector General paints a picture of an agency caught off guard and struggling to catch up with its response. The lack of preparation hurt the agency’s ability to identify, care for and ultimately reunite children who had been separated from their parents.

According to the inspector general, senior HHS officials had no idea the family separation policy was being implemented by the departments of Justice and Homeland Security until they learned about it from media reports.

The lack of planning for large-scale separations also resulted in the agency being unable to provide “prompt and appropriate care” for separated children.

It created a lack of available bed space, leaving hundreds of children inappropriately detained in Department of Homeland Security (DHS) custody, instead of with HHS.

And at the same time, the report found that warnings from staff were ignored. Key senior officials with HHS’s Administration for Children and Families (ACF) “did not act on staff’s repeated warnings that family separations were occurring and might increase,” the report said.

According to the report, “no procedures or systems had been established to track separated families across HHS and DHS for later reunification.”

The official policy resulted in about 2,700 children being separated from their parents over a six-week period in the spring of 2018.

Last fall, the ACLU said that an additional 1,500 children were separated than previously disclosed, bringing the tally to more than 4,000 from the roughly 2,700 children previously known to have been separated that year.

https://thehill.com…

Comment:

By Don McCanne, M.D.

No, this report is not about single payer Medicare for All, but rather it is about a program initiated by a government that the people elected to implement important public programs.

In this instance, after Donald Trump was elected president, he instituted aggressive immigration policies that included forcibly separating immigrant children from their parents. Without adequate preparation or management, the children were transferred from the Department of Homeland Security to the Department of Health and Human Services – an agency that should certainly be sensitive to the physical and emotional needs of children. The report does indicate that they were successful in inducing protracted periods of crying amongst the children – therapeutic emotional venting, I suppose.

We have observed this administration’s management of other government health programs, including its attack on the provisions of the Affordable Care Act. Can you imagine what their approach might be if we already had a single payer model of Medicare for All up and running? Elections do matter.

As a democracy, we can change the political culture by becoming well informed on the policies supported by the various political candidates, and then by carefully casting our votes appropriately. But instead of selecting a candidate who is empirically perceived as having the best chance of displacing a bogeyman, we should choose a candidate based on support of public policies that would serve America best.

In the meantime, to help bring an end to our nation’s cruel immigration policies, we should consider placing Stephen Miller in a cage for the duration of Trump’s term, maybe along with the humane gesture of supplying him with a crying towel.

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

Transitional job churn is a benefit of Medicare for All

Fundamental health reform like ‘Medicare for All’ would help the labor market

Job loss claims are misleading, and substantial boosts to job quality are often overlooked

By Josh Bivens
Economic Policy Institute, March 5, 2020

Fundamental health reform like “Medicare for All” would be a hugely ambitious policy undertaking with profound effects on the economy and the economic security of households in America. But despite oft-repeated claims of large-scale job losses, a national program that would guarantee health insurance for every American would not profoundly affect the total number of jobs in the U.S. economy. In fact, such reform could boost wages and jobs and lead to more efficient labor markets that better match jobs and workers. Specifically, it could:

  • Boost wages and salaries by allowing employers to redirect money they are spending on health care costs to their workers’ wages.
  • Increase job quality by ensuring that every job now comes bundled with a guarantee of health care—with the boost to job quality even greater among women workers, who are less likely to have employer-sponsored health care.
  • Lessen the stress and economic shock of losing a job or moving between jobs by eliminating the loss of health care that now accompanies job losses and transitions.
  • Support self-employment and small business development—which is currently super low in the U.S. relative to other rich countries—by eliminating the daunting loss of/cost of health care from startup costs.
  • Inject new dynamism and adaptability into the overall economy by reducing “job lock”—with workers going where their skills and preferences best fit the job, not just to workplaces (usually large ones) that have affordable health plans.
  • Produce a net increase in jobs as public spending boosts aggregate demand, with job losses in health insurance and billing administration being outweighed by job gains in provision of health care, including the expansion of long-term care.

The upshot: M4A creates a small amount of manageable churn but increases the overall demand for labor and boosts job quality.

The job challenge relating to a fundamental health reform is managing a relatively small increase in job churn during an initial phase-in period. Most Medicare for All plans explicitly recognize and account for the costs of providing these workers the elements of a just transition. This sort of just transition is far easier when health care is universally provided.

Besides this challenge, the effect of fundamental reform like M4A on the labor market would be nearly uniformly positive. The effect of a fundamental reform like M4A on aggregate demand is almost certainly positive and will therefore boost the demand for labor. The number of jobs spurred by increased demand for new health care spending (including long-term care) will certainly be larger than the number displaced by realizing efficiencies in the health insurance and billing administration sectors.

Finally, the introduction of fundamental health reform like M4A—particularly reform that substantially delinks health care provision from specific jobs—would greatly aid how the labor market functions for typical working Americans. Take-home cash pay would increase, job quality would improve, labor market transitions could be eased for employers and made less damaging to workers, and a greater range of job opportunities could be considered by workers. The increased flexibility to leave jobs should lead to more productive “matches” between workers and employers, and small businesses and self-employment could increase.

Fundamental health reform would benefit typical American families in all sorts of ways. Importantly, contrary to claims that such reform might be bad for jobs, this reform could substantially improve how labor markets function for these families.

https://www.epi.org…

Full report (13 page PDF):
https://www.epi.org…

Comment:

By Don McCanne, M.D.

We frequently hear about the economic catastrophe that would occur if we wiped out employment in the private health insurance industry. But is that true?

This important report by Josh Bevins of the Economic Policy Institute describes the tremendous societal benefit from moving those jobs to more productive sectors while eliminating job-lock, giving individuals much more freedom in choosing their occupations, including more options for self-employment and small business development. The gain in employment in the health care delivery system should provide greater job satisfaction because you are helping people with their health care needs rather than being stuck in an administrative occupation in an industry that profits by reducing patient access to health care – not exactly a job that generates pride in your work.

This report should be downloaded to be used in your advocacy work for health care reform. The health insurance industry job loss that people worry about is far more than offset by the beneficial impacts of this transitional job churn. Not only would everyone have affordable health care though single payer Medicare for All, society will also benefit from the positive effects on the labor market.

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

Dr. James Cowan on “Health Insurance 101”

PNHP Rhode Island vice president Dr. James Cowan gave a “Health Insurance 101” talk at the Lifelong Learning Collaborative’s Spring 2020 Convocation on March 5, 2020. He argued that our current health care financing arrangements funnel massive amounts of both capital and labor into unproductive sinkholes, to the detriment of the entire U.S. economy.

Dr. Steffie Woolhandler on “Democracy Now”

PNHP co-founder Dr. Steffie Woolhandler appeared on “Democracy Now” on March 5, 2020. She discussed coronavirus as a prime example of why the United States needs a single-payer national health program. Improved Medicare for All would eliminate many of the barriers that prevent people from seeking medical care, including lack of insurance and high copayments.

Health Insurance Stocks Are the Real Super Tuesday Winners

Interview with Dr. James Kahn

Background Briefing with Ian Masters, March 5, 2020

With Barron’s reporting that health insurance stocks were the real Super Tuesday winners as shares in United Health Group went up 8.9% Wednesday, Cigna climbed 7.3%, and Anthem gained 8.8%, Ian Masters spoke with Dr. James Kahn, emeritus professor at the Institute for Global Health Policy Studies in the Department of Epidemiology and Biostatistics and the Institute for Global Health Sciences at the University of California San Francisco.

Dr. Kahn discussed where Medicare For All stands and whether a gradual approach building on the ACA with a public option would be a viable alternative (spoiler alert: the answer is “no”).

https://soundcloud.com…

How Civil Rights Legislation Helped Birth Medicare

Interview with Drs. Corinne Frugoni and Susan Rogers

Jefferson Public Radio, The Jefferson Exchange, March 4, 2020

The term “Medicare for all” is getting a workout in the presidential campaign. People sometimes forget there was Medicare for none until 1965, and it took a big battle to get the program through Congress.

Note that 1965 was also the year of the Voting Rights Act, a companion to the Civil Rights Act of a year before.  Medicare played a part in integrating American medicine, a story covered by the documentary film “The Power to Heal:  Medicare and the Civil Rights Revolution.”

It will screen in Arcata on Saturday (March 7th), sponsored by Black Humboldt, Health Care For All-California, and Physicians for a National Health Program.

PNHP President-Elect Dr. Susan Rogers and Humboldt County physician Dr. Corinne Frugoni are the guests.

full audio:
https://www.ijpr.org…

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!

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