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…

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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.

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…

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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.

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

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…

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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…

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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…

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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…

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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…

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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…

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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…

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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…

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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…

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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…

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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…

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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…

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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…

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Comment:

By Don McCanne, M.D.

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

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

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

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

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

I opened with the following questions directed to the audience:

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

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

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

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

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

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

Sheer madness!

https://pnhp.org…

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

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

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

Abstract

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

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

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

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

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

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

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

From the Discussion

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

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

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

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

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

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

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

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

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