By Shelby Livingston
Modern Healthcare, February 18, 2020

The largest publicly traded health insurers grew profits by a combined 66% in 2019, driven by the massive mergers and acquisitions several of them completed the year before.

Those deals boosted the group of seven companies’ collective net income to $35.6 billion, according to Modern Healthcare’s analysis of company earnings reports. Combined revenue increased 31% over 2018 to $913 billion.

The combined growth of the companies’ top and bottom lines was propelled by deals with businesses other than insurance, including pharmacies and pharmacy benefit managers. These deals, which have escalated in recent years as insurers have sought to exert more control over healthcare spending, have made it harder to categorize the companies as insurers. Their operations are becoming much more varied.

“There are so many places where costs come from—the PBM, the hospital, the doctor’s office—and everything is separate from each other. The vertical integration is an attempt to control more pieces of the cost while also growing scale,” said Deep Banerjee, an insurance industry analyst with S&P Global.

Even insurers are reluctant to label themselves as such as they branch out into new businesses. Cigna Corp. CEO David Cordani has said he prefers the organization to be known as a “health service company.” Cigna acquired pharmacy benefit manager Express Scripts at the end of 2018.

The analysis of financial results included Anthem, Centene Corp., Cigna, CVS Health, Humana, Molina Healthcare and UnitedHealth Group.

The seven companies’ combined medical membership grew 1.7% to $165.4 million.

https://www.modernhealthcare.com…

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Comment:

By Don McCanne, M.D.

Those of us who have been working hard to try to make our very expensive health care system work well for everyone should take a breather and step back and look at what has been happening to the business structure of our health care delivery system.

Seven investor-owned publicly traded health insurers now control almost a trillion dollars of our health care spending. They are expanding beyond the role of insurance and becoming “health service companies.” In the last year their revenue increased by 31% whereas their profits increased at double that rate: 66%! Their combined membership is 165 million – half of the U.S. population. Seven Wall Street companies!

Buried in our agenda for improving the health financing system to make it work well for all of us is the removal of passive investors – shareholders – from the health care financing equation since the primary obligation of publicly traded corporations is to maximize profits for the shareholders even if doing do is not in the interests of patients.

Fantasize that we elect a president and a Congress that finally has an epiphany recognizing that we must enact a single payer model of an improved Medicare for All. Okay, now turn around and implement it, starting with taking control of the financing of the medical-industrial complex now controlled largely by Wall Street corporations. How on earth are we going to drain that swamp?

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

By Cheryl Clark
MedPage Today, December 3, 2019

Like many of the 22 million seniors now enrolled in Medicare Advantage (MA) plans, Tom Mills belatedly discovered its dirty little secret.

Also called Part C, these plans can cover a broad array of health services at low cost — that is, until one gets sick, at which point out-of-pocket costs can soar. But once in an MA plan, getting out can be even less affordable.

After Mills underwent a mitral valve repair and suffered a mild stroke with no lasting effects, the San Diego resident’s plan now charges him hundreds of dollars in monthly copays for drugs and other medical services. He had to pay $295 a night for his hospital stay.

But there was a much bigger shock. Mills, 71, learned that switching out of his MA plan will incur exorbitantly higher costs the next time he needs a serious medical intervention. If he moves to traditional Medicare and a prescription plan, he still needs a supplemental Medigap plan to pick up his 20% copays and deductibles.

Though the retired environmental geologist is training for his 57th half marathon, he now has a pre-existing condition. Medigap plans in all but four states (CT, MA, ME, NY) can and do reject people like him or require prohibitively higher premiums. Diabetes, heart disease, or even a knee replacement can be criteria for exclusion.

A health insurance broker told him no supplemental plan would cover him, and he’d be wasting his time if he applied.

No one told him about this side of MA when he enrolled at age 65. “You hear the pros, but nobody lists the cons.”

‘Confusing’ Tools

Medicare.gov websites aren’t always clear about the process of transferring out of MA to traditional Medicare with a Medigap plan, but the general bottom line is that getting accepted by a Medigap plan is guaranteed only within the first 12 months after enrolling in Medicare at age 65.

MA plans, which are managed by private insurers, can be very complex, with the potential for substantial out-of-pocket costs when beneficiaries get sick played down. Medigap policies, which pay for many expenses not covered in basic Medicare, may cost more in monthly premiums up front, but once one is enrolled, premiums are set solely through “community rating” and beneficiaries’ age. New-onset health issues do not lead to premium increases.

The catch is that if one initially enrolls in an MA plan and then decides to switch out more than a year later, Medigap insurers will take into account the individual’s pre-existing conditions, and may decline coverage or demand high premiums.

The newly revised Medicare Plan Finder tool does not explain this possibility. Nor does another CMS website, “Join, switch, or drop a Medicare Advantage plan.”

A third Medicare.gov website, “When can I buy Medigap?” is more specific, explaining in the third section that “there’s no guarantee that an insurance company will sell you a Medigap policy if you don’t meet the medical underwriting requirements,” meaning the Medigap issuer’s stance on pre-existing conditions.

Yet another Medicare publication does explain that if beneficiaries enroll in a Medicare Advantage plan at age 65 and want to get out, they must do so within 1 year, and then they have another 63 days from the disenrollment date to buy a Medigap plan without risk of coverage denial or being subject to underwriting.

But many of these documents are full of terms unfamiliar to ordinary laypeople, (Consultant Bonnie) Burns pointed out. “Networks and copayments and formularies and uncovered costs and appeals and who knows about that stuff? That doesn’t happen until you get sick. No one understands their insurance coverage until they have to use it.”

Besides MA’s lack of transparency on costs, critics also cite problems with insurers’ provider networks.

AMA spokesman Robert Mills referenced a Kaiser Family Foundation report that found 35% of plans studied were served by a “narrow” physician network, meaning that fewer than 30% of the physicians in that county were contracted.

“Plans may purposefully understaff specialties to avoid attracting enrollees with expensive pre-existing conditions like cancer and mental illness,” he said.

David Lipschutz, an attorney with the Center for Medicare Advocacy in Washington, D.C., also hears about limitations. “It’s a common scenario,” he said. “Often you have to jump through certain hoops or over certain barriers to access care, or it’s subject to prior authorization.”

AARP spokesman Gregory Phillips responded: “AARP supports increasing access through guaranteed issue to Medigap coverage, in addition to eliminating medical underwriting and age rating, to ensure that older Americans will get the coverage they need when they need it most.”

And he agreed that many beneficiaries may not be aware that plans “may terminate their relationship with Medicare in any given year; change the premiums, cost-sharing charges, or benefits from year to year (including drug coverage); and drop physicians from their networks during the year.”

“Beneficiaries may also not be aware that if they want to voluntarily leave an MA plan and return to traditional fee-for-service Medicare, they may be subject to medical underwriting for a Medicare supplement (Medigap) policy. This underwriting may result in their being refused a policy or being required to pay higher rates.”

https://www.medpagetoday.com…

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When can I buy Medigap?

Medicare.gov

Buy a policy when you’re first eligible

The best time to buy a Medigap policy is during your 6-month Medigap open enrollment period. During that time you can buy any Medigap policy sold in your state, even if you have health problems. This period automatically starts the month you’re 65 and enrolled in Medicare Part B (Medical Insurance). After this enrollment period, you may not be able to buy a Medigap policy. If you’re able to buy one, it may cost more.

During open enrollment

Medigap insurance companies are generally allowed to use medical underwriting to decide whether to accept your application and how much to charge you for the Medigap policy. However, even if you have health problems, during your Medigap open enrollment period you can buy any policy the company sells for the same price as people with good health.

Outside open enrollment

If you apply for Medigap coverage after your open enrollment period, there’s no guarantee that an insurance company will sell you a Medigap policy if you don’t meet the medical underwriting requirements, unless you’re eligible due to one of the situations below (use link).

https://www.medicare.gov…

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2019 Choosing a Medigap Policy

Centers for Medicare and Medicaid Services

What if I decide to drop my entire Medigap policy (not just the Medigap prescription drug coverage) and join a Medicare Advantage Plan that offers prescription drug coverage?

In general, you can only join a Medicare Prescription Drug Plan or Medicare Advantage Plan (like an HMO or PPO) during the Medicare Open Enrollment Period between October 15 –December 7. If you join during Medicare Open Enrollment Period, your coverage will begin on January 1. In most cases, if you drop your Medigap policy to join a Medicare Advantage Plan, you won’t be able to get it back so pay careful attention to the timing.

This 52 page booklet has much more information about Medigap plans:
https://assets.documentcloud.org…

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Medicare and You, 2020

Section 5 discusses Medigap:
https://www.medicare.gov…

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Comment:

By Don McCanne, M.D.

The traditional Medicare program – Part A for hospital inpatient and Part B for physician and outpatient services – has significant cost sharing and gaps in benefits, and, most importantly, there is no limit on beneficiaries’ out-of-pocket spending for services. Four-fifths of Medicare beneficiaries in the traditional program have some sort of supplemental coverage to avoid these potentially catastrophic losses. Supplemental coverage includes employer-sponsored insurance, Medigap plans and Medicaid. Others may leave the traditional program and enroll in private Medicare Advantage plans instead.

Those who still have employer-sponsored coverage when becoming eligible for Medicare may well have satisfactory coverage, but the rules that apply when leaving an employer-sponsored plan are quite detailed and if not followed carefully, can leave the individual exposed to potentially catastrophic losses. This will not be discussed further here, but the references at the links can be helpful.

Those who end up having to spend down their assets may be eligible for supplemental coverage through Medicaid, but it may be difficult to find physicians who are willing to accept patients on Medicaid.

For most individuals who do not have an employer-sponsored plan at the time of enrolling in Medicare, either a private Medigap plan or enrolling in private Medicare Advantage are options to establish a limit on out-of-pocket costs. Medigap plans are private insurance plans that cover much of the out-of-pocket expenses under traditional Medicare, and they do place a limit on catastrophic losses. Medicare Advantage plans are completely separate private insurance plans that replace traditional Medicare coverage, but also include limits on catastrophic losses within the network, though out-of-network exposure can be a problem.

People who want to choose their own physicians and hospitals and don’t want to be burdened with managed care intrusions such as prior authorization will likely want to enroll in traditional Medicare with a Medigap supplement plus a Part D supplement for drugs. If that is the preference then that decision must be made within the initial enrollment period or risk never being able to enroll in a Medigap plan, especially if there are pre-existing conditions.

The marketing of private Medicare Advantage plans has made them attractive and thus they have grown in popularity. However, it is common that when individuals develop serious conditions they find that the plans fall far short of the care they expected and thus they want to return to the traditional Medicare program with a Medigap supplement. In such circumstances, individuals will likely find that they are unable to enroll in a Medigap plan and thus they will be subject to potentially catastrophic losses. It can be humiliating when they find that they must spend down their assets in order to enroll in Medicaid – a welfare program.

Since Medicare benefits are inadequate, rather than adding the administrative burden and extra expenses through Medigap plans and Medicare Advantage plans, it would be much better to roll the additional benefits into the traditional Medicare program. It would be less expensive while allowing patients to retain their choices of health care professionals and institutions. Besides establishing an improved Medicare we should expand it to include everyone; it would be cheaper and better for all of us. Of course that’s the single payer model of an improved Medicare for All. That’s so much better than establishing a Medigap plan and then telling people they can’t enroll in it because they didn’t follow the rules that they didn’t know about.

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

By Alison Galvani, Alyssa Parpia, Eric Foster, Burton Singer, and Meagan Fitzpatrick
Lancet, February 15, 2020

Abstract

… Efforts are ongoing to repeal the Affordable Care Act which would exacerbate health-care inequities. By contrast, a universal system, such as that proposed in the Medicare for All Act, has the potential to transform the availability and efficiency of American health-care services.

Taking into account both the costs of coverage expansion and the savings that would be achieved through the Medicare for All Act, we calculate that a single-payer, universal health-care system is likely to lead to a 13% savings in national health-care expenditure, equivalent to more than US$450 billion annually. The entire system could be funded with less financial outlay than is incurred by employers and households paying for health-care premiums combined with existing government allocations.

This shift to single payer health care would provide the greatest relief to lower-income households. Furthermore, we estimate that ensuring health-care access for all Americans would save more than 68 000 lives and 1·73 million life-years every year compared with the status quo.

Time to act

As public support for health-care reform mounts in the USA, legislators are poised to transform the healthcare system and save thousands of lives every year. Single-payer universal health care has the potential to improve the quality, cost-effectiveness, and accessibility of medical services.

Our projections indicate that implementing the Medicare for All Act specifically would generate net savings across a wide range of possible expenditure and financing options. Objections to the Medicare for All Act based on the expectation of rising costs are mistaken.

Some Americans express concern about the federal government controlling this large sector of the economy, or about violating capitalist principles. However, the health-care sector is already highly regulated in many aspects, and deviates from capitalist ideals through opaque and often monopolistic pricing.

Strong opposition should be expected from powerful vested interests, including the health insurance and pharmaceutical industries. Counterbalancing these concerns is the moral imperative to provide health care as a human right, not dependent on employment or affluence.

The medical community should seize this opportunity to promote wellbeing, enhance prosperity, and establish a more equitable health-care system for all Americans.

The paywall has been removed and the full article is now available:
HTML: https://www.thelancet.com…
PDF: https://www.thelancet.com…

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Comment:

By James G. Kahn, M.D., M.P.H., Emeritus Professor, Institute for Health Policy Studies, University of California San Francisco

This important economic study of the Medicare for All Act (MAA, Sanders), in the prominent journal Lancet, is the first cost analysis of single payer in the medical literature since 1991, and the most extensive ever.

It’s notable and valuable for four reasons:

First, it projects that single payer – as crafted for the MAA – will save money, likely lots of money – 13% of current health care spending. This level of savings is more than current out-of-pocket costs. Therefore, new revenue just needs to cover current premium payments, and that’s relatively easy with a combination of payroll, income, and wealth taxes.

Second, the findings are consistent with cost estimates from 1990-2018, which we reviewed recently in PLoS Medicine: 19 of 22 analyses projected savings in the first year of single payer. This concurrence of rigorously peer-reviewed studies is very encouraging.

Third, the authors provide an online calculator, so that skeptics and quant geeks can explore the effects of different input values. This is standard fare for decision and cost-effectiveness models in medicine, but rarely done for economic models of single payer costs. It’s a very important resource.

Finally, the authors review the real reason we want single payer: improved health. They estimate tens of thousands of deaths averted per year, important synergies between health and prosperity (including less opioid use), and an improved care experience with free choice of doctors and continuity of care – no more insurance changes requiring a new provider network.

There’s a broadness of scope and richness of detail in this article. Single payer opponents will no doubt pick some details to dispute, but ignore that diversion.

Read and enjoy the article, and check out the online calculator.

Tell your friends: single payer saves money and lives. It defies the economic dictum, “there is no free lunch” – we can both have universal health care, and pay less for the privilege.

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

Public Agenda, February 5, 2020

The main findings from this research are:

1. Americans across political affiliations are calling for substantial changes to the health care system, including those who are satisfied with their current insurance.

2. Americans across the political spectrum share many of the same goals for health care, beginning with making it more affordable for ordinary people — perhaps because half of Americans have experienced serious financial difficulties due to health care or know someone who has. Other important shared goals include covering pre-existing conditions and covering long-term care.

3. The survey asked people to consider four approaches to health care reform. Of those, a public option-type plan is supported by a majority of Democrats while Republicans are split on it. A Medicare for All-type plan is also popular with Democrats but opposed by most Republicans. A market-based approach appeals to about half of Republicans and a plurality of Democrats. Giving states more responsibility for health care garners the least support overall.

4. As people grapple with the four approaches, common ground on protecting people with pre-existing conditions emerges strongly. Democrats are more comfortable with using tax increases to fund health care and with a larger role for the federal government than Republicans are, while Republicans particularly value consumer choice.

The data also suggest that the opinions of many Americans on health care are not set in stone. A quarter of Americans say they do not yet know enough to have an opinion about the various plans tested in this survey. Furthermore, we found that people themselves say that their support for various health care reform plans may change as they consider the implications of those plans. This signals substantial room for people’s views to evolve as they learn and deliberate, suggesting a crucial role for the news media in bringing forth the best evidence on what works to achieve America’s shared health care goals.

Questionnaire

As you may know, there are several proposals to make changes to the nation’s health care system. In general, which of the following comes closest to your opinion about the country’s current health care system overall?

Make major changes or redesign it completely
60 – Republican
64 – Democrat
65 – Independent

In order to improve health care in the United States, how important are the following to you?

Lowering the cost of prescription drugs
91 – Republican
98 – Democrat
96 – Independent

Improving the quality of health care
83 – Republican
95 – Democrat
90 – Independent

Making sure all Americans have health insurance coverage
72 – Republican
95 – Democrat
83 – Independent

Making sure all communities have access to enough doctors and hospitals
89 – Republican
97 – Democrat
93 – Independent

Covering treatment for mental health and addiction services
82 – Republican
98 – Democrat
88 – Independent

Covering long-term care for the elderly and disabled
91 – Republican
98 – Democrat
94 – Independent

Making sure people with pre-existing medical conditions can get affordable health insurance
90 – Republican
98 – Democrat
95 – Independent

Making health care more affordable for ordinary Americans
92 – Republican
98 – Democrat
97 – Independent

Making sure that lower-income people have about the same quality of basic care as higher-income people
84 – Republican
97 – Democrat
87 – Independent

One idea would create a new federal health insurance program that gives people a new option beyond what’s currently available in the private insurance marketplace. Any adult could buy into the program on a sliding scale (those with less money pay less, those with more money pay more).
Which of the following comes closest to how you feel about this idea?

I would support it or probably support it
37 – Republican
61 – Democrat
46 – Independent

Another idea would create a single federal health insurance program that automatically covers all Americans, replacing all private and employer-provided insurance. This program would be completely free for individuals and families; instead, it would be paid for through taxes.

I would support it or probably support it
22 – Republican
65 – Democrat
38 – Independent

Another idea would use tax incentives to encourage people to save money for their health needs. It would also require doctors and hospitals to post prices clearly so people can shop for the best deal, and it would deregulate insurance companies to spur development of new, low-cost options like short-term, minimal-coverage, or high deductible policies.

I would support it or probably support it
55 – Republican
41 – Democrat
51 – Independent

Another idea would shift more responsibility, resources and authority for health care reform from the federal government to the states. State policymakers could then decide on the reforms that would make the most sense for their residents.

I would support it or probably support it
46 – Republican
37 – Democrat
34 – Independent

Report:
https://www.publicagenda.org…

Topline:
https://www.publicagenda.org…

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Comment:

By Don McCanne, M.D.

This survey provides very convincing evidence that Americans across the political spectrum are in strong agreement that our health care system needs changes. They agree especially on making care more affordable, making sure all Americans have health insurance coverage, lowering the cost of prescription drugs, ensuring access to doctors and hospitals, covering mental health and addiction services, covering long-term care, guaranteeing coverage for pre-existing disorders, and making sure that lower-income people have the same quality of basic care as higher-income people.

In contrast, of four basic models of reform – public option, national single payer, private consumer-driven health care, and state-based reform – there is no uniform support across the political spectrum. The strongest support is that 65 percent of Democrats support national single payer. Also, 61 percent of Democrats support a public option, while 55 percent of Republicans and 51 percent of Independents support consumer-driven health care.

There is a problem with these numbers. Though there is a division on which model of reform should be supported, there is only one model that would achieve the specific reform on which there is very strong agreement. That model, of course, is single payer. Single payer could also be established at the state level with enabling federal legislation, but state solutions have the weakest support.

About one-fourth of respondents indicated that they did not have enough information to make a decision on these models (Topline link above). Many indicated that they could change their mind based on various potential policy impacts. Also there is the perennial problem that people may know what they know, but they frequently do not know what they don’t know, and that is especially true when considering the complexities of health policy.

The public does need to be better informed on policies that would actually work to bring us the high performance health care system that they desire. Our task is made more difficult in this day in which obfuscation and deception have seemed to become the norm for the opponents of health care justice for all. We need a fact-based national dialogue on reform, and we need it now. Otherwise we’re in for more of the same.

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

By Kate Sullivan
CNN, February 12, 2020

The influential Culinary Union distributed a flier that says Vermont Sen. Bernie Sanders would “End Culinary Healthcare” if elected president of the United States.

The flier, obtained by CNN on Tuesday, outlines where the leading 2020 Democratic candidates stand on health care, immigration and “Good Jobs.” It singles out Sanders as the candidate who will end the union’s health care among the top six Democratic candidates, pointing to his “Medicare for All” plan.

Former Vice President Joe Biden, former South Bend, Indiana, Mayor Pete Buttigieg, Minnesota Sen. Amy Klobuchar and businessman Tom Steyer are expected to “Protect Culinary Healthcare,” according to the flier.

https://www.cnn.com…

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Statement by Culinary Union Secretary-Treasurer Geoconda Arguello-Kline

Culinary Workers Union Local 226, Press Release, February 12, 2020

The Culinary Union is Nevada’s union and largest immigrant organization with members who come from 178 countries and speak over 40 different languages. Our union is comprised of majority women, and we are proud to have changed the lives of over 800,000 hospitality workers in 85 years through rank-and-file organizing and mass actions.

Culinary Union members are empowered to engage in democracy – whether at the bargaining table, while canvassing in neighborhoods, or on the streets in the desert heat – we fight for workers across Nevada, union and non-union alike.

We have welcomed Senator Bernie Sanders into our union for a town hall with Culinary Union members, and we hosted tours of the Culinary Health Center and the Culinary Academy of Las Vegas with Senator Sanders, to show what we have fought for and won.

Our union believes that everyone has the right to good healthcare and that healthcare should be a right, not a privilege. We have already enacted a vision for what working people need – and it exists now. Workers should have the right to choose to keep the healthcare Culinary Union members have built, sacrificed for, and went on strike for 6 years, 4 months, and 10 days to protect.

It’s disappointing that Senator Sanders’ supporters have viciously attacked the Culinary Union and working families in Nevada simply because our union has provided facts on what certain healthcare proposals might do to take away the system of care we have built over 8 decades.

We have always stood up for what we believe in and will continue to do so. The Culinary Union has faced some of the toughest companies who wanted to break our union, and even the President of the United States Donald Trump – and won.

Together, we will figure out the best way to fix healthcare in America, and the Culinary Union is committed to fighting until we win for everyone.

https://www.culinaryunion226.org…

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Culinary Health Fund: Las Vegas Plan Unit 150

Weʼre the Culinary Health Fund. The Fund provides healthcare benefits (insurance) to culinary workers in Las Vegas. We provide medical, dental, pharmacy and eye care benefits. The Culinary Health Fund is a multi-employer Taft-Hartley Fund. We were established in 1981. We’re funded by collective bargaining agreements that are negotiated by unions and funded by employers.

The Summary of Benefits and Coverage (SBC) document shows you how you and the plan would share the cost for covered health care services.

Summary of Benefits and Coverage (SBC)

(Edited excerpts from a seven page document. Parenthetical comments are by Don McCanne and are based on PNHP’s Physicians’ Proposal for Single-Payer Health Care Reform, sometimes referred to as single payer Medicare for All which is very similar to the legislative proposals of Sen. Bernie Sanders and Rep. Pramila Jayapal.)

• The plan type is a PPO (Preferred Provider Organization). It is a form of managed care that uses a provider network.

(Single payer Medicare for All – M4A – is not a managed care entity. It includes all physicians, hospitals and other health care facilities such as laboratories and radiology services.)

• This plan uses a provider network. You will pay less if you use a provider in the plan’s PPO network. You will pay the most if you use a Non-PPO provider, and you might receive a bill from a Non-PPO provider for the difference between the Non-PPO provider’s charge and what your plan pays (balance billing). Be aware, your PPO network provider might use a Non-PPO provider for some services (such as lab work). Check with your provider before you get services.

(M4A does not use a PPO network. It pays in full the publicly administered prices for all covered services. The patient pays nothing.)

• No deductible is required for covered services. This does not apply to non-PPO providers.

(Under M4A, there are no deductibles and since there are no networks there are never any deductibles.)

• There are copayments required for primary care visits ($15), specialist visits ($30), X-rays ($20 to $45), blood work ($0 to $15), CT/MRI ($125), PET scan ($175 to $225), drugs ($10 to $35 and 25% coinsurance for Tier 4 drugs), outpatient surgery ($150 to $250), emergency room care ($350), emergency medical transportation (25% coinsurance for ground, $500 copay for air), urgent care ($40), hospital admission ($250), mental health/substance abuse (outpatient $0 to $15; partial admission $150; inpatient $250), childbirth facility ($250), home health care ($0), Rehabilitation ($250 inpatient; $20 to $40 outpatient), skilled nursing care ($250), durable medical equipment (10% coinsurance), hospice ($0), and children’s eye exam ($20). Non-PPO providers are not covered for any of these services except for a $2000 copay and 40% coinsurance of allowed charges for hospital facility fee, inpatient mental health services, and childbirth facility fee.

(Under M4A, there are no copayments nor coinsurance fees, and there is no out-of-network care since all professionals and facilities are covered. The patient pays nothing to access these services and products.)

• The out-of-pocket limit that the patient must pay is $6,350 individual / $12,700 family. Premiums, balance billing, and out-of-network care do not apply to the out-of-pocket limit, and thus the financial exposure to the patient could be much greater.

(Under M4A, there are no premiums, deductibles, copayments, coinsurance, out-of-network care, surprise bills or balance billing and thus there is no need to establish an out-of-pocket limit. The only payment made is a tax contribution based on ability to pay – a progressive tax – which may be as little as $0. Thus health care is affordable for everyone.)

• Services that are not covered include bariatric surgery, cosmetic surgery, infertility treatment, long term care, non-emergency care when traveling outside of the U.S., private duty nursing, and weight loss programs.

(Under M4A, with the exception of vanity cosmetic surgery, most of these services are covered when they are legitimately indicated. Long term care, management of obesity, bariatric surgery, and infertility treatment are particularly important services that should be covered, and they are under M4A.)

• You do not need a referral to see a specialist, but you might receive a bill from a Non-PPO provider for the difference between the Non-PPO provider’s charge and what your plan pays (balance billing). Be aware, your PPO network provider might use a Non-PPO provider for some services (such as lab work). Check with your provider before you get services.

(Under M4A, there is no balance billing and no surprise medical bills.)

• Employees must work 240 hours every two months to maintain health benefits. For those who work fewer hours, it may be possible to continue the benefits through self-pay, but that can be a problem at a time that income is reduced.

(Under M4A, coverage is automatic, forever, even for those who have no income. Health benefits should be totally de-linked from employment, especially since this is an unstable source of coverage as over 60 million people leave their jobs each year.)

https://www.culinaryhealthfund.org…

PNHP’s Physicians’ Proposal for Single-Payer Health Care Reform:
https://pnhp.org…

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Comment:

By Don McCanne, M.D.

The Culinary Union is opposed to single payer Medicare for All because they went on a strike for six years to protect the coverage they have? Well, that’s a non sequitur. Rather they should be comparing their current coverage with the single payer model of Medicare for All and decide their support on that basis.

They would find that the single payer benefits are significantly better; financial barriers to care are eliminated; they would have free choice of physicians and hospitals rather than being limited to a network; the coverage would be stable – for life, and the costs would be significantly less for the beneficiaries because the system would be funded through progressive taxes making it less expensive for those with modest incomes, plus single payer efficiencies would recover profound administrative waste currently estimated to be about $600 billion of our annual national health expenditures.

Perhaps the most important reason that they should reconsider their position on single payer Medicare for All is that, as a strong and effective union, they should be able to negotiate with the employers a deal that will cost the employers no more than what they are already paying, but a deal that will greatly benefit the employees. The employers should agree to give their employees a pay raise equivalent to the current insurance premium that they will no longer be paying, minus any health care tax that they would be required to pay under a single payer system. The employers will be paying the same whereas the employees will receive a much better health plan plus a net pay increase equivalent to the total pay raise negotiated with the employers minus the health tax paid by the employee which would be quite modest because it would be based on their modest incomes. Much better insurance plus a significant pay raise – how can you beat that?

In their release they state, “we will figure out the best way to fix healthcare in America, and the Culinary Union is committed to fighting until we win for everyone.” Even though their plan is quite good by today’s standards for private plans, it is still deficient compared to what they could have. And fighting to protect their existing plan will do nothing to provide “a win for everyone.”

We really want our sisters and brothers in the Culinary Union to have the best in health care plus a pay raise, but they are going to have to use their negotiating strength to achieve that, convincing the employers that they have nothing to lose, but they actually gain by being relieved of their obligation to provide health care benefits as part of the employees’ compensation packages. If the union members read this brief analysis of their current plan and the potential of single payer Medicare for All, maybe they’ll decide to do the right thing for themselves, which will then benefit all of us – that “win for everyone” they support.

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Financing Medicare for All

By Gabriel Zucman
January 24, 2020

• Full private funding of health care is impossible because of its high costs
• Premiums for employer-sponsored plans are a privatized poll tax
• A tax because it’s mandatory (over 50 employees) and reduces wages
• A poll tax because all pay the same regardless of income
• A privatized tax because it is managed by employers
• For the middle class, health insurance is the biggest tax they pay
• Solution: replace insurance premiums (poll tax) by taxes based on ability to pay
• Convert current premiums to additional employee wages
• Broad-base flat tax on all income. 6% rate enough to replace all private premiums.
• Can be supplemented with progressive taxes
• Biggest take-home pay increase in a generation for working families

22 minute video, with PPT:
https://ucsf.app.box.com…

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Comment:

By Don McCanne, M.D.

Gabriel Zucman, along with his colleagues Emmanuel Saez and Thomas Piketty, have demonstrated the injustices of income and wealth inequality and have suggested ways to remedy these injustices. The profound inequities of health care financing in the United States provide an opportunity to use tax policies to painlessly move in the direction of improving equity in both income and in health care. Here Gabriel Zucman provides one example of how that could be done.

If employers converted their current health insurance premiums to employee pay increases, there would be no net cost to the employers. Zucman estimates that a six percent tax on income would be enough to pay for the additional costs of single payer Medicare for All. That six percent tax would be considerably less than the premiums currently paid by payroll deductions and forgone wage increases. Thus the net result would be the biggest take-home pay increase in a generation for working families, helping to favorably reset the current inequities in income.

This is only one example of how tax policy can be used to make health care affordable for each and everyone of us. Most importantly we can refute those who say that we cannot afford single payer Medicare for All. On the contrary, we cannot afford not to enact and implement it.

There is a message here for those union executives who are fighting single-payer Medicare for All. You can help by seeing that this message is delivered to them.

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Corporate Crime Reporter, February 10, 2020

National Public Radio’s Mara Liasson this weekend entered a new term into the corporate liberal establishment’s attack on single payer healthcare.

Mandatory Medicare for All.

As in — do you want Bernie Sanders’ Mandatory Medicare for All — or Mayor Pete Buttigieg’s Voluntary Medicare for Those Who Want It?

It was the first time that the term “Mandatory Medicare for All” popped into the mainstream debate over single payer national health insurance.

On NPR’s Weekend Edition broadcast, Liasson reported that Buttigieg “has been pushing back against Sanders’ more extreme positions, like mandatory ‘Medicare for All’ with his own voluntary Medicare buy-in for those who want it.”

She then reported that Sanders “is one of the most ideologically defined politicians in America. He’s been saying the same things for 40 years. And many of the things he’s calling for, whether it’s mandatory Medicare for All or taxing everyone to pay for it, are majority unpopular positions in battleground states.”

Leaders of the single payer movement were taken aback by the use of the term and did not know where it came from.

Andrea Witte, a single payer activist from Tucson, Arizona, said she had not heard the expression before.

“Like other Medicare for All naysayers in the corporate media, Liasson is trying to indict Medicare for All by adding the negative right-wing framing of ‘mandatory government program,’ while she contrasts it with Buttigieg’s ‘voluntary; public option,” Witte said. “It’s like saying ‘mandatory clean air and water’ or ‘mandatory fire department coverage’ to try to drive down support for those public goods. Also, I do not know about any polls that back her claim that Medicare for All is unpopular in battleground states — especially in a Democratic primary.”

“I do not know where the phrasing originated but certainly it sounds like campaign rhetoric,” said Matt Bruenig of the People’s Policy Project. “As to what I think about it, I don’t mind it except to the extent that it is used to suggest Mayor Pete’s plan is a purely voluntary affair. It is not. Under his plan, employers can change or eliminate your health insurance any time they want, including putting you on to his public option whether you want to be on it or not. In his plan, uninsured people will be fined upwards of $7,000 per year in a supercharged version of the unpopular Obamacare mandate. All health care proposals serious about universal coverage require these kinds of rules. Mayor Pete’s is no different in that regard. It just applies it’s coercion towards a worse end than Medicare for All, namely worse coverage at a higher cost.”

Kevin Zeese of Health Over Profit for Everyone (HOPE) called the phrase “creative propaganda.”

“This is the first time I’ve heard this poll and focus group tested PR term,” Zeese said. “The thieves that rip people off with insurance and high prices are good at inflammatory words to confuse people. And, ‘liberal’ NPR is the perfect place to get the phrase out.”

“The way mandatory is being used by NPR is to make Buttigieg’s completely unworkable ‘Medicare for those who want it’ sound appealing and Sanders’ Medicare for All sound extreme,” said HOPE’s Margaret Flowers. “Buttigieg’s plan would keep our current complicated expensive and unjust system intact and would continue the same problems we have now of people not having health insurance and even if they do have insurance, not being able to afford care. Medicare for all means everyone can get healthcare if they want it. Nothing is forced. It just means that if someone needs or wants to go to the doctor they can.”

“The current Medicare is complicated,” Flowers said. “Everyone is enrolled in the traditional Medicare plan, but if you want a supplemental plan or a pharmaceutical plan, you have to enroll in that yourself separately. Medicare for All would mean that everyone could get the healthcare they need under one system.”

Don McCanne of Physicians for a National Health Program said that the term mandatory Medicare “does feed into the moderates’ view that single payer Medicare for All represents government overreach.”

“A better term would be automatic Medicare,” McCanne said. “Everyone would automatically be enrolled in Medicare for All regardless of the taxes that they may or may not be required to pay to finance the system. People who qualify don’t reject Medicare today. Why would they reject Medicare in a truly universal program that is affordable for each of us?”

Dr. John Geyman, author of a number of books on single payer, says that this is the first he’s heard of the term “mandatory Medicare.”

“It looks like a gambit against progressive challenges on health care,” Geyman said. “There is no credibility to the argument against Medicare for All that it will cost Americans a lot more through new taxes. That ignores all the big savings that go with it. The work of the two economist groups at the University of Massachusetts Amherst show how we will pay for it through progressive taxes whereby only those with annual incomes more than $400,000 will pay more. The moderate Democrats have no answer to health care reform, just delaying the inevitable by such approaches as the public option.”

Former insurance industry public relations executive Wendell Potter, who is currently with Business for Medicare for All, says this was the first time he’s seen the term used.

“It could be a term that some in the media — and single payer opponents — are using as a shorthand way of saying there would not be a private insurance option and everyone would be required to enroll in Medicare,” Potter said. “My feeling is that it has negative connotations and that we very likely will see it show up more in the future. My team and I will monitor the use of the term.”

David Himmelstein and Steffie Woolhandler, two founders of Physicians for a National Health Program, said that they too had never heard the term.

“Medicare for All would be, and should be, mandatory, just as Medicare is currently mandatory,” they said. “At present, everyone eligible for Medicare is automatically enrolled.”

https://www.corporatecrimereporter.com…

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Comment:

By Don McCanne, M.D.

Moderate politicians who oppose single payer Medicare for All have framed their position by saying that a Medicare public option should be made available for those who want it but that the government should not take away the private insurance plans from those who are pleased with their coverage. Apparently NPR’s Mara Liasson has introduced rhetoric that reduces this to a sound bite: “Mandatory Medicare for All.” This seems to imply government overreach by forcing Medicare on everyone, whether they want it or not (Liasson having learned well her lessons in deceptive rhetoric in her other job at Fox News).

What people do want are the assurances of single payer Medicare for All: guaranteed coverage forever, affordability of coverage based on ability to pay, everyone covered, comprehensive benefits, and choice of health care professionals and institutions in a high quality health care delivery system. What they do not want are the deficiencies in our current multi-payer system: unaffordable premiums, excessive deductibles and other cost sharing, limitation to care in provider networks selected by the insurers, surprise medical bills from unavoidable out-of-network care, high prices, a false promise of employer-sponsored coverage when over 60 million individuals leave their employment each year and lose the insurance that the opponents of single payer claim is prized so highly, instability of coverage because of ever changing eligibility for public and private programs, and they especially do not like the financial barriers to care that are resulting in financial hardship, physical suffering, and even death.

Another very annoying false claim is that we cannot afford single payer Medicare for All. The recent systematic review of economic analyses of single payer financing published in PLOS Medicine demonstrated that all plans analyzed would result in long term net savings compared to the status quo. Others who claim that their public option models would cost much less are not being honest. They may cite an estimate of the cost of adding a public option, but they are ignoring the trillions of dollars that the current system costs – a system that they would leave in place, resulting in net costs that are significantly more than single payer Medicare for All. (If you have not downloaded the PLOS Medicare paper, do so now – link below. You need to use it to refute those who claim we cannot afford single payer when it is the highly deficient status quo, with or without a public option, that we cannot afford.)

Mandatory for everyone? Automatic enrollment? Forever? Medicare – the most popular financing system of all – in an improved version that ensures access and affordability for each of us? Pray that this will be the future of our health care.

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Projected costs of single-payer healthcare financing in the United States: A systematic review of economic analyses

By Christopher Cai, Jackson Runte, Isabel Ostrer, Kacey Berry, Ninez Ponce, Michael Rodriguez, Stefano Bertozzi, Justin S. White, James G. Kahn
PLOS Medicine, January 15, 2020, Open Access

https://doi.org…

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UCSF Institute for Global Health Sciences
UC Berkeley, January 24, 2020

In this colloquium, we gather leaders in Medicare-for-All design from the U.S. along with international health system experts. The discussion will review current plans in Congress and from candidates, and will highlight the best approaches and trickiest issues in implementing Medicare-for-All.

Program and Speakers:
https://globalhealthsciences.ucsf.edu…

Videos: (2020 GHEcon) Medicare for All: How to Do it Right
(Use the program to determine precisely the speakers in each of the twelve videos.)
https://www.youtube.com…

PowerPoint for each speaker (not in order of presentation – correlate with program):
https://ucsf.box.com…

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Comment:

By Don McCanne, M.D.

For those who were unable to attend this superb conference, these videos and slides can fill you in on what transpired. Now that the single payer model of Medicare for All is being seriously considered as the ideal model for reform in the United States, it is helpful to receive input from these noted national and international experts in health system reform, even if not the final word on reform.

When you have the urge to kick back and watch television, but there isn’t much worthwhile to watch at the moment, you can spoon feed yourself these presentations, and then feel good about using your relaxing time gainfully.

Let’s keep moving the process forward.

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By Vilsa Curto, Liran Einav, Amy Finkelstein, Jonathan Levin, Jay Bhattacharya
American Economic Association, American Economic Journal: Applied Economics, April 2019

Abstract

We compare health care spending in public and private Medicare using newly available claims data from Medicare Advantage (MA) insurers. MA insurer revenues are 30 percent higher than their health care spending. Adjusting for enrollee mix, health care spending per enrollee in MA is 9 to 30 percent lower than in Traditional Medicare (TM), depending on the way we define “comparable” enrollees. Spending differences primarily reflect differences in health care utilization, with similar reductions for “high-value” and “low-value” care, rather than health care prices. We present evidence consistent with MA plans encouraging substitution to less expensive care and engaging in utilization management.

From the Introduction

While Traditional Medicare (TM) offers publicly administered insurance, a significant fraction of the over-65 Medicare population has opted out of TM in the last decade and enrolled in private insurance plans through Medicare Advantage (MA). In MA, private insurers receive capitated payments from the government for providing Medicare beneficiaries with health insurance that roughly mimics commercial health insurance for the under-65 population.

A simple tabulation of the MA and TM claims points to a large difference in public and private health care spending levels. We calculate that MA spending per enrollee-month in 2010 totaled $642, of which $590 was paid by MA insurers and the rest by enrollees out of pocket. In contrast, average spending per enrollee-month in TM was $911, of which $771 was paid directly by the Medicare program to providers. Capitated payments to the MA plans roughly track the latter amount; the MA plans in the HCCI data received on average $767 per enrollee-month. In other words, the revenue of the MA plans we observe is 30 percent higher than the payments they make for their enrollees’ health care. If this applied to the entire MA population in 2010 (including those outside our sample), it would imply $21 billion in annual (2010) revenue for MA insurers in excess of their spending on health care claims.

Lower health care spending in MA than in TM primarily reflects lower utilization of services rather than lower payments for the same services.

From the Conclusion

We find that MA insurer revenues are 30 percent higher than their health care spending. Health care spending per enrollee-month in MA is 30 percent lower than in TM; holding enrollee county and risk score fixed, this spending difference shrinks to 25 percent, and adjusting for mortality differences further reduces it to 9 percent.

The lower spending by MA enrollees is entirely due to lower health care utilization. Prices appear similar in MA and TM. Where we can most directly measure this—the price of an admission for a given DRG at a given hospital—we estimate that average prices in MA are 1.1 percent higher than in TM. Reductions in utilization appear similar both for types of care where there is concern about “overuse” (e.g., imaging and diagnostic tests) and where there is concern about “underuse” (e.g., preventive care).

We provide suggestive evidence for some of the potential channels by which MA may reduce health care utilization for enrollees. We find that utilization is lower in MA but that, conditional on an encounter, spending per encounter is similar or slightly higher in MA. This suggests that MA plans restrict utilization on the margin to sicker individuals. Relatedly, individuals discharged from the hospital are much more likely to be sent home—and less likely to be sent to a post-acute care facility—if they are enrolled in MA rather than in TM. We also find evidence consistent with substitution to less expensive types of care in MA; for example, differences in specialist visits are much larger than differences in primary care visits.

Finally, in light of the widespread interest in geographic variation in health care spending in TM, and recent work on geographic variation in commercial (under-65) private insurance, we explore similar comparisons in MA. Although geographic variation in spending in TM is often viewed as a reflection of the inefficiencies in a public health insurance system, we find similar—in fact, slightly larger—geographic variation in spending in MA compared to TM. And while recent work has emphasized the much greater geographic pricing variation in private commercial insurance than in TM, we find similar—in fact, slightly smaller—geographic variation in pricing in MA compared to TM.

One natural question these findings raise is their implications for MA insurers and consumers. For insurers, our estimates from MA data indicate that their revenue exceeds their health care expenditures by $177 (about 30 percent) per enrollee-month. Implications for consumers are more elusive, since the elements of their objective function are not as straightforward to define or measure.

https://www.aeaweb.org…

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Comment:

By Don McCanne, M.D.

Per capita health care spending is much higher in the United States, on average twice that of other wealthy nations. It is now clear that this high level of spending is not due to greater utilization of health care services but rather is due to our high prices. Medicare is an exception. Medicare has been much more effective in controlling high prices than has the private commercial insurance sector.

This study is important because it provides a direct comparison of prices and utilization between the traditional Medicare (TM) program and the private Medicare Advantage (MA) plans offered as an option to Medicare beneficiaries.

Early on it was recognized that the private MA plans were successful in marketing their products to healthier Medicare beneficiaries while being paid at rates reflecting the lower average health of the entire, more expensive, Medicare population. To correct this scheme, risk adjustment was introduced with the intent of adjusting payments based on the health of each Medicare beneficiary. Private insurers, always being advocates of innovation, then began to upcode – adding diagnoses to each patient to make them appear sicker than they actually were. From a business perspective, that worked well since shareholders benefited from greater profits and rising stack evaluation.

So how effective was this? The MA plans have been able to keep payments down at the level of the TM program rather than having to pay higher rates comparable to the commercial plans. Yet by being paid capitation rates more appropriate for patients who were sicker than their healthier insured clients, the MA plans have been paid 30 percent higher than their spending on actual health care – comparable to a medical loss ratio (MLR) of 70 percent (medical loss being an insurance term for what has to be paid out on actual health care). Compare that to the requirement that larger employer-sponsored plans are required to meet an MLR of 85 percent, leaving only 15 percent for their administrative costs and profits. This explains why the larger insurance companies that dominate the MA market have done so well on Wall Street – the MA plans holding back 30 percent rather than the 15 percent or less of the larger commercial plans.

Supporters of the private MA plans contend that this shows that they are more effective in reducing unnecessary utilization of health care – that is, managing care – and thus they are entitled to greater rewards. In fact, this study shows that utilization of specialized services by MA patients is much lower, and there is also much lower utilization of post-acute care facilities. Since physicians are paid about the same in both TM and MA and have no reason to game referrals, this lower utilization strongly suggest that the MA patients are significantly healthier and that the MA plans are guilty of very serious upcoding.

The MA plans continue to grow in popularity. If patients think they are doing such a great job, then they should grapple with the question as to why there are so few specialty referrals. Could it be that physicians are withholding information about specialty care that they should have in order to increase the profits of the MA plans? Highly unlikely, especially since the physicians would have nothing to gain by doing this. Rather it is much more probable that the patients are healthier and have less need for specialized services. Yes, these patients are happy with their care – care that they don’t need and thus know nothing about. But what would these patients think if they knew that the insurers were being paid 30 percent more than it costs them to provide care? Would they really agree with this egregious waste of our tax dollars?

Since the private MA plans have been cheating us, why would we want to continue to support them with our tax dollars? Since the commercial insurance plans have been complicit in the exorbitantly high health care spending in the U.S., why would we want to leave them in charge of our health care dollars? Haven’t we had enough? Wouldn’t it be much better to improve the benefits of the traditional Medicare program, expand it to cover everyone, and then fund it equitably through progressive taxes that each of us could afford? Single payer, improved Medicare for All is just what we need to correct our health care injustices.

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