PNHP

Gov. Newsom on homelessness and health

Gov. Newsom on homelessness and health

Governor Newsom Delivers State of the State Address on Homelessness

Office of California Governor Gavin Newsom, February 19, 2020

The California Dream is for all.

To that end, there are 1.6 million fewer Californians living in poverty today than in 2011—a full quarter of the nation’s decrease.

But no amount of progress can camouflage the most pernicious crisis in our midst, the ultimate manifestation of poverty: homelessness.

That’s why I’m devoting today’s remarks to this crisis.

Let’s call it what it is, a disgrace, that the richest state in the richest nation—succeeding across so many sectors—is failing to properly house, heal, and humanely treat so many of its own people.

Every day, the California Dream is dimmed by the wrenching reality of families, children and seniors living unfed on a concrete bed.

Military veterans who wore the uniform of our country in a foreign land, abandoned here at home.

LGBTQ youth fleeing abuse and rejection from their families and communities.

Faces of despair. Failed by our country’s leaders and our nation’s institutions.

As Californians, we pride ourselves on our unwavering sense of compassion and justice for humankind—but there’s nothing compassionate about allowing fellow Californians to live on the streets, huddled in cars or makeshift encampments.

And there’s nothing just about sidewalks and street corners that aren’t safe and clean for everybody.

The problem has persisted for decades—caused by massive failures in our mental health system and disinvestment in our social safety net—exacerbated by widening income inequality and California’s housing shortage.

The hard truth is we ignored the problem.

We turned away when it wasn’t our sister, our brother, our neighbor, our friend.

And when it was a loved one, help wasn’t there.

Most of us experienced homelessness as a pang of guilt, not a call to action.

Back in 2005, when we started our point-in-time counts, there were over 188,000 homeless people in California—35,000 more than we have today. Even at that peak, the state didn’t treat it with the urgency required.

It became normalized.

Concentrated in skid rows and tent cities in big urban centers.

Now it’s no longer isolated.

In fact, some of the most troubling increases have occurred in rural areas, in small towns, and remote parts of our state.

No place is immune.

No person untouched.

And too often no one wants to take responsibility.

I’ve even heard local officials proclaim in public: it’s not my problem.

Servants of the public too busy pointing fingers to step up and help? That’s shameful.

After all, every homeless Californian, living on a boulevard of broken dreams, is a casualty of institutional failures—a person who’s fallen through every possible hole in the safety net.

Homelessness impacts everyone, but not equally. Some communities have been hit much harder.

Urban renewal and gentrification broke up communities of color and throttled their abilities to move into the middle class.

These are systemic issues rooted in poverty and racial discrimination.

Black Californians comprise 8 percent of Los Angeles County’s population—but 42 percent of its homeless.

And a recent poll found that nearly half of Latinos in the state are afraid that they or a family member could become homeless.

The State of California can no longer treat homelessness and housing insecurity as someone else’s problem, buried below other priorities which are easier to win or better suited for soundbites.

It is our responsibility.

In the 1940’s and 50’s, our nation began the trend toward “deinstitutionalization.”

Not a single policy, but a series of policies.

Outrage over conditions in institutions—as well as the creation of new medications to treat mental illness—sparked a movement to treat people in their communities, rather than locking them away.

California passed the Short-Doyle Act in 1957 to fund community mental health services.

The federal government, too, pursued this worthy goal.

President Kennedy envisioned a system in which, in his words, “the reliance on the cold mercy of custodial isolation will be supplanted by the open warmth of community concern.”

State mental hospitals were closed. But the promise of community mental health was never fully realized.

The states were burdened with the responsibility but provided little in the way of support.

Laws were changed that made it harder to compel mental health treatment. Governor Ronald Reagan signed the Lanterman-Petris-Short Act in 1967, designed to end the inappropriate lifetime commitment of people with mental illness.

And critically, in 1975, a U.S. Supreme Court decision, O’Connor v. Donaldson, ruled that “mental illness alone cannot justify a state locking a person up against his will.”

All of these changes, coincided with safety net cuts, block grants, and tightened eligibility standards of the 80’s and 90’s, along with wholesale razing of skid rows and SROs—which for so many was the only housing option.

The cumulative impact made county jails the de facto mental health institutions.

Patients and their families were left with inadequate options to get the mental health care they needed.

In a politically polarized world, liberals and conservatives blame one another for these failures.

Historically speaking, both are right.

It’s time to stop pointing fingers and join hands in a transformational solution.

This year, we have proposed CalAIM, a once-in-a-generation reform of our Medi-Cal system, based on the obvious, but long-ignored principle, that physical health and brain health are inextricably linked.

After all, 10 million Californians—1 in 4—suffer from some type of behavioral health condition. It’s not a narrow issue, nor a new one.

The deeper truth is that our healthcare system has been designed to treat some of our parts, not the sum of our parts. That must change.

This landmark proposal calls for leveraging Medi-Cal as a tool to help California’s most vulnerable residents: the homeless, our children, and people cycling in and out of the criminal justice system.

This is about integrating care. Targeting social determinants of health and expanding our Whole Person Care pilots statewide.

Health care and housing can no longer be divorced. After all, what’s more fundamental to a person’s well-being than a roof over their head?

Doctors should be able to write prescriptions for housing the same way they do for insulin or antibiotics.

That’s the aim of CalAIM, transforming Medi-Cal as we know it, backed by a $695 million budget request to make this real.

We need a new approach.

In the budget I just submitted, I proposed a new California Access to Housing Fund, and, with it, a whole new way of investing in homeless solutions.

We have a clear purpose for this Fund: paying for what works.

Gap financing for innovative housing models like hotel/motel conversions and securing vacant units wherever we can find them.

Stabilizing and expanding board and care homes.

And preventing homelessness in the first place through rent subsidies and rapid rehousing to help people one job loss, one illness, away from homelessness.

With this first-in-the-nation statewide housing fund, we can braid together state and philanthropic dollars, as well as health care, mental health, and social services—paying for housing, not overhead, by capping all administrative costs at 10 percent.

Nimble and flexible to evolve from best practices to next practices.

Look: not one city, not one county, not even one state can shoulder this responsibility alone. This is a national crisis.

Federal decision-making contributed to this moment and our federal government has an obligation to match its rhetoric with specific, constructive, and deliverable results.

California has and will continue to extend its hand of partnership to Washington, seeking to jointly address this issue.

Honestly, this partnership should be a given.

But empty words and symbolic gestures won’t mask a 15 percent across-the-board cut to HUD’s budget.

I’m old enough to remember when HUD was in the housing business. And I’m hopeful it will be again.

After all, homelessness isn’t a blue or a red issue. It’s an everyone issue—a blight on the soul of America.

It’s time for California to say yes to housing. We cannot wait.

So this is the challenge before us and those are the tough choices we must make.

Overcoming adversity and tackling intractable problems are as ingrained in California’s character as our sun-kissed coast and our bread-basket valley.

With homelessness, I know it can be done because I’ve seen successes along the way.

15 years ago, when I was Mayor of San Francisco, in the face of long odds and stiff opposition, we established Project Homeless Connect to bring local government services directly to people. It has been wildly successful and adopted in 250 other cities.

Last year, I went back to Homeless Connect and spoke with a man named Richard Oliva.

Four years ago, Richard was homeless, drug addicted and seeking medical help at one of Connect’s neighborhood fairs.

Thanks to this program, Richard got clean, obtained disability support and ultimately moved into subsidized permanent housing.

This time, he was back—but as a volunteer.

For three years now, he has been passing out free reading glasses to people in need.

While I was there, Richard hugged me with tears in his eyes and said, “thanks to this program, I have a home of my own.”

Richard’s story reminds us that there are no lost causes in our California community.

It’s an enduring California value that every Californian has value.

So when critics tell you homelessness can’t be solved, introduce them to Richard, and the thousands of others like him who are a living testament.

I don’t think homelessness can be solved.

I know homelessness can be solved.

This is our cause. This is our calling.

Let us rise to the challenge and make California stand as an exemplar of what true courage and compassion can achieve.

Let’s get to work.

https://www.gov.ca.gov…

Comment:

By Don McCanne, M.D.

Housing is a crucial factor in personal health and public health. Homelessness cannot possibly be eliminated through charitable, voluntary effort. It requires public policies administered through the community on all levels. We can’t do it alone, but we can do it together.

The same goes for our health care system. Voluntary, charitable efforts cannot and do not fill the voids in our health care delivery. We are already spending more than enough to meet the health care needs of all of our residents, but we cannot expect to achieve equitable allocations of our health care without guiding public policies. It’s not that we don’t understand how to do it – single payer Medicare for All would fix this problem for us – it’s just that we have to decide to go ahead and do it.

Homelessness provides the visual and olfactory stimuli that should spur our public stewards into action. Too bad that there is a lack of transparency of financial hardship and human suffering that is so prevalent as a result of the dysfunction of our health care financing system. But then, since before now we seem to have been unable to overcome the inertia preventing us from assisting the homeless in moving from their miserable subhuman accommodations into facilities that at least provide the bare basics, will we actually be inspired to move forward with the plea of Governor Newsom for us to get to work – not only for the homeless but also with his perpetual plea to provide health care for all? What will it take?

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

Medicare For All Will Help Improve The Lives Of Black Women

By Sen. Bernie Sanders
Essence,

It is impossible for any rational person to deny that our current healthcare system is dysfunctional and cruel. As a nation, we spend more than twice as much on healthcare as the people of almost every major country on earth while achieving worse outcomes.  Even worse, Black Americans see only a fraction of those sub-par returns.  In America today, Black babies are more than twice as likely to die in infancy than babies born to white mothers, and Black women are three or four times more likely to die from pregnancy-related complications than their white peers.

To change those unacceptable outcomes, it’s important to recognize that maternal health disparities don’t start at pregnancy. They start before mothers are even born.

According  to The Center for Reproductive Rights the key drivers of the maternal mortality crisis are poverty, racism, and lack of health insurance. Tragically, women who are uninsured or enrolled in Medicaid report that they often receive no postnatal care, and inadequate prenatal care. They are also less likely to receive paid parental leave, during which they can adequately recover from the physical toll of pregnancy. Moreover,  because women of color are more likely to live in poverty without health insurance, they’re more prone to risk factors for maternal death, like diabetes and heart disease.

In my view, any plan that targets Black maternal health that doesn’t include unequivocal support for a universal healthcare system that is free at the point of delivery is not good enough.

The Medicare For All Bill I’ve introduced will help prevent Black mothers from being discriminated against as they’re poised to give birth — left laboring in hallways because of their perceived inability to pay. It also means that large numbers of Black Americans who live in southern, Republican-controlled states like Mississippi will no longer have to suffer because local legislators rejected President Obama’s Medicaid expansion. Medicare For All will provide long-term home health care and community-based services for everyone.

We also have to address point-of-care discrimination due to provider bias and unequal resources for marginalized communities. That’s why Medicare For All requires us to address racial health disparities. It creates an Office of Primary Health to make sure that people living in underserved areas receive the high-quality health care that they need and that we adequately train doctors, nurses and medical providers to eliminate the unacceptable disparities in healthcare in urban and rural areas.  And by substantially increasing funding for the National Health Service Corps as well as fully funding all Historically Black Colleges and Universities, which have a proud tradition of graduating a disproportionate share of Black doctors and nurses, we can facilitate the education of medical professionals and make sure that Black patients are treated with the respect and dignity that they deserve.

And let’s be clear: African Americans are disadvantaged by an employer-based insurance system.  In America today, Black employment rates remain disproportionately low due to well-documented employment discrimination, unequal public education, and other systemic biases. While 65 percent of white families receive insurance through their employer, only 46 percent of Black families do, which in part explains why the uninsured rate for Black Americans is 11 percent – over 50% higher than that of white Americans.

Health care disparities expose the intersection of racism, classism, and greed that is destroying the social fabric of America.  Aetna — a company that just apologized for their role in the slave trade in 2000 — now makes enormous profits by denying needed care, charging outrageously high premiums and deductibles and refusing to cover people they deem are too “expensive, all while providing a $500 million bonus to its CEO for merging with CVS in 2018.

While Black families receive subpar treatment for expensive care, the top 177 healthcare CEOs in America took home $2.6 billion in total compensation in 2018. While millions of Americans plead on the phone for insurers to pay for life-saving treatment, those same insurers spend millions on lobbyists to make sure that Members of Congress continue to protect the profits of the insurance industry over the lives of their constituents.

Further, there is something profoundly wrong in America today when Black children disproportionately go without dental care, while profitable companies like Amazon, owned by the wealthiest person in America, paid nothing in federal income taxes last year.

The dignity of life should start at birth and extend into retirement.  Having high-quality dental, vision, hearing, and long-term home healthcare should not be a privilege reserved for the rich.  As a nation, it is time for us to go beyond “recognizing” or “acknowledging” health care disparities to advancing policies that will end them for good.  And that is exactly what the Medicare For All legislation that I have introduced will accomplish.

The cruel indignity of not being able to afford health care is an experience that knows no color boundaries. But it is an experience disproportionately shouldered by Black and Brown women in this country and it is time for that to come to an end.

In the richest country in the history of the world, we can and we must guarantee healthcare as a human right and eliminate the outrageous healthcare disparities that exist in the United States of America. And working together, that is exactly what we will do.

https://www.essence.com…

Dr. Claudia Fegan on “Chicago Tonight”

PNHP national coordinator Dr. Claudia Fegan appeared on “Chicago Tonight” on February 20, 2020. She discussed the considerable benefits of single-payer Medicare for All, including comprehensive coverage, true universality, and zero out-of-pocket costs for patients. Dr. Fegan contrasted these benefits with employer-sponsored coverage, which often proves insufficient when people actually need to access care.

Here’s that Medicare-for-all study Bernie Sanders keeps bringing up

A single-payer health-care system would save more than 68,000 lives and $450 billion a year, new research shows

By Christopher Ingraham
Washington Post, February 20, 2020

A new analysis published in the journal Lancet adds some empirical heft to an argument many progressives have been making for years: A national single-payer health-care system would save tens of thousands of lives each year — and hundreds of billions of dollars.

If you watched last night’s Democratic debate in Nevada you might have heard Sen. Bernie Sanders (I-Vt.) cite “a major study [that] came out from Yale epidemiologist[s] in Lancet, one of the leading medical publications in the world” in support of his Medicare-for-all plan. He was talking about this study, which was just published last week.

The study’s lead author, Alison Galvani, is the director of Yale University’s Center for Infectious Disease Modeling and Analysis. The paper discloses that Galvani served as an “informal, unpaid advisor” to Sanders’s Senate office as it developed the Medicare For All Act. None of the other authors disclosed any outside or competing interests.

All told, the study concludes, a single-payer system akin to Sanders’s plan would slash the nation’s health-care expenditures by 13 percent, or more than $450 billion, each year. Not only that, “ensuring health-care access for all Americans would save more than 68,000 lives.”

In their breakdown of the numbers, researchers applied the existing Medicare fee structure across the entire health-care system and found it would save about $100 billion annually. Keep in mind that this basically represents less money going to doctors and hospitals, a major sticking point for medical groups that oppose Medicare-for-all. But those declines would be more than offset by several hundred billions in savings from reduced administrative and billing costs, Galvani and her colleagues estimate. The lack of patient billing under a Medicare-for-all system would also eliminate the roughly $35 billion a year that hospitals now pay to chase down unpaid bills.

The authors estimate an additional $219 billion in savings from reduced “administrative overhead” that the current decentralized system creates, including “the elimination of redundant corporate functions and the truncation of the top-heavy salary architecture of health insurance corporations.” For instance, the plan would replace dozens of health insurance executives, many of whom make well over $20 million a year, with one administrator paid the same salary as the current Secretary of Health and Human Services.

Finally, letting the national Medicare system negotiate pharmaceutical prices would save about $180 billion, according to the analysis.

Add it all up and here’s what you get: a new system that would cost about $3 trillion a year, instead of the $3.5 trillion that is being spent now.

Galvani and her colleagues estimate that to fully fund Medicare-for-all, the federal government would have to bring in an additional $773 billion a year relative to current revenue levels. They estimate this could be paid for, in part, by a 10 percent payroll tax that would bring in $436 billion annually. Given that current employer contributions to health care work out to about 12 percent of payrolls, this would still be about $100 billion less than what employers currently pay.

The remaining funding could be paid via a 5 percent tax on household income, yielding $375 billion a year. Again, with the elimination of employee contributions to existing health insurance premiums, the average household could expect to save well over $2,000 a year — and have no co-pays or deductibles to worry about.

Galvani’s $3 trillion estimate is somewhat lower than the annual spending estimates produced by other observers, including the libertarian Mercatus Center ($3.3 trillion per year) and the more centrist-oriented Urban Institute ($3.4 trillion per year) and RAND Corporation ($3.9 trillion).

All of these estimates — Galvani’s included — are built on various assumptions about how costs and payments and patient behaviors would work in the real world with a Medicare-for-all plan in place: How much would doctors and hospitals actually save on administrative overhead? How many people would increase their use of medical services once they’re paid for? Would a single payer system make it easier to detect medical fraud?

Experts answer those questions differently, which is reflected in their final cost estimates. And though we can’t predict the future, we do have plenty of data on what’s happening in the American health-care system right now. Relative to people in other wealthy nations, Americans are less likely to be in good health and more likely to die of preventable causes. Our babies and mothers are more likely to die after child birth, and our lives are shorter overall.

Lack of a universal health-care system means that regular medical care is unaffordable for many Americans: fully one quarter of us have put off needed care because of cost. More than 8 million Americans have started a crowdfunding campaign to pay for medical care, with approximately 1 in 5 Americans contributing to somebody else’s medical crowdfunding campaign. Ninety percent of those campaigns will fail to raise the necessary funds.

By addressing these and other problems, Galvani and her colleagues estimate that regardless of cost, Medicare-for-all would save about 69,000 lives each year. They end their paper by calling on the medical community to answer “the moral imperative to provide health care as a human right, not dependent on employment or affluence.”

https://www.washingtonpost.com…

What the Doctors Ordered

Once opponents of universal health care, medical professionals may now help win it

By Adam Gaffney, M.D., M.P.H.
The Baffler, February 19, 2020

“Compulsory Health Insurance is an Un-American, Unsafe, Uneconomic, Unscientific, Unfair and Unscrupulous type of Legislation [supported by] Paid Professional Philanthropists, busybody Social Workers, Misguided Clergymen and Hysterical Women.” So affirmed Dr. J. A. O’Reilly to the Kings County Medical Society of New York in the waning days of the nation’s first fight for a European-style health care reform, some hundred years ago. 

If Dr. O’Reilly’s screed—which is quoted in Ronald L. Numbers’s 1978 chronicle of the saga, Almost Persuaded: American Physicians and Compulsory Health Insurance, 1912–1920—strikes modern readers as rather histrionic, it bears some resemblance to the position held by American Medical Association (AMA) ever since. As the title of Numbers’s book suggests, the AMA was at first tempted by arguments for what was then called “compulsory health insurance,” but eventually realized it despised it—and helped to scuttle it. This became part of a pattern: in the late 1940s, the AMA famously fought, and defeated, national health insurance legislation supported by President Harry S. Truman and backed by organized labor. It even opposed Medicare in the 1960s, enlisting Ronald Reagan to record a ridiculous LP wherein the actor and future president described health insurance for the elderly as the death knell of American freedom. “One of the traditional methods of imposing statism or socialism on a people,” Reagan sternly warned, “has been by way of medicine.”

But it was not just fear of the Reds or Hysterical Women. National health insurance was, some physicians felt, a threat to their livelihood as well as their autonomy—and to the sacrosanct doctor-patient relationship. “State medicine . . . means death of individualism, of humanitarianism, and of scientific practice,” Dr. Morris Fishbein, editor of the AMA’s medical journal and a leading opponent of national health insurance, contended in 1928. Yet though the AMA succeeded in its fight against national health insurance, it failed to protect the independence of physicians. Instead of “state medicine,” we have witnessed the “rise of corporate enterprise in health services,” as sociologist Paul Starr described it in his 1982 classic, The Social Transformation of American Medicine. This new corporate medical landscape seems to be making just about everyone miserable. So miserable, perhaps, that today doctors are coming to see national health insurance, now popularly referred to as “Medicare for All,” as less an existential threat and more a solution, both for their patients and their profession.

The shift is becoming obvious in the highest echelons of organized medicine. In January, the nation’s largest medical specialty society—the American College of Physicians (ACP), which represents internal medicine doctors—swung out in support of universal health care reform, explicitly endorsing single-payer Medicare for All alongside a universal “public choice” model. The announcement in the pages of the ACP’s official journal was followed a day later by an open letter, published as a full-page ad in the New York Times, signed by over two thousand physicians (including such prominent doctors as Partners-in-Health co-cofounder Paul Farmer and the developer of the defibrillator, Bernard Lown) “prescribing” Medicare for All to the nation—an effort organized by Physicians for a National Health Program (PNHP), for which I serve as president.

These widely reported events came on the heels of some remarkable developments within the AMA, in large part driven by medical student activism. In June, members of PNHP’s student wing organized a demonstration outside the AMA’s national convention in Chicago to protest the organization’s opposition to Medicare for All—and its support of the anti-single-payer, deep-pocketed, dark-money lobbying group, the Partnership for America’s Health Care Future (which you may know from its goofy multimillion dollar ad campaign attacking what it calls “one-size-fits-all” health care). Student members inside the AMA conference subsequently introduced a motion in its House of Delegates to end the group’s opposition to single-payer and were—startlingly—only narrowly defeated, by 47 percent to 53 percent. Then, in August, the AMA withdrew from the insurer- and pharmaceutical-led Partnership: a remarkable retreat.

These developments represent a dramatic, if incomplete, shift in the profession, although they are not without precedent. As Danielle Carr recently described in The Nation, a “rebellion” of more than four hundred well-known doctors endorsed national health care reform in the face of AMA opposition in 1937, an event that was covered on the front page of the New York Times. In subsequent decades, various physician groups—the radical Physicians Forum of the post-war decades, the Medical Committee for Human Rights in the civil rights era, and PNHP today—have helped keep the flame of the universal health care ideal alive in the face of institutional (and corporate) intransigence. Something new, however, is unfolding in the mainstream of the profession today.

Perhaps this is unsurprising, considering the hardship that physicians regularly see inflicted on their patients. As an intensive care unit physician, for instance, I have treated patients with “hypertensive emergencies”—high spiking blood pressure that can lead to swelling in the brain or a suffocating buildup of fluid in the lungs—because they were uninsured and went for years without care and medicine. Studies have found that patients in the throes of heart attacks are delaying coming to the hospital out of financial fears, and that women with breast cancer and high-deductible health care plans put off biopsies and even the initiation of chemotherapy due to costs.

There is more to it than being witness to suffering, however. The medical landscape of Dr. O’Reilly’s day—of black-bag toting independent practitioners beholden, they might contend, to nobody but their patients and professional creed—has ceased to exist. Consolidation and corporatization have led to a brave new world of giant insurance conglomerates and sprawling hospital systems. For doctors, this has been a mixed bag. On the one hand, physicians are still well remunerated—some particularly so, like those who join private-equity owned staffing organizations infamous for using “surprise billing” as a business tactic. On the other hand, physicians are unmistakably moving from the ranks of small businesspeople to those of employees. In 2016, Modern Healthcare reported that for the first time, less than half of physicians were owners of their medical practices. The new owners, increasingly, sit at the commanding heights of the American economy. A 2018 article in Bloomberg, for instance, described how the insurance giant UnitedHealth has built “an army of tens of thousands of physicians to fend off invaders” in the health care space. Dr. O’Reilly wouldn’t recognize this corporate-dominated medical landscape—and might not have liked it much more than “compulsory health insurance.”

Consider that this landscape is upending the work life of physicians with ever increasing requirements to bill, code, and document—and to sit on the phone and fight insurers for authorizations of care for their patients. One study found that nearly half of a physician’s working day now consists of time spent on the computer or doing desk work, double the proportion spent face-to-face with patients. Another study found that primary care doctors spend some four-and-a-half hours each workday glued to their computers—plus about another hour-and-a-half after they get home at night. Such a large administrative burden appears to be contributing to a rampant epidemic of physician burnout. In a 2019 Medscape poll of some 15,000 physicians, 44 percent reported experiencing burnout—and by far the leading contributing factor cited was “too many bureaucratic tasks (e.g. charting, paperwork).” Even putting professional satisfaction aside, it’s clear that our financing system generates enormous waste: in 2011, one study estimated that in the United States, we spend more than $80,000 on each physician annually merely to cover their costs of wrangling with insurers—nearly four-fold higher than in Canada. These costs are ultimately passed on to patients, but they can drain the joy out of medical practice, too.

Over the last century, our failure to achieve national health insurance—and the resultant rise of a corporate medical behemoth—has meant, far too often, the neglect of patients. Yet it also seems to be leading to a growing sense of alienation within the profession. And so, while previous generations of physicians felt they had much to lose from national health insurance, today physicians increasingly feel that they, like their patients, have much to gain from a universal system. As the political tides shift, Medicare for All will once again be within reach. This time around, rather than standing in its path, physicians may help to win it.

Dr. Adam Gaffney is a pulmonary and critical care physician and public health researcher at Harvard Medical School and the Cambridge Health Alliance, and serves as president of Physicians for a National Health Program. He writes about issues of health policy and politics and is the author of “To Heal Humankind: The Right to Health in History,” published by Routledge in 2017.

https://thebaffler.com…

Publicly traded health insurers have taken over

Publicly traded health insurers' revenue nears $1 trillion mark

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…

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.

Locked out of trading in your Medicare Advantage plan for a Medigap plan

Medicare Advantage Enrollees Discover Dirty Little Secret: Getting out is a lot harder than getting in

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…

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…

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…

Medicare and You, 2020

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

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.

Dr. Ed Weisbart on “Single Payer and its Alternatives”

PNHP-MO chair Dr. Ed Weisbart participated in a panel, “The Future of Health Care: Single Payer and its Alternatives,” on February 18, 2020 at the University of Louisville’s McConnell Center. Dr. Weisbart debated the merits of improved Medicare for All with Thomas P. Miller of the American Enterprise Institute. He argued that Medicare was an effective, efficient, and beloved program, and that it would provide an ideal foundation for a single-payer national health program.

Of course you want to give up your current healthcare plan

By George Bohmfalk, M.D.
Denton (Texas) Record-Chronicle, February 17, 2020

Contrary to Congressman Burgess’ claim in a recent congressional hearing, people should want to give up their private insurance plans.

In the Dec. 12 House Energy and Commerce Committee Hearing on Proposals to Achieve Universal Health Care Coverage, Congressman Burgess paraphrased a 2018 Gallup poll finding to say that “more than 70% of Americans like their employer-provided health insurance plans.”

Such a statement doesn’t mean much and probably isn’t true.

Employer-provided health insurance has become so expensive that people quit their jobs to qualify for Medicaid. Around a million Americans dropped their coverage as premiums rose in 2017. Women with breast cancer delay care because of high deductibles. A young diabetic is “alive today not because of insurance companies but despite them.” A college basketball coach waited in pain for two months before his insurer approved tests that diagnosed his cancer, during which time he became paralyzed.

We hear, over and over, that most Americans love their current health insurance plans and do not want to give them up for a government-financed program. That is insurance industry propaganda, and it’s not true.

Everyone cares about having their choice of doctors and hospitals. No one really cares who writes their health insurance policy. People are fond of their doctors, not Blue Cross, Anthem, WellPoint or Cigna. We all need dependable healthcare coverage at an affordable price. That is rapidly disappearing in the private marketplace.

In an August Business Insider poll, 59% of respondents said they would switch their employer-based health insurance to Medicare for All as long as it meant no change in coverage. Finally, the question was properly asked.

An even better question would be whether they would switch if they would get substantially better coverage, including prescription drugs, dental, vision and hearing care, with no deductibles or copays. And that they could keep their doctors and go to any hospital. And that they and their employer would pay less for this than they currently do.

This is the guarantee of Medicare for All. So why isn’t everyone demanding it?

First, they simply don’t know about it. Poll after poll after poll reveal that many Americans have either never heard of Medicare for All or don’t know enough to form an opinion. Others recoil from the mere idea of a government-financed program, although as they approach 65, most are eager to get on Medicare. Others fear that these promises are just too good to be true and would rather stick with a familiar, if worsening, private insurance plan.

These promises are true. Every other modern country offers universal health care for their citizens for about half of what we spend per capita. They don’t wait in long lines or have rationed care. Their health outcomes, including life expectancy, are better than ours. If you want a familiar plan, look at Medicare. It’s highly popular and efficient, with a 50-year track record. Medicare for All will be a dramatic improvement in that program, while eliminating the profound administrative waste and rationing that are part and parcel of the private insurance industry. This one-size-fits-all plan is ideal precisely because it does fit all the needs of all people.

What’s the downside? None, unless you are a highly-paid insurance company executive. We waste billions each year on a uniquely inefficient system that no serious businessperson can defend. We truly can have comprehensive, permanent, privately delivered healthcare coverage at lower cost with Medicare for All. It will benefit families and businesses. There’s not a single valid reason not to do it.

So of course you want to give up your employer-provided healthcare plan. It’s failing you, your employer, and your family. It’s failing the country. It’s rapidly becoming unaffordable. It’s restricting your choice of doctors and hospitals. It’s benefiting insurance executives and shareholders at the expense of your health, wages and pocketbook. Tell Congressman Burgess and other representatives that you want to give it up soon, for truly protective and efficient Medicare for All.

Dr. George Bohmfalk practiced neurosurgery in Texarkana and is a member of PNHP, Physicians for a National Health Program. He may be contacted at improvedmcare4all@gmail.com.

https://dentonrc.com…

13% reduction in health care costs projected for Sanders Medicare-for-All Act

Improving the prognosis of health care in the USA

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…

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.