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Debunking the myths about Medicare for All

Debunking the myths about Medicare for All

By Joshua Freeman, M.D.
Arizona Daily Star, Letters, August 21, 2019

I was thrilled to read the letter by Drs. Eve Shapiro and Paul Gordon, “Local Opinion: We’re doctors, and we’re debunking myths about Medicare for All.” I, too, am a physician and support an improved and expanded Medicare for All as called for in the House (Jayapal) and Senate (Sanders) bills. The two most contradictory concerns the letter’s authors address are “how will we pay for it” and “we need to keep private insurance”; indeed a large part of the answer to the first is to eliminate the profit and administrative costs engendered by private insurance companies!

Under Medicare for All, everyone will get all the health care they need, without the restrictions on providers most insurers now impose. And, precisely because everyone will be in the same plan, and the wealthy cannot “buy out”, the more educated, better-off, and empowered will make sure that it is a good plan and it will work for everyone.

https://tucson.com…

New HRA rule: Converting employer-sponsored plans from a defined benefit to a defined contribution?

Health Reimbursement Arrangements and Other Account-Based Group Health Plans

A Rule by the Internal Revenue Service, the Employee Benefits Security Administration, and the Health and Human Services Department
Federal Register, June 20, 2019

Action: Final rule.

Effective date: These final rules are effective on August 19, 2019.

Summary: This document sets forth final rules to expand opportunities for working men and women and their families to access affordable, quality healthcare through changes to rules under various provisions of the Public Health Service Act (PHS Act), the Employee Retirement Income Security Act (ERISA), and the Internal Revenue Code (Code) regarding health reimbursement arrangements (HRAs) and other account-based group health plans. Specifically, the final rules allow integrating HRAs and other account-based group health plans with individual health insurance coverage or Medicare, if certain conditions are satisfied (an individual coverage HRA). The final rules also set forth conditions under which certain HRAs and other account-based group health plans will be recognized as limited excepted benefits. Also, the Department of the Treasury (Treasury Department) and the Internal Revenue Service (IRS) are finalizing rules regarding premium tax credit (PTC) eligibility for individuals offered an individual coverage HRA. In addition, the Department of Labor (DOL) is finalizing a clarification to provide assurance that the individual health insurance coverage for which premiums are reimbursed by an individual coverage HRA or a qualified small employer health reimbursement arrangement (QSEHRA) does not become part of an ERISA plan, provided certain safe harbor conditions are satisfied. Finally, the Department of Health and Human Services (HHS) is finalizing provisions to provide a special enrollment period (SEP) in the individual market for individuals who newly gain access to an individual coverage HRA or who are newly provided a QSEHRA. The goal of the final rules is to expand the flexibility and use of HRAs and other account-based group health plans to provide more Americans with additional options to obtain quality, affordable healthcare. The final rules affect employees and their family members; employers, employee organizations, and other plan sponsors; group health plans; health insurance issuers; and purchasers of individual health insurance coverage.

Background: Executive Order

On October 12, 2017, President Trump issued Executive Order 13813, “Promoting Healthcare Choice and Competition Across the United States,” stating, in part, that the “Administration will prioritize three areas for improvement in the near term: association health plans (AHPs), short-term, limited-duration insurance (STLDI), and health reimbursement arrangements (HRAs).” With regard to HRAs, the Executive Order directs the Secretaries of the Treasury, Labor, and HHS to “consider proposing regulations or revising guidance, to the extent permitted by law and supported by sound policy, to increase the usability of HRAs, to expand employers’ ability to offer HRAs to their employees, and to allow HRAs to be used in conjunction with nongroup coverage.” The Executive Order further provides that expanding “the flexibility and use of HRAs would provide many Americans, including employees who work at small businesses, with more options for financing their healthcare.”

Isolated quotes under “II. Overview of the Final Rules on Individual Coverage HRAs and Excepted Benefit HRAs—the Departments of the Treasury, Labor, and Health and Human Services”:

“Some commenters expressed general support for allowing employers to move to a defined contribution approach for health insurance coverage, including because this likely permits greater employee choice.”

“One commenter expressed general concern about the shifting of employees from a defined benefit health plan system to a defined contribution health plan system, because, according to the commenter, it may result in less comprehensive coverage.”

“Other commenters stated that individuals in the individual market could face more expensive plans, lower employer contributions, narrower networks, and higher cost sharing.”

https://www.federalregister.gov…

Could next year be the beginning of the end of traditional employer-sponsored health insurance?

By Michael Kolber
The Hill, August 20, 2019

The same type of transformation that turned traditional pension plans into employee-directed 401(k)s may be coming for employer-sponsored health plans—and sooner than most realize.

The consequences of this transformation would be widespread, with impacts throughout the health care system, from hospitals and doctors to drug and device makers to insurance companies, brokers and vendors. It could even impact the political debate about single-payer health care.

A new rule from the IRS and other federal agencies could set this afoot. Beginning in January 2020, any employer can give employees pretax compensation to buy individual market health insurance instead of providing a traditional employer-sponsored group health plan.

Thinkers from across the political spectrum have long decried the uniquely American phenomenon of tying health benefits to employment. In addition to creating an artificial linkage between employment and health coverage, generous employer-sponsored health benefits may play a role in driving health care inflation. But two factors have generally preserved the status quo, with about half of Americans in employment-based coverage.

First, until the Affordable Care Act was implemented, the individual market for health insurance was not functional in many places, leaving employers with few options if they wanted to ratchet back their health benefits. Individuals could have been denied coverage or charged higher rates based on health status, or had pre-existing condition exclusions imposed.

Second, both before and after the ACA, employers had a significant incentive to provide generous health benefits because employer spending on a health plan is not treated as taxable income for the employee, effectively increasing the value of this form of compensation to the employee. The ACA added to this incentive by affirmatively requiring large employers to share in the responsibility for providing health coverage to employees. On top of this, Obama-era rulings interpreting the ACA effectively precluded all employers (large and small) from contributing to the cost of individual coverage obtained by employees.

The ACA fixed the first problem—guaranteeing access to individual market coverage at a uniform price regardless of health status and without pre-existing condition exclusions—but in doing so exacerbated the second. The new federal rule now solves the second problem: Employers will be permitted to fund “health reimbursement arrangements” (HRAs) for employees to buy individual market health insurance. The employee does not pay income tax on amounts the employer contributes to the HRA.

The major remaining constraint on the 401(k)-ization of employer health benefits will be the pressures of the labor market. Will employees accept jobs that don’t guarantee them particular health benefits but instead offer defined contributions to an HRA that may or may not be sufficient to buy equivalent coverage on the individual market? Many employers would love not to have to bear the administrative burdens of running a traditional health plan, and all are looking for ways to keep health costs down. How many will be willing to test the labor market in this way?

The federal government estimates that within five years, about 11 million people will receive individual market coverage funded through an HRA, but those people will be spread across 800,000 employers, meaning only about a dozen employees will get health care this way from each participating employer. The IRS admits this estimate is highly uncertain, but there is little reason to think so few employers will make this shift, or that it will remain limited to very small employers. As with other disruptive innovations, it is entirely plausible that what begins in the low end of employers will take over the entire sector. Further, even among the 11 million the IRS predicts, the IRS estimates that most will be replacing conventional group health plans with HRAs—these are not employees, for the most part, whose employers are using an HRA to offer coverage for this first time.

The consequences could be dramatic. Today, reimbursement by employment-based health plans is the fuel that drives many sectors of the health economy, in many cases keeping afloat hospitals, physicians, dialysis providers, drug and device makers, and other providers that may receive lower reimbursement for patients on Medicare or Medicaid (and nothing for those who remain uninsured). And, at least today, the individual market coverage that an HRA would buy is quite different from employment-based coverage: Typically there are fewer providers in network, who may receive lower reimbursement rates. There may be no out-of-network benefits except in emergencies, and deductibles and other enrollee cost-sharing are often much higher.

If millions more people join the individual market through HRAs, these plan design features could change to look more like conventional employment-based coverage—or HRAs may further incentivize lower-premium plans, reinforcing the need for less comprehensive plans. Either way, each sector of the health care system will need to think about the implications: Hospitals and doctors will need to continue their focus on collecting payments from individual patients with high-deductible plans, and all providers will need to understand a world of potentially lower reimbursement and higher enrollee cost-sharing. Brokers and tech vendors will need to help employees navigate increasingly complex coverage decisions. Insurers may need to adjust to the higher administrative costs implicit in individual market coverage.

The shift could also impact political realities: A significant hurdle to state and federal “single payer” health care reform is the general satisfaction today of the millions of people in employment-based coverage, representing about 60 percent of nonelderly adults. If these people are shifted to higher-deductible plans with narrower provider networks, and are forced to comparison-shop for a plan each year, the fortunes of single payer could improve, as the alternative begins to seem less attractive.

n short, the health care system must wrestle with whether HRAs will make traditional group health plans as rare as traditional “defined-benefit” pensions, and, if so, how quickly.

Michael Kolber is a partner at Manatt Health.

https://thehill.com…

Comment:

By Don McCanne, M.D.

President Trump’s Executive Order of October 12, 2017 (quoted above) generated alarm because he ordered the prioritization of association health plans (AHPs), which historically have had a terrible track record, and the prioritization of short-term, limited-duration insurance (STLDI), which are grossly inadequate plans. Although considerable concern was expressed then about these recommendations, it is likely that any impact will be negligible since there is essentially no market interest in these plans. What should concern everyone instead is his third order: the prioritization of health reimbursement arrangements (HRAs).

HRAs sound benign, sort of like health savings accounts (HSAs) or flexible spending accounts (FSAs). The primary difference is that HRAs are designed to be full health benefit plans by pairing them with health insurance plans. Why is that important?

Most of you are aware what happened when 401k retirement plans were established. Employers began discontinuing their traditional pension plans which provided a defined benefit – essentially guaranteed income in retirement, but they are mostly history now (only 16% of Fortune 500 companies offer them, down from 59% in 1998). In contrast, the 401k plans are funded by a defined contribution with no guarantee of the amount the plan will pay nor how long the payments will last. This shift from defined benefit to defined contribution has been disastrous for many who find that Social Security payments along with the 401k distributions fall far short of the financial needs in their retirement years.

It looks now like the new rule based on Trump’s order to prioritize HRAs is a setup to convert today’s defined benefit employer-sponsored health plans into defined contribution HRA health plans, beginning with smaller businesses, especially new businesses that are just initiating their plans. But large businesses have been looking for relief so certainly a defined contribution approach will be appealing to them. According to today’s Quote of the Day sources, that conversion means lower premiums that buy less generous plans, higher deductibles and other cost sharing, lower provider payments and narrower networks which may threaten the adequacy of the health care delivery system. Those currently favoring employer-sponsored plans over Single Payer Medicare for All should immediately reconsider what they are wishing for.

Michael Kolber suggests that the inevitable increased dissatisfaction may drive greater support for a single payer system, but based on previous decades of the perpetual inertia preventing us from enacting effective, efficient, and equitable reform, it may be a decade or more before the light bulb goes on. Many more people will suffer, go bankrupt, or even die prematurely.

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Since 1978, CEO compensation up 940%; workers 12%

CEO compensation has grown 940% since 1978. Typical worker compensation has risen only 12% during that time.

By Lawrence Mishel and Julia Wolfe
Economic Policy Institute, August 14, 2019

What this report finds: The increased focus on growing inequality has led to an increased focus on CEO pay. Corporate boards running America’s largest public firms are giving top executives outsize compensation packages. Average pay of CEOs at the top 350 firms in 2018 was $17.2 million—or $14.0 million using a more conservative measure. (Stock options make up a big part of CEO pay packages, and the conservative measure values the options when granted, versus when cashed in, or “realized.”) CEO compensation is very high relative to typical worker compensation (by a ratio of 278-to-1 or 221-to-1). In contrast, the CEO-to-typical-worker compensation ratio (options realized) was 20-to-1 in 1965 and 58-to-1 in 1989. CEOs are even making a lot more—about five times as much—as other earners in the top 0.1%. From 1978 to 2018, CEO compensation grew by 1,007.5% (940.3% under the options-realized measure), far outstripping S&P stock market growth (706.7%) and the wage growth of very high earners (339.2%). In contrast, wages for the typical worker grew by just 11.9%.

Why it matters: Exorbitant CEO pay is a major contributor to rising inequality that we could safely do away with. CEOs are getting more because of their power to set pay, not because they are increasing productivity or possess specific, high-demand skills. This escalation of CEO compensation, and of executive compensation more generally, has fueled the growth of top 1.0% and top 0.1% incomes, leaving less of the fruits of economic growth for ordinary workers and widening the gap between very high earners and the bottom 90%. The economy would suffer no harm if CEOs were paid less (or taxed more).

From the Conclusion

Some observers argue that exorbitant CEO compensation is merely a symbolic issue, with no consequences for the vast majority of workers. However, the escalation of CEO compensation, and of executive compensation more generally, has fueled the growth of top 1.0% and top 0.1% incomes, generating widespread inequality.

High CEO pay reflects economic rents—concessions CEOs can draw from the economy not by virtue of their contribution to economic output but by virtue of their position. Clifford (2017) describes the Lake Wobegon world of setting CEO compensation that fuels its growth: Every firm wants to believe its CEO is above average and therefore needs to be correspondingly remunerated. But, in fact, CEO compensation could be reduced across the board and the economy would not suffer any loss of output.

Another implication of rising pay for CEOs and other executives is that it reflects income that otherwise would have accrued to others: What these executives earned was not available for broader-based wage growth for other workers. (Bivens and Mishel 2013 explore this issue in depth.) It is useful, in this context, to note that wage growth for the bottom 90% would have been nearly twice as fast over the 1979–2017 period had wage inequality not grown. Most of the rise of inequality took the form of redistributing wages from the bottom 90% (whose share of wages fell from 69.8% to 60.9%) to the top 1.0% (whose wage share nearly doubled, rising from 7.3% to 13.4%).

https://www.epi.org…

Comment:

By Don McCanne, M.D.

There has been much written about the growth in income and wealth inequality and the injustices that result therefrom. As one important contributor, this study shows that CEO compensation is obscene, but does that really matter, and, if so, what should we do about it?

Some say that we should not begrudge those with very high incomes and wealth, but the problem is that, as this and many other studies have shown us, their high compensation “reflects income that otherwise would have accrued to others.”

The greatest concern that most people have regarding health care is its affordability. At 18% of our GDP, the majority cannot afford to pay their proportionate share into a pool of funds that would comprise our national health expenditures.

It becomes immediately obvious that an important step towards making health care affordable for all of us would be to recover some of the excess income from the very wealthy that should be accruing to others and place that in a universal risk pool for health care. Taxes function not only as a source of public revenues, but they also serve to make income and wealth more equitable (not necessarily equal, but fair).

There are certainly other policies that can be established to inject more fairness into our economy, but establishing an equitable Single Payer Medicare for All that’s affordable for each of us would be a giant first step toward rectifying the injustices of income and wealth inequality, while providing us all with the great benefit of access to health care nirvana.

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Decrease in private nongroup coverage leaves more uninsured

Health Insurance Coverage Declined for Nonelderly Americans Between 2016 and 2017, Primarily in States That Did Not Expand Medicaid

By Laura Skopec, John Holahan, and Caroline Elmendorf
Robert Wood Johnson Foundation, Urban Institute, August 15, 2019

The Issue

Between 2013 and 2016, the uninsurance rate for nonelderly Americans from birth to age 64 fell every year, and 18.5 million more Americans had health insurance coverage in 2016 than in 2013. However, these coverage gains stalled in 2017. Using the American Community Survey, this research finds that uninsurance increased between 2016 and 2017, despite a strong economy and accompanying increases in incomes and employer-sponsored insurance (ESI) coverage.

Key Findings

  • The uninsured rate climbed from 10.0 percent in 2016 to 10.2 percent in 2017, the first increase since 2013, after significant declines driven by the Affordable Care Act (ACA). This decline resulted in 700,000 more uninsured people in 2017 than in 2016.
  • The uninsured rate held stable in Medicaid expansion states at 7.6 percent, but increased from 13.7 percent to 14.3 percent in states that did not expand Medicaid.
  • Non-Medicaid expansion states lost marketplace coverage at twice the rate of expansion states.

Conclusion

Factoring in population growth in 2017, gains in ESI mitigated, but did not overcome reductions in Medicaid and CHIP and ACA marketplace coverage. Researchers observed broadly distributed losses across all age groups and income levels. Non-Hispanic white and black nonelderly people, those with at least some college education, and those living in the South and Midwest, experienced disproportionate coverage losses. The authors conclude that these increases in uninsurance will likely occur disproportionally in nonexpasion states, given their greater reliance on private coverage.

From the Brief

Overall, coverage losses were concentrated in the 19 states that did not expand Medicaid eligibility under the Affordable Care Act by July 1, 2017. Between 2016 and 2017, uninsurance held stable in Medicaid expansion states but increased by 0.5 percentage points in nonexpansion states. Though both expansion and nonexpansion states saw increases in employer-sponsored insurance and decreases in Medicaid/CHIP and private nongroup coverage over this period, the percentage-point decline in private nongroup coverage in nonexpansion states was nearly double that in expansion states (-0.6 percentage points versus -0.3 percentage points), precipitating larger coverage losses.

The increasing uninsurance rate in nonexpansion states between 2016 and 2017 may reflect their greater exposure to changes in the availability and affordability of marketplace and private nongroup coverage. In nonexpansion states, nonelderly people with incomes between 100 percent and 138 percent of the federal poverty level are eligible for marketplace subsidies to purchase private nongroup coverage, rather than Medicaid/CHIP coverage, so coverage gains in these states between 2013 and 2016 relied more on the availability and affordability of private nongroup coverage than coverage gains in Medicaid expansion states. Further changes to private nongroup coverage and marketplace policies in 2018 and 2019, including shorter open enrollment periods, availability of short-term, limited-duration policies, loss of federal funds to support cost-sharing subsidies, and repeal of the individual mandate to purchase coverage, may also disproportionately reduce coverage in nonexpansion states in the coming years.

https://www.rwjf.org…

Comment:

By Don McCanne, M.D.

With the implementation of the Affordable Care Act (ACA), 18.5 million more Americans had health insurance coverage in 2016 than in 2013. However, the numbers of uninsured declined by 700,000 between 2016 and 2017. The decline was predominantly in the private nongroup and ACA marketplace plans and occurred primarily in states that did not expand their Medicaid eligibility.

Although the greatest success of ACA was in the expansion of Medicaid, the Medicaid program already existed and could have been expanded without enactment of ACA. The other ACA program – establishment of the private insurance exchanges or marketplaces – has fallen short of goals of universality and affordability, and enrollment began reversing in 2016. ACA also increased regulatory oversight, but at a cost of increased financial barriers to care through higher deductibles, and diminished access to care because of wider use of restricted provider networks. There is also some question about the expansion of Medicaid since many were forced into Medicaid managed care programs that seem to be falling short on performance.

The current debate over reform is whether 1) to continue to try to tweak ACA, perhaps adding more administrative complexity through a public option, in spite of the post-ACA highly flawed, dysfunctional health financing infrastructure, or 2) to replace the system with an as yet undefined Republican plan which would likely transfer more of the responsibility of obtaining care to individual patients making care even less affordable and less accessible, or 3) to enact and implement a single payer model of an improved version of Medicare that would cover everyone. There is really only one reasonable choice here: Single Payer Medicare for All – that is if we want to have a high quality health care system that takes care of everyone of us and is affordable for each of us.

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

A cure for our dysfunctional health-care system

By David McLanahan, M.D.
The Seattle Times, August 19, 2019

Re: “Murder-suicide is suspected in pair’s deaths” [Aug. 11, B7]:

The news of the elderly couple’s death is another in the litany of tragedies inflicted upon American families by our dysfunctional health-care system.

As the article points out, current Medicare and Medicaid cover only 65% of medical expenses. As well as bearing the discomfort of illness, elderly people face deductibles, co-pays, high-cost medications, other out-of-pocket expenses and oppressive insurance paperwork. They often face the prospect of going bankrupt, losing their life savings, if any, and the prospect of asking family members and friends to help out. We all can understand this couple’s resolution.

The tragic decision facing this family would likely have been averted if they were covered by Improved Medicare for All, such as embodied in Rep. Pramila Jayapal’s H.R. 1384. This legislation would enable all of us to receive the health care we need from birth without any financial worries.

It’s time for all of our representatives — national, state, and local — to follow the lead of their constituents to join us in supporting justice in health care.

https://www.seattletimes.com…

Sweet Dreams: The Future of Medicine

By Brent W. Beasley, M.D., M.B.A.
Physician Leadership Journal, August 19, 2019

Enter the brave new world of science fiction, and discover the benefits of universal coverage, deep-learning artificial intelligence, and solutions to pharmaceutical affordability — all of which is within our grasp.

I’VE TOLD MY FRIENDS THAT I know  we won’t time travel in the future because the first thing I would do is return to the past to tell myself that it’s going to happen. That was a great after-dinner conversation until 


During a recent lunch hour, I was sitting on a park bench at our medical school campus, frustrated by the third prior-authorization denial of the morning, when the smell of sulfur tickled my nose, a quick breeze blew through my hair, a sound like a clap of thunder startled me, and, as if an elevator opened in front of me, a person looking a lot like my father stepped through a crack in space and said, “There will be time travel in our future!”

I was most surprised. I stood up next to myself and stared. I actually touched my — or, rather, I should say, his so you can keep us apart — forehead and noted the deep wrinkles of laugh lines and sorrows. It was me, or more precisely will be me. We sat down, chuckled together and talked.

He wouldn’t answer about my future, my children’s lives, my friends — something about avoiding paradoxes and becoming my own grandfather. So, we were stumped. What could my older me say about the future?

“Well, I suppose I could tell you about the future of medicine!” he exclaimed.

“Aren’t you concerned I could mess it up?” I asked.

“As if you have any power to change the current or future state of medicine?” he harrumphed. “Of course, I’m not concerned.”

“You have a point,” I shrugged. “So, what does the future hold for health care?”

He thought with eyes squinted. Finally, he announced, “I can tell you that universal coverage passed in the U.S. Congress.”

“You’re joking? The liberals finally pushed it through?” I asked, jaw hanging.

“Of course not! The business community rose up en masse when they realized that, instead of corporations paying a trillion dollars in health care costs per year, all U.S. citizens could be covered, as other first-world countries have done, at a huge savings to them. Individual taxes went up, but we pay nothing for health insurance and have no out of pocket costs. Three trillion dollars in health care savings the first decade! Not only that, the administrative costs burdening doctors’ offices dropped like a rock overnight.”

“Wow,” I exclaimed. “I never thought that would happen. Did Bernie live to see the day?”

“They rolled him out to wave at the crowd,” he affirmed. “In the first year, many of the racial disparities in care disappeared as all people had equal coverage,” he affirmed. “There was evidence that would result back before 2020, when the Affordable Care Act Medicaid expansion states provided improved care to people of color and those in poverty.”1,2

“Did the government take over the hospitals?” I asked.

“Nope,” he shook his head, “they left them alone. Universal coverage was only about ensuring all citizens had insurance.”

“But what about free enterprise? Competition in the market place?” I retorted.

He snorted. “Once all the public held the same ‘currency,’ ” he said, making air quotes, “health systems became truly competitive, regardless of their location and payer mix.”

“Didn’t health care costs keep rising?” I asked naively.

He laughed. “No, it was exactly as Anderson kept telling us back in the day: ‘It’s the prices, stupid!’ Having one large payer doing the negotiating ensured high-value care was provided at affordable prices.”3

“So, what else you got in that brave new world?” I prodded, elbows on my knees, and eager. He placed his hands behind his head, and leaned back.

“Let’s see,” he pondered. “Artificial intelligence 
 that’s been a game changer,” he said, pointing his finger at my chest and nodding.

“You mean robot doctors?” I asked, eyes wide.

He looked at me with disdain. “I mean the ‘deep learning’ kind of AI that helps with diagnosis and treatment.4 My smartwatch app listens to patient encounters, tracks symptoms and signs, and spits out a prioritized differential diagnosis with an evidence-based workup and treatment plan individualized for the patient. The diagnostic accuracy is much higher than any physician could develop alone. At first it was off-putting, and my patients looked askew when they heard the app talking to me in the exam room. A decade later, patients expect it.”

“I’m not sure I’d feel comfortable with that kind of intrusion,” I added, eyebrows crossed.

“You won’t. I wasn’t,” he demurred. He raised an eyebrow, “More problematic is AI radiology and pathology. Even in your days, computer-based radiology and pathology were more sensitive than the human ability to find problems.5 That trend continued, and the specificity only improved with time. There are very few radiologists and pathologists in practice anymore. They exist in our future mainly to characterize anomalies and oddities.”

I stroked my chin. Should I alert our medical students so they make informed decisions about career choice? Or would that be meddling with the future?

“And then, you’ll be glad to know we don’t enter data into EHRs anymore,” he smirked.

“Great Osler’s ghost!” I exclaimed.

“Instead, we have a video camera in the room, recording the visit. It parses into an electronic document the history, the exam, the diagnoses, and the treatment plans discussed. It creates a relatively short note, since,” he smiled, “with universal coverage, nobody is concerned about documenting for payment reasons.”

My excitement was growing.

“Tell me about the pharmaceutical industry. Have you tamed the beasts yet?” I asked expectantly.

He nodded, and stuck his bottom lip out. “It’s better. Universal coverage gave Americans one strong bargaining partner for Big Pharma. The Food and Drug Administration, which sits under the executive branch of government, finally limited the patentability of inconsequential changes in “me too” medicines, stopped extending patents, and put more resources into reviewing generic drugs—all to increase their availability. They also got tough on new devices.”

We both leaned back against the park bench and looked up into the wild blue yonder.

“Wow,” I said after a minute, shaking my head slowly, not taking my eyes off the white billowing clouds set in the sky, “it sounds like a great place to practice medicine.”

“It truly is,” he nodded, then looked over at me. “But, now you have to get back to the clinic and see your patient.” He grabbed my arm and shook me. I pushed his hand away. He seemed very insistent and shook me more. I looked over at him.

“Dr. Beasley,” he said with a woman’s voice, “please wake up and come back inside. Ms. Jones is waiting to be seen.”

Suddenly, I awoke and looked up at my nurse, who scowled.

“Wait! Where did I go?” I asked with a start, looking behind and underneath the park bench for my older me, as my nurse put her hands on her hips and tapped her toe, impatiently.

Brent W. Beasley, M.D., M.B.A., is a frequent commentary contributor to the Physician Leadership Journal. He is medical director for internal medicine and a professor in the School of Community Medicine at the University of Oklahoma at Tulsa.

https://www.physicianleaders.org…

REFERENCES

1. Daw JR, Sommers BD. Association of the Affordable Care Act Dependent Coverage Provision With Prenatal Care Use and Birth Outcomes. JAMA. 2018;319(6):579-587.

2. Swaminathan S, Sommers BD, Thorsness R, Mehrotra R, Lee Y, Trivedi AN. Association of Medicaid Expansion With 1-Year Mortality Among Patients With End-Stage Renal Disease. JAMA. 2018 Dec 4;320(21):2242-2250.

3. Anderson GF, Reinhardt UE, Hussey PS, Petrosyan V. It’s the prices, stupid: why the United States is so different from other countries. Health Aff (Millwood). 2003 May-Jun;22(3):89-105.

4. Hinton G. Deep Learning—A Technology With the Potential to Transform Health Care. JAMA.2018;320(11):1101–1102.

5. Jha S, Topol EJ. Adapting to Artificial Intelligence: Radiologists and Pathologists as Information Specialists. JAMA.2016;316(22):2353–2354.

We’re doctors, and we’re debunking myths about Medicare for All

By Eve Shapiro, M.D. and Paul Gordon, M.D., M.P.H.
Arizona Daily Star, August 17, 2019

As physicians who have been working on improving our health care system by implementing an improved “Medicare for All,” we are dismayed by the current debate on health care reform, both on the part of the journalists and politicians.

We hope to clear up some of the myths that have been commonly portrayed in the media.

Myth No. 1: Medicare for All will cause Americans to lose their private health insurance coverage.

Fact: yes, but it will be replaced by a comprehensive government-financed (not government-controlled) insurance plan that will cover all Americans and include all physicians.

Your current physician from your private health insurance plan, will be part of the Medicare for All plan. There will be no out-of-pocket costs, no copays, no deductibles, no surprise billing or risk of medical bankruptcy.

After all, what do private insurance companies contribute to health care other than adding to complexity, paying CEOs exorbitant salaries (in the 100s of millions of dollars) and reaping enormous profits? Right now, over 20% of all the money spent on health care goes to these companies, which provide no benefit.

That money could be used to insure the 20 million Americans without health coverage now.

Myth No.2: Taxes will go up.

Yes, Medicare for All will be paid for by a progressive tax and possibly other taxes on the wealthy and financial transactions. For the vast majority of Americans, their costs on health care will drop significantly.

Currently, health insurance costs the average family of four over $12,000 a year from premiums, copays and deductibles.

This will be replaced by an equitable tax based on income and most people will wind up paying far less in new taxes than they are currently paying for all of their healthcare costs.

Myth No. 3: We can’t afford it.

Currently, the U.S. pays more than twice as much as most other developed countries and our health outcomes are worse than theirs. These other countries all have a version of single-payer, and if they have any private insurance, they are closely regulated and must be nonprofit.

In other words, we can’t afford NOT to introduce Medicare for All because our current costs are going to keep rising.

Myth No. 4: It’s too disruptive.

Changes in employment or marital status, reaching age 26, or increased income above eligibility thresholds for Medicaid or exchange subsidies currently disrupt coverage for needed care. Improved Medicare for All is cradle to grave coverage that each of us can afford.

Having no cost at the time of service is important to avoid disruptions. Medicare for All is actually less disruptive.

Myth No. 5: We need to take smaller, safer steps.

Incremental steps, such as a Medicaid or Medicare public option, have been proposed by several of the Democratic candidates.

Yet it is putting a Band-Aid on a dirty, infected wound and won’t solve our health-care problems. For-profit insurance companies collude with the drug and large hospital corporations, creating the current extreme costs for health care and gaps in care that are so prevalent in our country.

If we continue private insurance with the public option, two problems emerge. We won’t get the savings we can get from eliminating private insurance and the private insurance companies will cherry pick the healthier people and the public option will not survive.

The improved Medicare for All legislation includes vision, dental, hearing, mental health and long-term care.

It will eliminate the financial burden of premium, deductibles and copays so nobody would ever have to choose between paying their bills and going to the doctor; medical bankruptcy will be a thing of the past.

Dr. Eve Shapiro is a pediatrician and Dr. Paul Gordon is a family practice physician in Tucson.

https://tucson.com…

Trump Is Scaring Immigrants Away from Healthcare Services to Help the Rich

The new public charge rule was created to isolate working class people from the healthcare benefits they need to survive.

By Adam Gaffney, M.D., M.P.H.
Vice, August 16, 2019

Ana felt that she had to make a choice: obtain desperately-needed health services—like therapy—for her nine-year old daughter with autism, or risk that her family would have to leave the country or be separated, NPR reported last January. As an immigrant living in Texas, Ana feared that seeking more services for her daughter could jeopardize the process of obtaining legal permanent residency status (a “green card”), even though her daughter was a citizen enrolled in Medicaid.

Such fears—well-founded or not—may be growing. On Monday, the Trump administration fanned them when it released a new regulation branding legal immigrants “public charges,” and hence persona non grata, as punishment for using programs like Medicaid or food assistance. The rule also makes wealth a key criterion by which immigrants will be sorted when it comes to determining who can stay, and who must go.

In response, some immigrants will predictably avoid or disenroll from social programs—including healthcare—to which they are entitled. But even immigrants who are not targeted by the rule will invariably be confused and fearful of it, said Leah Zallman, a colleague at Harvard Medical School and the Cambridge Health Alliance who studies immigrant health. Like Ana, some will be afraid that even enrolling family members in government programs could jeopardize their immigration status—potentially leading to the separation of their family. And so, Zallman told me, parents “are dis-enrolling kids even when the kids have legal access to these benefits and are not subject to the rule.”

This “chilling effect,” as researchers call it, is a feature of such programs, not a bug. It would be a mistake to see the public charge rule as the consequence of ignorance among administration policymakers, or a failure to read the relevant public health literature. Their obvious purpose—in design if not in word—is redistribution: taking healthcare from low-income families in order to pad the bank accounts of the rich. This was the story of the 2017 Obamacare repeal bills, just as it is the story of Medicaid work requirements, and the public charge rule today.

A few months after the public charge rule was proposed last October, for instance, a study from the Urban Institute found that about a fifth of adults in low-income immigrant families were already avoiding government programs out of fear of sinking their prospects of obtaining legal permanent residency.

One recent study in JAMA Pediatrics, led by Zallman, found that more than eight million children are at risk of losing access to health coverage or food assistance because of the rule. Those at risk include children with serious medical conditions—including hundreds of thousands with asthma and epilepsy. Without treatment, children with asthma can struggle to breathe, miss school, wind up in the ER or hospital—even asphyxiate. Failure to treat epilepsy, in turn, can lead to recurrent, dangerous, life-disrupting seizures. But that is simply a price the administration is willing to pay.

In 1882, in an earlier age of flourishing nativism, Congress passed the first “public charge” exclusion into federal law. However, the “public charge” rule has had a narrow scope in recent years, applying only to those who received cash assistance or public nursing-home care. The Trump administration’s new regulation upends that, casting legal immigrants who use a broad range of services—ranging from food stamps to housing assistance to Medicaid—as undesirables. Such “public charges” can then be denied a change in immigration status, such as issuance of a “green card.”

The new public charge rule hence weaves the administration’s xenophobic agenda into its broader regressive economic agenda. The administration’s head immigration official Ken Cuccinelli defended this draconian approach in an interview on NPR Tuesday by revising the famous quote inscribed on the Statue of Liberty’s pedestal. “Give me your tired and your poor,” he said, “who can stand on their own two feet, and who will not become a public charge.”

Not surprisingly, the rule mirrors the administration’s other health policies, such as the Medicaid work requirements championed by CMS administrator Seema Verma. Just like the public rule, Medicaid work requirements are ostensibly designed to reward a good work ethic. But in reality, both mainly serve to confuse working-class people—and squeeze them out of health coverage.

More than 18,000 individuals lost Medicaid coverage after work requirements went into effect in Arkansas last year, even though few were actually targeted by the policy as written. A failure to understand the arcane requirements and exclusions “may explain why thousands of persons lost coverage even though more than 95% of the target population appeared to meet the requirements or qualify for an exemption,” as a recent study in the New England Journal concluded.

The stakes are high, because programs like Medicaid can be a lifeline for working-class families, immigrant and non-immigrant alike. Activist Kristian Hernandez, whose parents both emigrated from Mexico and who today helps guide immigrants applying for asylum through the legal process in Texas, told me how important food and healthcare benefits were for her working-class family growing up: “[W]e wouldn’t have been able to survive otherwise,” she said. Hernandez fears that the rule could keep immigrant families in a similar position from such benefits today.

The public charge rule is cut from the same cloth as the administration’s larger redistributive agenda. Together, these policies are engineered to take healthcare (and other benefits) from the working class—disproportionately immigrants and people of color—so as to benefit the privileged few. It’s class warfare, and the kids with asthma and epilepsy are the collateral damage.

Adam Gaffney is a physician and public health researcher at Harvard Medical School and the Cambridge Health Alliance. He serves as president of the advocacy organization, Physicians for a National Health Program.

https://www.vice.com…

AMA bails out of partnership opposed to Medicare for All

AMA drops out of industry coalition opposed to Medicare expansion

By Dan Diamond and Adam Cancryn
POLITICO, August 15, 2019

The American Medical Association has quit a coalition that’s led the health industry’s fight against Medicare expansion, the first crack in its opposition to Democratic candidates’ proposals.

The AMA’s logo is no longer visible on the website of the Partnership for America’s Health Care Future, and multiple individuals with knowledge of the decision told POLITICO that the physicians’ organization decided to drop out after the coalition broadened its opposition last month from “Medicare for All” to more incremental proposals like former Vice President Joe Biden’s plan for a government-run public option. The AMA in June agreed at an annual meeting to study the feasibility of a public option after years of opposition to single-payer health care.

The AMA confirmed its departure. “Missing in the recent debate is an ongoing discussion of practical solutions that will result in more affordable insurance options,” CEO James Madara said in a statement to POLITICO, adding that the association recently laid out proposals to help achieve universal coverage. “The AMA decided to leave the Partnership for America’s Health Care Future so that we can devote more time to advocating for these policies that will address current coverage gaps and dysfunction in our health care system.”

The partnership — comprised of nearly 60 groups, including the American Hospital Association and AHIP — has spent millions of dollars advertising against Democrats’ Medicare expansion ideas and is currently running a messaging campaign against Biden’s public option proposal.

The AMA was among the partnership’s founding members in spring 2018. Several other member organizations affirmed that they will remain part of the industry coalition, blaming the AMA’s departure on internal dissension between younger doctors who support Democrats’ proposals and older physicians who remain wary of expanding government-run coverage.

https://www.politico.com…

Comment:

By PNHP President Adam Gaffney, M.D., M.P.H.

Yesterday, the American Medical Association announced that it is leaving the Partnership for America’s Health Care Future, a coalition of private insurance, pharmaceutical, and for-profit hospital companies whose sole purpose is to fight single-payer Medicare for All.

This is a big victory for single-payer supporters. In June, a coalition of doctors, nurses, students, seniors, and disability rights advocates descended on the AMA annual meeting in Chicago. We held a lively march and rally in the streets outside the meeting, while a group of activists launched a surprise “die-in” in the middle of the conference proceedings. Our demands to the AMA were clear: Leave the Partnership for America’s Health Care Future and drop your opposition to single payer.

While the AMA voted to maintain its anti-single payer policy, the razor-thin margin — 53% to 47% — stunned observers. And today we celebrate our second victory: The AMA’s resignation from this shameful campaign against health care justice.

I’m grateful to everyone who participated in this campaign, especially the SNaHP students (Students for a National Health Program) who originally conceived of the action. It was truly a team effort, from those of you who marched with me in Chicago, organized your fellow activists to attend, wrote letters and op-eds, talked to news reporters, and shared the #AMAGetOutTheWay campaign on social media.

As our movement grows, the industry is going to fight even harder against improved Medicare for All. We must be prepared, and we must continue to push the AMA to build on this first step by not only dropping its opposition to single payer, but by fully supporting improved Medicare for All.

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

AMA Drops Out of Group Opposing Medicare for All

Wants to study a public option and other potential solutions

By Joyce Frieden
MedPage Today, August 16, 2019

The American Medical Association has dropped out of the Partnership for America’s Health Care Future, a coalition of healthcare stakeholders dedicated to torpedoing the idea of a single-payer healthcare system such as Medicare for All.

The coalition “has extensively highlighted the many serious problems with Medicare for All and other proposals that would lead to a single payer health care system,” James Madara, the AMA’s executive vice president and CEO, said in a statement about the move, which was first reported by Politico. “Missing in the recent debate is an ongoing discussion of practical solutions that will result in more affordable insurance options.”

“Practical solutions have been identified and continue to be championed by the AMA,” Madara continued. “The AMA decided to leave the Partnership for America’s Health Care Future so that we can devote more time to advocating for these policies that will address current coverage gaps and dysfunction in our health care system.” He emphasized that the association “[remains] opposed to Medicare for All, and policies that reduce patient choice and competition, and are built on flawed financing policies.”

In response, the coalition issued a cordial statement saying it “strongly agrees with the American Medical Association (AMA) that Medicare for all is the wrong approach for America’s healthcare and we have appreciated the opportunity to work with them throughout the past year.” The partnership’s members include America’s Health Insurance Plans, the American Hospital Association, the BlueCross BlueShield Association, the Biotechnology Innovation Organization, and other groups that would be affected by any move to a publicly financed health insurance program.

“Today, too many individuals and families who do not have employer sponsored insurance and are ineligible for government subsidies face costly premiums and high deductibles that restrict their access to care. Action is needed now to assist this population without disrupting coverage that works for most Americans,” he said. “Additional policy improvements will further the goal of expanding coverage and offering more affordable options for the uninsured and those struggling to secure meaningful health insurance coverage.”

Such options could possibly include a “public option” that would allow people to buy into a public program such as Medicare if they would like. At its annual meeting in June, the AMA House of Delegates referred the AMA Board of Trustees to a resolution calling for the organization to “study the impacts of various approaches that offer a public option … including but not limited to a Medicare buy-in; a public option offered on health insurance exchanges; and buying into either the Federal Employees Health Benefits Program or a state employee health plan.” (The Partnership for America’s Health Care Future opposes a public option, which it says could “decimate” rural hospitals’ finances.)

The resolution also reaffirmed AMA policy which states that coverage options offered in a health insurance exchange “be self-supporting; have uniform solvency requirements; not receive special advantages from government subsidies; include payment rates established through meaningful negotiations and contracts; not require provider participation; and not restrict enrollees’ access to out-of-network physicians.” The board will report back to the delegates on the resolution, possibly as early as the association’s interim meeting in November.

Medicare for All was a flashpoint at the June meeting, as several hundred protesters gathered outside the meeting hotel to demand that the AMA support Medicare for All; several dozen protesters came inside the main meeting room and staged a “die-in” on the House of Delegates floor.

At least one group was happy with the AMA’s exit from the partnership. “This is a big victory for single-payer supporters,” Adam Gaffney, MD, president of Physicians for a National Health Program (PNHP), which supports single-payer, said in a statement. “For decades, the AMA has been on the wrong side of history, fighting efforts to establish Medicare and Medicaid in the 1960s, and resisting movements to bring racial equality to the delivery and practice of health care … The AMA’s exit from this explicitly anti-single payer lobbying group shows that change is within reach.” PNHP was one of several groups that organized the protest at the AMA meeting.

https://www.medpagetoday.com…

The Cost-Effectiveness of Medicare for All

A health consultant says the free market has failed to rein in medical costs.

By Ken Lefkowitz
New York Times, Letters, August 16, 2019

To the Editor:

Re: “The Tough Calls on ‘Medicare for All’” (The Upshot, Aug. 13):

The discussions about choice and competition, as well as cost, ignore some critical information and perspectives.

American health care is financed through a free market that has proved ineffective in controlling costs because it requires transparency so consumers can compare prices. But the dizzying complexity of both medical care and insurance plan design precludes the consumer from making informed choices. Primary care physicians strongly influence choice, and insurance company provider networks limit choice even further.

Also, single-payer universal health care, or Medicare for all, is quite cost-effective. It has proved to be less costly in other countries. It will wring out the duplicative and wasteful administrative costs of the free marketplace and provide powerful national negotiating leverage to stabilize medical provider and pharmacy costs.

A University of Massachusetts study demonstrated that Medicare for all can cover all citizens, including today’s uninsured, eliminating deductibles and co-pays, and still save an estimated $600 billion.

Even those who receive health care through their unions or companies should welcome such a plan, since premiums, deductibles and co-pays have been rising at a rapid rate in their plans.

The writer, a consultant, has designed and managed health care plans for major companies.

https://www.nytimes.com…

Medicare for All Explained Podcast: Episode 18

Interview with Kristy Fogle

August 15, 2019

Emergency medicine physician assistant and Maryland Progressive Healthcare Coalition founder Kristy Fogle discusses her recent organizing work and reminds listeners that all private health insurance plans pale in comparison to improved Medicare for All. Hosted by Joseph Sparks. Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com