By Drs. James G. Kahn and Elliot Marseille
The Hill, July 17, 2019

The discussion of “Medicare for all” in June’s two Democratic primary debates was both gratifying and confusing. While it was heartening to see agreement on the principle of universal health care as a human right, the debate format eliminated any opportunity for nuance.

That’s why we’re clarifying seven critical issues raised in the debates, and which will likely return during the campaign. Full disclosure: We support Medicare for all and we think that with a clear understanding of the facts, most people will too.

1. What is Medicare for all?

It’s a system with a single, public, nonprofit health insurer, instead of the dozens of private and public insurers we have now. It is not “government-run health care.” It is “government-run health insurance.” Like with Medicare today, health care would be provided by independent doctors and hospitals.

Everyone would be covered for life by a single comprehensive benefit package and would choose their own doctors. Private insurance premiums and out-of-pocket costs would disappear, replaced by taxes that are fair and progressive (richer people pay more). Simplified insurance rules and billing would reduce paperwork costs while negotiations would reduce drug prices. Overall, we would save money while covering everyone.

2. What is a Medicare expansion, as opposed to Medicare for all?

Several candidates (e.g., Michael Bennet and Pete Buttigieg) mentioned a public option, such as a Medicare buy-in. A public option could be offered on state health insurance exchanges, providing what might appear to be a cheaper alternative to private insurance. But it won’t solve our problems. A buy-in would leave the complicated multi-payer system in place, so the opportunities for savings on paperwork and pharmaceuticals would disappear. Moreover, the health insurance industry would use every tactic it knows to push the sickest people into the public option, jeopardizing the financial stability of the program.

3. How do you define “working” when it comes to health care?

Rep. John Delaney (D-Md.) said, let’s “keep what’s working” in our current system. What does that mean? Today, millions of Americans remain uninsured or underinsured — with exorbitant deductibles and out-of-pocket costs on top of their ever-rising insurance premiums.

Medical bankruptcy is common, even among the insured — as Sen. Elizabeth Warren (D-Mass.) noted. And people with employer-sponsored private insurance? They lack health-care security. If they lose their job, they lose their insurance. If “working” means decent and reliable coverage, private health insurance is definitely not cutting it.

4. Which health-care choices really matter?

Beto O’Rourke said “Choice is fundamental” as an argument to retain commercial insurance. Yet it is our choice of doctor (not insurance company) that is fundamental to our care and that’s exactly the freedom that commercial insurance denies us — for profit.

5. What do we mean by private insurance under Medicare for all?

When asked, “Who would get rid of private insurance?” Bernie Sanders, Warren, Bill de Blasio, and Kamala Harris raised their hands. Harris later clarified that she wouldn’t want to abolish private insurance altogether. She has a point: Medicare for all could co-exist with private insurance for supplemental services, like fancier hospital rooms, or alternative therapies. However, private insurance for core medical benefits would be unnecessary. In fact, keeping it would undercut the savings we could enjoy from reducing insurance complexity and pharmaceutical prices.

6. What’s a “glide path?”

Buttigieg endorsed a “glide path,” that is, taking intermediate steps to Medicare for all. This makes sense if the timeline is short and the steps are direct. For example, filling in Medicare’s existing coverage gaps and adding all 50-65 year-olds would be excellent first steps. Alternatively, we could move quickly to help everyone suffering today. It only took about a year to roll out Medicare in 1966, without the use of the Internet or computers.

7. How will doctors and hospitals fare under Medicare for all?

Delaney suggested that if hospitals were paid Medicare reimbursement rates, they’d go bankrupt. This is a misrepresentation. First, under most Medicare for all plans, hospitals would be paid lump sums to cover operating costs. Second, payments would be negotiated to assure financial viability. Raising the specter of hospital closures is a scare tactic.

While Medicare for all may sound complex, it boils down to this: Everyone would get comprehensive health coverage for less money than we’re spending now. Don’t let the confusing debate rhetoric fool you. It really is that simple.

James G. Kahn, M.D., is an emeritus professor of health policy at the University of California San Francisco. Dr. Elliot Marseille, DrPH, is CEO of Health Strategies International.

https://thehill.com…

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Comment:

By Don McCanne, M.D.

Polls have shown that the majority of the public at large supports Medicare for All, but they also show a poor understanding of the all-important nuances of the single payer model of Medicare for All. Even members of the media do not always grasp the subtle but crucially important features of the model that make it so effective in ensuring affordable, accessible, comprehensive health care for absolutely everyone. Drs. Kahn and Marseille clarify for us some of the important nuances behind the rhetoric.

(A parenthetical comment on the “glide path”: There may be important logistical considerations for phasing in the implementation of a single payer Medicare for All program, but we must be certain that 1) the process is more efficient and effective than implementing the entire program all at once, 2) the transition of phasing out the current fragmented system while phasing in single payer does not result in precarious difficulties in winding down operations while simultaneously providing essential services to those still in transition, 3) any delay is based on crucial policy considerations rather than the politics of ideology, and 4) most important, the entire transition needs to be precisely specified in the original enabling legislation rather than merely defining the first steps with the intent of crafting later legislation for additional incremental steps in the glide path to reform. Half a century ago, Medicare for our retired population was to be the first step toward a Medicare program for all, but we never progressed beyond the first increment of including individuals with long-term disabilities and chronic kidney disease. We do not want to make that mistake again. If a glide path proves to be beneficial, it is imperative that it includes the landing lest we end up with another disaster on our hands.)

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By Fred Schulte and Lauren Weber
Kaiser Health News, July 16, 2019

Health insurers that treat millions of seniors have overcharged Medicare by nearly $30 billion the past three years alone, but federal officials say they are moving ahead with long-delayed plans to recoup at least part of the money.

Officials have known for years that some Medicare Advantage plans overbill the government by exaggerating how sick their patients are or by charging Medicare for treating serious medical conditions they cannot prove their patients have.

Getting refunds from the health plans has proved daunting, however. Officials with the Centers for Medicare & Medicaid Services repeatedly have postponed, or backed off, efforts to crack down on billing abuses and mistakes by the increasingly popular Medicare Advantage health plans offered by private health insurers under contract with Medicare. Today, such plans treat over 22 million seniors, more than 1 in 3 people on Medicare.

Now CMS is trying again, proposing a series of enhanced audits tailored to claw back $1 billion in Medicare Advantage overpayments by 2020 — just a tenth of what it estimates the plans overcharge the government in a given year.

At the same time, the Department of Health and Human Services Inspector General’s Office has launched a separate nationwide round of Medicare Advantage audits.

As in past years, such scrutiny faces an onslaught of criticism from the insurance industry, which argues the CMS audits especially are technically unsound and unfair and could jeopardize medical services for seniors.

America’s Health Insurance Plans, an industry trade group, blasted the CMS audit design when details emerged last fall, calling it “fatally flawed.”

Insurer Cigna Corp. warned in a May financial filing: “If adopted in its current form, [the audits] could have a detrimental impact” on all Medicare Advantage plans and “affect the ability of plans to deliver high quality care.”

But former Sen. Claire McCaskill, a Missouri Democrat who now works as a political analyst, said officials must move past powerful lobbying efforts to hold health insurers accountable and demand refunds for “inappropriate” billings.

“There’s a lot of things that could cause Medicare to go broke. This would be one of the contributing factors,” she said. “Ten billion dollars a year is real money.”

Catching Overbilling With A Wider Net

In the overpayment dispute, health plans want CMS to scale back — if not kill off — an enhanced audit tool that, for the first time, could force insurers to cough up millions in improper payments they’ve received.

For over a decade, audits have been little more than an irritant to insurers because most plans go years without being chosen for review and often pay only a few hundred thousand dollars in refunds as a consequence. When auditors uncover errors in the medical records of patients they paid the companies to treat, CMS has simply required a rebate for those patients for just the year audited — relatively small sums for plans with thousands of members.

The latest CMS proposal would raise those stakes enormously by extrapolating error rates found in a random sample of 200 patients to the plan’s full membership — a technique expected to trigger many multimillion-dollar penalties. Though controversial, extrapolation is common in medical fraud investigations — except for investigations into Medicare Advantage. Since 2007, the industry has successfully challenged the extrapolation method and, as a result, largely avoided accountability for pervasive billing errors.

“The public has a substantial interest in the recoupment of millions of dollars of public money improperly paid to health insurers,” CMS wrote in a Federal Register notice late last year announcing its renewed attempt at using extrapolation.

Penalties In Limbo

In a written response to questions posed by Kaiser Health News, CMS officials said the agency has already conducted 90 of those enhanced audits for payments made in 2011, 2012 and 2013 — and expects to collect $650 million in extrapolated penalties as a result.

Though that figure reflects only a minute percentage of actual losses to taxpayers from overpayments, it would be a huge escalation for CMS. Previous Medicare Advantage audits have recouped a total of about $14 million, far less than it cost to conduct them, federal records show.

Though CMS has disclosed the names of the health plans in the crossfire, it has not yet told them how much each owes, officials said. CMS declined to say when, or if, they would make the results public.

This year, CMS is starting audits for 2014 and 2015, 30 per year, targeting about 5% of the 600 plans annually.

This spring, CMS announced it would extend until the end of August the audit proposal’s public comment period, which was supposed to end in April. That could be a signal the agency might be looking more closely at industry objections.

Health care industry consultant Jessica Smith said CMS might be taking additional time to make sure the audit protocol can pass muster. “Once they have their ducks in a row, CMS will come back hard at the health plans. There is so much money tied to this.”

But Sean Creighton, a former senior CMS official who now advises the industry for health care consultant Avalere Health, said payment error rates have been dropping because many health plans “are trying as hard as they can to become compliant.”

Still, audits are continuing to find mistakes. The first HHS inspector general audit, released in late April, found that Missouri-based Essence Healthcare Inc. had failed to justify fees for dozens of patients it had treated for strokes or depression. Essence denied any wrongdoing but agreed it should refund $158,904 in overcharges for those patients and ferret out any other errors.

Essence also faces a pending whistleblower suit filed by Charles Rasmussen, a Branson, Mo., doctor who alleges the health plan illegally boosted profits by overstating the severity of patients’ medical conditions. Essence has called the allegations “wholly without merit” and “baseless.”

Essence started as a St. Louis physician group, then grew into a broader holding company in 2007 backed by prominent Silicon Valley venture capitalist John Doerr with his brother, St. Louis doctor and software designer Thomas Doerr. Neither would comment on the allegations.

How We Got Here

CMS uses a billing formula called a “risk score” to pay for each Medicare Advantage member. The formula pays higher rates for sicker patients than for people in good health.

Congress approved risk scoring in 2003 to ensure health plans did not shy away from taking sick patients who could incur higher-than-usual costs from hospitals and other medical facilities. But some insurers quickly found ways to boost risk scores — and their revenues.

In 2007, after several years of running Medicare Advantage as what one CMS official dubbed an “honor system,” the agency launched “Risk Adjustment Data Validation,” or RADV, audits. The idea was to cut down on undeserved payments that cost CMS nearly $30 billion over the past three years.

The audits of 37 health plans revealed that on average auditors could confirm just 60% of the more than 20,000 medical conditions CMS had paid the plans to treat.

Extra payments to plans that had claimed some of its diabetic patients had complications, such as eye or kidney problems, were reduced or invalidated in nearly half the cases. The overpayments exceeded $10,000 a year for more than 150 patients, though health plans disputed some of the findings.

But CMS kept the findings under wraps until the Center for Public Integrity, an investigative journalism group, sued the agency under the Freedom of Information Act to make them public.

Despite the alarming results, CMS conducted no audits for payments made during 2008, 2009 and 2010 as they faced industry backlash over CMS’ authority to conduct them, and the threat of extrapolated repayments. Some inside the agency also worried that health plans would abandon the Medicare Advantage program if CMS pressed them too hard, records released through the FOIA lawsuit show.

CMS officials resumed the audits for 2011 and expected to finish them and assess penalties by the end of 2016. That has yet to happen amid the continuing protests from the industry. Insurers want CMS to adjust downward any extrapolated penalties to account for coding errors that exist in standard Medicare. CMS stands behind its method — at least for now.

At a minimum, argues AHIP, the health insurers association, CMS should back off extrapolation for the 90 audits for 2011-13. Should CMS agree, it would write off more than half a billion dollars that could be recovered for the U.S. Treasury.

https://khn.org…

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Comment:

By Don McCanne, M.D.

We continue to hear that people like their private Medicare Advantage plans that replace traditional Medicare coverage. The most likely reason is that they have premiums that are competitive compared to the Medigap plans that people would need to protect themselves from potential catastrophic losses which the traditional program fails to cover. Individuals also are attracted by the plans’ marginal expansion of benefits.

It is no secret as to how the plans are able to afford to reduce out-of-pocket spending while adding a few benefits. The plans have been very successful in marketing to healthier patients – favorable selection – leaving more costly patients in the traditional program. Once the degree of favorable selection was acknowledged, CMS decided to introduce risk adjustment so that they could recover overpayments to insurers that were gaming the system. Very soon the insurers learned how to upcode their patients, making them seem to have greater health care needs than they really had, thus escaping risk adjustment reductions. Also, each year the insurers were successful in inducing CMS to use innovative methods to increase the annual adjustments in payment rates, helped by the annual letter from Congress endorsing the excess payment increases.

Today’s article indicates the degree to which the private insurers have been successful in overbilling taxpayers for their Medicare Advantage plans – literally billions of dollars. The article also discusses the efforts CMS has made to identify and then recover these excess payments. But what is most important here is what is written between the lines. The implementation of these programs has not resulted in recovery of these excess payments. Based on the battles that are taking place behind the scenes, once compromises are made it is likely that the amounts recovered will be so minimal that they will have no impact on the insurers’ profit and loss statements. Consequently, this results in a tremendous gift of taxpayer funds to the private insurers, and CMS has been passively complicit in this, as has Congress.

What is particularly objectionable is the unfairness, not only to the taxpayers at large, but also to the beneficiaries enrolled in the traditional Medicare program. The exposure to catastrophic costs in the traditional Medicare program is so great that enrollees must purchase relatively expensive Medigap plans to provide that protection if they’re not fortunate enough to be covered by union or employer-sponsored retiree plans. Even there, retirees are often shoved into the Medicare Advantage plans where they lose their choices in physicians and hospitals because of the restrictive provider networks selected by the Medicare Advantage insurers.

Why should we taxpayers be supporting these dishonest (read today’s article) private Medicare Advantage insurers while those of us in the traditional program are being deprived of the extra benefits that Congress has funded for the private insurers? It seems obvious that just plain fairness would require that Congress fund coverage for catastrophic losses in the traditional Medicare program while also funding the extra benefits that the Medicare Advantage plans use as a lure for enrollment, but there is a problem with this approach. It would be a comparatively modest incremental step that would further delay for perhaps decades enactment of the reform we really need – the single payer model of an improved Medicare for all.

Would that get rid of the crooks? No, they will always be with us. But a government that is willing to do the right thing by enacting and implementing a health care program that takes care of all of us would also be a government that would be willing to ferret out the crooks and actually eliminate their malfeasance, though that would have to be an ongoing process since this is an industry that touts its innovations even if those innovations have resulted in ripping us off to such a great degree.

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By Benjamin Studebaker & Nathan J. Robinson
Current Affairs, July 14, 2019

At one point, the meaning of “Medicare For All” was quite clear. Under Medicare For All, every American, instead of having to navigate the tangled and inefficient marketplace of for-profit health insurance corporations, would simply be enrolled in Medicare. Instead of people paying premiums and copays to an insurance company, they would pay taxes, and those taxes would be used to pay providers. As Dr. Abdul El-Sayed wrote in this magazine, Medicare For All is “single-payer healthcare that would provide cradle-to-grave government-supported healthcare for all Americans.”

But as Democrats have realized how well the phrase “Medicare For All” polls with voters, its meaning has been deliberately muddied. Most of the Democratic presidential candidates now support something they call “Medicare For All,” but it’s often not clear what they mean by it. Some, when they clarify specifics, make it clear that what they actually want is a “public option,” i.e. a new kind of government insurance plan that you can buy within the structure of the existing healthcare marketplace.

Why abolish private insurance? Why not just have insurance companies compete against a government plan in an open marketplace where people can choose? That way, everyone who wants Medicare gets it, while people who are satisfied with their current insurance can keep it. Everyone wins. The implication here is that anyone who supports a full single-payer plan, in which everyone would just be insured under a government program, must be rigidly ideological, wanting to shutter the private insurance industry for no good reason. Why would we do that instead of just providing a new option?

To understand why full “single payer” health insurance is the left’s goal, rather than just “another insurance plan on the marketplace,” it helps first to understand the left’s vision for how healthcare should work. In an ideal world, your healthcare would not be something you have to think about very much. If you got sick, you would choose a doctor’s office and make an appointment. You would go to that appointment and see the doctor. Then you would leave. You would not have to apply for insurance, not have to pay bills. And this would be the case no matter who you were or how much money you made. Your relationship is between you and your doctor, not you and your doctor and your doctor’s hospital’s billing department and your insurance company. Leftists dream of making healthcare as easy as possible to receive and universally accessible to all regardless of how much money they have.

Private health insurance is an unnecessary part of the healthcare system. Insurance companies are middlemen, and insurance just exists to make sure that providers get paid. It was the federal government that subsidized private insurance companies and encouraged employers to use them. Other countries didn’t build this kind of healthcare system, for two reasons:

1. It doesn’t cover everyone.
2. It creates a bloated, inefficient insurance bureaucracy.

Our government has always been playing catch-up trying to get more people covered. It’s created employer subsidies, Medicaid, CHIP, and the Obamacare exchanges in a desperate bid to get this system to do its job, and despite decades of piecemeal healthcare reforms 13.7 percent of Americans remain without health insurance and millions more have inadequate coverage. Offering to let Americans “buy-in” to Medicare keeps Americans paying premiums, and as long as Americans must personally pay premiums to receive healthcare there are going to be some people who can’t or won’t pay those premiums and go without. It turns Medicare-For-All into a publicly run HMO. Maintaining an employer-sponsored health insurance system means remaining in a situation where large numbers of people go through a period of being uninsured each year, because when you lose your job you lose your insurance. (Currently 1 in 4 Americans go through an uninsured period each year.) Single payer advocates ask the question: “Why have a nightmarish tangle of public and private options, varying by state, with people moving on and off all the time? Why not just pay for healthcare with taxes, cover everyone, and make it free at the point of use?”

Not only will a public option fail to cover everyone, it will do nothing to restrain the growth of healthcare costs. Single payer systems control costs by giving the health service a monopoly on access to patients, preventing providers from exploiting desperate patients for profit. If instead there are a large number of insurance companies, providers can play those insurance companies off each other.

The bloat doesn’t just come from providers. Because insurance works on a profit incentive, the insurance companies must extract rents as well. So the patient is paying to ensure not only that their doctor or hospital is highly-compensated, but that the insurance company generates profit too. Each insurance company has its own managers — its own CEO, its own human resources department, and so on. We have to pay all of these people, and because there are so many private insurance companies, there are so many middle managers to pay.

These duplicate bureaucracies are expensive to maintain and do nothing to improve the quality of care. The providers make them compete to offer higher compensation, and you pay for it. Getting rid of these middle men makes the system far more efficient. People do not associate government with efficiency, but when it comes to moving money from one place to another — which, after all, is all an insurance company does — it can be quite good, and it makes far more sense to have government handle healthcare payments than to leave it to companies with a direct financial incentive to deny treatment.

Private insurance is inconvenient, inefficient, and continues to leave large numbers of Americans with inadequate insurance or no insurance at all. The Affordable Care Act shored up this system by funnelling more public money into subsidies for private insurance. Now these Democratic candidates are proposing to make a new insurance company, call it “Medicare,” and charge you premiums to use it. That doesn’t get rid of the problem of wasteful duplicative bureaucracies, and will guarantee that some people remain uninsured. It was the federal government’s decision to build this bizarre, burdensome system. Nothing about private health care is natural or inevitable. It doesn’t have to be like this.

A single payer system requires a lot of political commitment, because it means going up against the insurance companies and the ritzy providers and telling them they can’t screw us over anymore. They can’t deny us coverage, extract heavy rents, and keep us on the phone forever. If a Democratic candidate doesn’t see a meaningful difference between a public option and single payer, if that candidate sees these things as two different “paths” to the same place, that candidate cannot be trusted to put an end to this madness. They are offering just one more piecemeal reform to prop up a failing system — not a true overhaul.

Single payer healthcare is a tried and tested system, and it isn’t radical. Trying to cobble together “universal” coverage from a patchwork of giant for-profit bureaucracies and government insurance products is senseless. “Eliminating private insurance” rather than “adding choice” may sound unnecessarily sweeping. But private insurance just gets in the way of efficiently paying healthcare providers and covering everybody. Medicare-For-All makes sense, and we shouldn’t let it be watered down.

Use this link for the full version of this article:
https://www.currentaffairs.org…

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Comment:

By Don McCanne, M.D.

An inordinately large percentage of individuals who seem to support public insurance has bought the concept that we can avoid disruption of the existing private health plans by the incremental addition of a public option – an optional Medicare plan that individuals can choose to purchase. Supposedly everyone would recognize the superiority of the public option Medicare plan and would eventually shift to that coverage thus ending up with a single payer system. This vision of reform is a fantasy, and today’s article describes, once again, why this pathway will not lead to single payer.

Some say, “Well, isn’t this fine? Those who want their private plans can keep them, and those who prefer Medicare would now have that option.” But the Medicare public option is structured like an individual private insurance plan. It would have a premium, which, in itself, creates considerable administrative complexity – determining the amount of the premium, collecting the premium from the individual, determining the amount of a government subsidy, if any, and crediting that amount to the individual, making premium adjustments each year, and keeping track of shifting between the Medicare option, employer-sponsored plans, plans in the marketplace, and the all too common periods of lapsed insurance coverage. The administrative hassles with premiums alone do not begin to account for the half trillion dollars in other recoverable administrative waste, almost all of which would remain in place if we accept the incremental step of merely adding a public option.

Moving all health care funding to a highly efficient, tax-financed single risk pool while removing financial barriers to the access of health care (eliminating deductibles, coinsurance, etc.) are essential features of a single payer model but would not be achieved through incremental steps, including the step of offering a Medicare public option.

Our current health care financing infrastructure has nothing in common with a single payer system. That transition will have to be made sometime. Until then, we will have to put up with uninsurance, underinsurance, personal financial hardship, profound administrative waste, inequity in financing, inequity in health care, and physical suffering and preventable premature death. Merely adding a public option cannot have more than a negligible impact.

As the authors state, the public option and single payer are not two different paths to the same place. One is just one more incremental tweak that leaves us pretty much where we are, and the other is the infrastructure reform that will accomplish our goals of effectiveness, equity, and efficiency so that we all have the health care that we need. No more delay. We need to end the suffering.

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By Yusra Murad
Morning Consult, July 11, 2019

In a July 8-10 survey of 1,988 registered voters, a 44 percent plurality said it’s unlikely that the lawsuit will be successful in gutting the ACA, compared to 37 percent who see it as a possibility. Faith in the lawsuit’s success rests comfortably along party lines: Democrats aren’t betting on it, with almost 6 in 10 saying the court is unlikely to upend the ACA, while a majority of Republicans (54 percent) say the opposite.

This is not the ACA’s first confrontation with legal challenges, but this time, top lawmakers from both parties have been relatively less animated about the possibility of repeal. Republicans have worked to distance themselves from the case, wary of its implications for millions of Americans with pre-existing conditions and haunted by the 2018 midterm elections, in which dozens of Republicans were unseated over the issue of health care.

Among voters who think the ACA may be gutted, 60 percent are confident the Trump administration has a replacement plan. That includes 87 percent of Republicans.

For months, President Donald Trump has vowed his administration is on the brink of unveiling a health plan fit to replace the ACA. That plan — or any of its details — has yet to be seen.

https://morningconsult.com…

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Republicans make U-turn on health care

By Alexander Bolton
The Hill, July 14, 2019

Senate Republicans are reversing course and now taking a hard look at health care legislation to replace the 2010 Affordable Care Act in case the courts strike down former President Obama’s signature achievement.

There’s a sense of urgency among GOP lawmakers to come up with a plan to replace the most popular components of ObamaCare after a panel of appellate judges on Tuesday aggressively questioned whether the law passes legal muster following Congress’s repeal of the tax penalty for not having insurance.

A nullification in the courts could leave millions of people with pre-existing medical conditions without insurance and disrupt coverage for others.

Just the consideration of legislative action is an about-face from a few months ago when Senate Majority Leader Mitch McConnell (R-Ky.) said Senate Republicans would not move legislation to replace ObamaCare before the 2020 election, arguing it would have no chance of passing Congress, particularly with a Democratic-controlled House.

But on Tuesday, McConnell pledged that the Senate would act swiftly to protect people with pre-existing medical conditions if a GOP-backed lawsuit is successful in overturning ObamaCare.

“I think the important thing for the public to know is there’s nobody in the Senate not in favor of covering pre-existing conditions,” McConnell said.

“We would act quickly on a bipartisan basis to restore” those protections if struck down by the courts, he added.

Sen. Mitt Romney (R-Utah), who as governor of Massachusetts in 2006 implemented a health insurance law that later served as a template for ObamaCare, is taking the lead in negotiations, according to Republican senators who have spoken to him.

Romney is working with Sen. Rick Scott (R-Fla.) and consulting closely with (Sen. Lamar) Alexander (R-Tenn.) and Senate Judiciary Committee Chairman Lindsey Graham (R-S.C.).

Republican lawmakers say they need to be more prepared with ideas to replace ObamaCare than they were in 2017, when a seven-month effort to repeal and place the law failed on the Senate floor in spectacular fashion.

Romney met with Alexander and Graham on Thursday afternoon to discuss what a Republican alternative to ObamaCare would look like, according to a Senate aide familiar with the meeting.

Scott says the goals of the legislation would be to protect people with pre-existing conditions and allow young adults to stay on their parents’ health insurance plan until age 26, two of the Affordable Care Act’s most popular provisions.

“There’s two things that were in ObamaCare — pre-existing conditions and staying on your parents’ plan. We don’t have any idea what’s going to happen in the court case, but what we ought to be doing anyway is trying to figure out how to pass something that covers those two issues,” Scott said.

“A bunch of us have been trying to figure out how to do it,” he said. “We’ve talked to a lot of people.”

Asked how he would pay for any costs associated with protecting people with pre-existing medical conditions and extending health coverage for young people until age 26, Scott asserted the GOP plan will not require a major expenditure.

“It’s not really something to be paid for. It’s something insurance companies have to do, and they’re doing it now,” he said. “They’re all complying with it now.”

“Republicans on this issue of pre-existing conditions can’t have it both ways. You can’t support the lawsuit and say you give a damn about pre-existing conditions,” said Sen. Bob Casey (D-Pa.), a member of the Senate Health Committee. “They have nothing prepared.”

When informed of Romney’s effort to put together a fallback plan to protect people from losing health insurance, Casey said, “They’ve been saying that for at least eight years.”

“This is what happens when the leadership of a political party doesn’t spend much time on health care for 25 years. They come up with loopy ideas,” he said of Scott’s argument that protecting pre-existing conditions would not require significant additional federal spending.

https://thehill.com…

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Comment:

By Don McCanne, M.D.

Compared to the problem that our health care system is performing very poorly in spite of the trillions of dollars we are spending on it, this issue of covering preexisting conditions is almost trivial. Yet for a couple of years the Republicans have fixated on it as their proposal for reform should they be successful in abolishing the Affordable Care Act (ACA), whether through legislation or the courts.

Now that two of three appeals court judges have hinted that the individual mandate may be unconstitutional and not severable from the rest of ACA, the Republicans are facing the prospect that they may have to fulfill their promise of a better option for health care reform. In the last election they said that guaranteeing coverage of preexisting conditions and extending coverage for dependents until age 26 was their proposal for reform, even though those policies were already part of ACA. That feeble proposal did not sell well and the control of the House shifted to the Democrats.

Although Republicans have been pursuing in the courts the revocation of the entirety of ACA, they seem to have waited until the threat that they may be successful in eliminating ACA to begin crafting the replacement proposal. Astonishingly, they have reverted to supporting the same guaranteed issue and dependent coverage proposals.

This time they brought in newly elected Sen. Mitt Romney of Romneycare fame – the basis of ACA. There is no hint that they would repeal ACA (Obamacare) and replace it with Romneycare, so what are they to do? They are now also turning to Sen. Rick Scott, former Columbia/HCA chief executive – a company that paid a $1.7 billion fine for Medicare and Medicaid fraud.

So what is Sen. Scott’s solution? Guaranteed issue and dependent coverage. And how is that to be financed? “It’s not really something to be paid for. It’s something insurance companies have to do.” So they get rid of the individual mandate, pass a measure that makes unaffordable insurance even more expensive, and then give individuals the option of not buying the insurance they can’t afford. Some solution.

So where are the Democrats in all of this? Let’s have Medicare for All but we must leave in place the private insurance plans. High premiums? Unaffordable deductibles? Limited choices within provider networks? Surprise out-of-network bills? Gouging by pharmaceutical firms? A Medicare public option would be only one more in the menu of health plans, having eliminated none of the profound administrative waste that greatly adds to the very high costs of our health care system. Some solution.

The single payer model of an improved Medicare for All would fix this. Yet we do not have a Congress nor a president who are willing to move forward with the requisite legislation. Whose fault is that? How can you draw any other conclusion than the fact that the voters have failed in their responsibility to put democracy in action for the benefit of all? It is disingenuous to simply blame “the other party” for our ills.

Physicians for a National Health Program does not support any political party or candidate for office.

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By Roosa Tikkanen and Robin Osborn
The Commonwealth Fund, July 11, 2019

As recent congressional hearings on Medicare for All proposals have illustrated, members of Congress and presidential candidates are looking outside the United States to find ways to achieve universal coverage. Some have suggested that other countries are able to provide universal coverage because they “ration” care — a term rife with negative connotations. This post examines the extent to which health care is rationed in Germany, the Netherlands, Sweden, Switzerland, and the United Kingdom — as compared to the U.S.

Examples of health care rationing tend to focus on long wait times for procedures —such as hip replacements, or MRIs — or limited access to the newest drugs. This happens in some (but not all) countries and can be a challenge for policymakers. But there are other ways in which health systems engage in rationing, by restricting access to insurance, through insurance benefit design, or by imposing high patient cost-sharing. While other countries may ration because of national budget constraints and supply-side factors, the United States’ lack of access to comprehensive insurance and affordable care represent a de facto form of rationing that leads people to delay getting care or going without it entirely.

Getting in the Door

In the five European countries we examined, all residents are entitled to health care through the national system. These range from tax-funded systems in Sweden or the U.K. to private insurance-based systems in Germany, the Netherlands, and Switzerland. In the latter, governments regulate premiums to be affordable and provide income-related subsidies to low-income families, which include 27 percent of Swiss and 30 percent of Dutch residents. Governments also mandate generous benefit packages that typically guarantee a minimum set of services: primary, specialty, and hospital care; prescription drugs; mental health; maternity; and palliative care.

In comparison, there are 30.4 million uninsured people in the U.S. Not having affordable, comprehensive insurance coverage often means that sick Americans do not even get in the door to see a doctor. For those who do have coverage, new rules that allow states to circumvent the Affordable Care Act’s mandated essential health benefits may mean skimpy coverage for some.

Waiting to Be Seen

Patients in some countries face longer wait times for specialty care than in the U.S., where only 25 percent of Americans need to wait longer than one month for a specialist appointment. Patients in Germany and Switzerland get in just as fast (27% and 26%, respectively) as their U.S. counterparts, but those in Sweden and the U.K. do not (45% and 43%, respectively). Similarly, very few U.S., Dutch, and Swiss patients (4% to 7%) who need elective surgery face wait times longer than four months, while 12 percent of Swedish and British patients do. It should be noted that in Sweden and the U.K., where wait times for specialty care are longer, people can buy supplemental insurance to gain quicker access to private specialists.

While Americans overall enjoy shorter wait times for specialty care, wait times for same- or next-day appointments when sick are around average compared to other countries. U.S. adults are among the most frequent users of emergency departments. Nearly half who do report doing so because they couldn’t get an appointment with their regular doctor.

Weighing Health Against Your Wallet

In a recent Commonwealth Fund survey, fewer than one of 10 patients in the U.K., Germany, the Netherlands, or Sweden reported skipping needed care or treatments because of cost. This contrasts sharply with the U.S., where one of three Americans reported the same. This is partly because of the rise in high deductibles, unpredictable and opaque copayments, and higher health care prices in the U.S. than in other countries. An estimated 44 million Americans who have insurance are effectively underinsured because their out-of-pocket costs and deductibles are very high relative to their incomes.

Other countries are more protective. In the U.K., Germany, and the Netherlands, patients have no out-of-pocket costs when they visit a primary care doctor, and Brits never pay for hospital care. In Germany, out-of-pocket costs are capped at 2 percent of annual household income and 1 percent for chronically ill people. In Sweden, out-of-pocket costs for physician visits and drugs are capped at $370 annually. No one in these five countries declares bankruptcy because of medical debt.

Paying for Value

A commitment to providing universal coverage means that other countries have to make hard choices to ensure that each health care dollar is spent effectively.

Countries aim to give patients access to the most clinically meaningful and cost-effective drugs. In the U.K., only drugs that are deemed cost-effective are covered, while in Germany, manufacturers have to demonstrate that their new drug adds clinical benefit to negotiate a higher price than other existing drugs. This doesn’t mean that new technologies aren’t available; in fact, 79 percent of new cancer drugs are approved for routine use in the U.K.

These kind of controls, coupled with fixed copayments and annual caps on patient drug spending, translate into better access. While nearly one of five U.S. adults skip doses or do not fill a prescription because of costs, just 2 percent to 9 percent of patients do so in the other countries discussed here.

Conclusion

It would be a missed opportunity for America to ignore lessons about universal coverage from other countries out of a fear that they ration health care more than we do. In reality, more people in the U.S. forgo needed health care because access to care is rationed through lack of access to adequate insurance or unaffordable services and treatments.

https://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

Opponents of single payer frequently claim that if we enact Medicare for All we will have rationing of health care like they have in Canada and the European nations. They then usually provide a selected statistic from a selected country (often Canada or the United Kingdom) that shows a delay (queue) for some service (such as cataract removal), or a product (often a drug) that may be in short supply. This Commonwealth Fund report provides a proper perspective by comparing the United States with five European nations – Germany, the Netherlands, Sweden, Switzerland, and the United Kingdom.

Supply side controls sometime result in prolonged queues for services such as elective joint replacement. Some nations do better than others in providing stewardship of their system capacities and application of queue management. Excessive queues are not an inevitability though they can occur even in nations with very high spending, as we sometimes see in the United States. But the United States is unique in that millions of individuals are not allowed a place in the queue.

Drug prices? Most other nations use government oversight to demand that drugs be cost effective, but not the Unites States, not to mention that we allow exorbitant pharmaceutical firm profits plus middleman gouging such as through pharmacy benefit managers.

Access to acute and primary care services tends to be quite adequate in all nations, except the United States. So what is going on?

In this report, these authors state, “In reality, more people in the U.S. forgo needed health care because access to care is rationed through lack of access to adequate insurance or unaffordable services and treatments.” That is, as has been stated many times before, we ration based on the ability to pay. In spite of per capita spending at twice the average of other nations, this rationing based on our flawed health care financing system has resulted in relatively poor outcomes on average compared to other higher performance nations. Of course, those poor outcomes are much more prevalent amongst the uninsured and underinsured – health financing deficiencies that are almost nonexistent in other nations.

We are spending more than enough to eliminate rationing in the United States, except for legitimate scarcity such as organs for transplant. But to do that we need to change the way we collect and allocate our health care funds. That is precisely what the single payer model of Medicare for All is designed to do. Merely adding a Medicare public option will not fix our financing system.

So when are at a meeting and you hear that Medicare for All will bring rationing to the United States, use your bullhorn to let the speaker know that single payer will virtually eliminate our highly prevalent form of rationing – rationing by ability to pay. If they try to pull you out of the meeting, flip your bullhorn over to a colleague – and keep passing it to other colleagues until we are absolutely certain that they got the message.

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By Frederick J. Zimmerman, PhD, Nathaniel W. Anderson, BA, of the Jonathan and Karin Fielding School of Public Health, Department of Health Policy & Management, University of California, Los Angeles
JAMA Network Open, June 28, 2019

Abstract

Importance: Health equity is an often-cited goal of public health, included among the 4 overarching goals of the Department of Health and Human Services’ Healthy People 2020. Yet it is difficult to find summary assessments of national progress toward this goal.

Objectives: To identify variation in several measures of health equity from 1993 to 2017 in the United States and to test whether there are significant time trends.

Design, Setting, and Participants: Survey study using 25 years of data, from January 1, 1993, to December 31, 2017, from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System to assess trends in health equity and health justice by race/ethnicity, sex, and income in 3 categories by year.

Main Outcomes and Measures: Health equity was assessed separately for each of 2 health constructs: healthy days—the average of physical and mental healthy days over the previous 30 days—and general health in 5 categories, rescaled to approximate a continuous variable. For each health construct, average health was calculated along with 4 measures of health equity: disparities across 3 income groups; black-white disparities; health justice—a measure of the correlation of health outcomes with income, race/ethnicity and sex; and a summary health equity metric.

Results: Among the 5 456 006 respondents, the mean (SD) age was 44.5 (12.7) years; 3 178 688 (58.3%) were female; 4 163 945 (76.3%) were non-Latinx white; 474 855 (8.7%) were non-Latinx black; 419 542 (7.7%) were Latinx; and 397 664 (7.3%) were of other race/ethnicity. The final sample included 5 456 006 respondents for self-reported health and 5 349 527 respondents for healthy days. During the 25-year period, the black-white gap showed significant improvement (year coefficient: healthy days, 0.021; 97.5% CI, 0.012 to 0.029; P < .001; self-reported health, 0.030; 97.5% CI, 0.025 to 0.035; P < .001). The health equity metric for self-reported health showed no significant trend. For healthy days, the Health Equity Metric declined over time (year coefficient: healthy days, −0.025; 97.5% CI, −0.033 to −0.017; P < .001). Health justice declined over time (year coefficient: healthy days, −0.045; 97.5% CI, −0.053 to −0.038; P < .001; self-reported health, −0.035; 97.5% CI, −0.046 to−0.023; P < .001), and income disparities worsened (year coefficient: healthy days, −0.060; 97.5% CI, −0.076 to −0.044; P < .001; self-reported health, −0.029; 97.5% CI, −0.046 to −0.012; P < .001).

Conclusions and Relevance: Results of this analysis suggest that there has been a clear lack of progress on health equity during the past 25 years in the United States. Achieving widely shared goals of improving health equity will require greater effort from public health policy makers, along with their partners in medicine and the sectors that contribute to the social determinants of health.

From the Discussion

The results of this study show a worrisome lack of progress on health equity during the past 25 years in the United States. Although there are some differences across conceptualizations of health equity, and small differences across the 2 concepts of overall health, the overall pattern is one of stagnation mixed with unambiguous decline.

Conclusions

Improving health equity often figures as an important goal for communities, thought leaders, and policy makers in public health. Yet, this analysis suggests that across the past 25 years, the promise of improving health equity has not been met. Greater or different efforts than those tried in the past will have to be mustered if health equity is to improve. Performance tracking of health equity may help to keep policy makers accountable to making the necessary changes.

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

The authors conclude that the overall pattern of health equity during the past 25 years in the United States is one of “stagnation mixed with unambiguous decline.”

Shocking! Shocking! Absolutely shocking!

How can anyone call this a great nation when we tolerate such injustices?

Progress will not come from the private sector. There is an urgent need for the enactment and implementation of new public policies if we ever hope to reverse these injustices.

Although there is much to be done, we have before us legislation that would would take a giant step forward in improving health equity, and that is the Medicare for All Act of 2019 in the House (Jayapal) and in the Senate (Sanders). The features of this single payer model of health care would dramatically advance health equity because it would automatically include absolutely everyone in a system financed equitably through progressive taxes.

Yet the House is bogged down in protecting the private insurance industry instead – a source of much of the inequity in health care – and the Senate is going to do all they can to prevent the government from becoming involved.

The authors state, “Greater or different efforts than those tried in the past will have to be mustered if health equity is to improve.” Let’s start with enacting single payer improved Medicare for all. If our politicians won’t do that, then we should replace them. Or shall we just abandon our claim of being a great nation?

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