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The Harkness Fellows on the paradoxes of US health care

The Harkness Fellows on the paradoxes of US health care

An International Perspective On The Paradoxes Of US Health Care

By Angèle Malâtre-Lansac
Health Affairs Blog, August 28, 2019

Editor’s Note: In addition to Angèle Malâtre-Lansac, this post was conceived of and written by the 2018-2019 Harkness Fellows on health care policy and practice listed at end of this post.

Each year, the Commonwealth Fund selects an international cohort of Harkness Fellows in health care policy and practice, consisting of mid-career researchers, policy makers, and practitioners with leading positions in their countries, who come to the US to study the health care system, work with renowned US health policy experts, and provide input to US health care and research, drawing on insights from their own international contexts.

Reflections on health care in the US are commonplace: In our view, what is less common are observations and reflections from health experts from seven other countries on US health care. What are the most surprising aspects of the US system through the lenses of 10 observers from Australia, France, Germany, the Netherlands, New Zealand, Norway, and England?

No Such Thing As The US Health Care System

The United States undeniably provides some of the best health care and is one of the most innovative nations in the world. Financial investments in health and medical research are the envy of us all. Pockets of excellence can be seen in so many places. However, one of our first realizations is that there is no such thing as a single, unified, and coordinated US health care system — but rather a complicated and fragmented health care marketplace. Variations between US states, communities, and health insurance plans are in many cases greater than the differences between our countries. There are many reasons for this, but key among them are our countries’ shared principle of universal health coverage (both within single and multi-payer systems) and our usually nationally negotiated prices.

The diversity across US states is striking to us, particularly in terms of access to, and quality of, health care services. Perhaps, most surprising from our international perspective is the importance of political differences as a unique determinant of regional variations in health care performance. The ongoing debate over the Affordable Care Act (ACA) and the state-based variation in implementation of the ACA are vivid examples of this diversity and polarization within health care.

While there can be many benefits to diversity and choice, particularly in terms of tailoring services and resources to meet the specific needs of different populations and to ensure appropriate care, too much of a good thing can create problems. As an example, the sheer number of options individuals need to review and decide upon when considering a private health insurance plan or selecting a provider creates complexity, decision fatigue, and frustration.

Health Care As A Privilege, Not A Right

In our countries, there is a broad consensus on the role of the government in health care, as there is in education. Health care is considered a fundamental right. In the US, the federal government does not assume full responsibility for ensuring the right to health care for its citizens. The predominant narrative here frames health as a privilege. This plays out in many ways, but perhaps most notably it is advanced by proponents of work requirements for Medicaid, premised on the idea that access to health care is something to be earned. And yet, many US people cherish Medicare, a government program that provides universal coverage for people ages 65 years and older.

In addition, although we hear a lot of discussion about the costs of care, it is surprising how little of the conversation is on the costs of care not delivered. Approximately 28.5 million Americans have no health insurance, and it’s well known that being uninsured negatively affects your health and is costly. There are costs for the individuals; for the families who rely on those individuals for financial and other forms of support; for the businesses whose employees are absent, unproductive, or retire early; for the health care system, which ends up providing more expensive reactive care; and for society at large.

Another stark difference between the US and our own countries is the high level of financial burden placed on its people. Prominent in the US health care system are the high-deductible health plans driven by the idea that cost-sharing obligations will encourage people to prioritize high-value care and reduce health care spending. Yet, recent evidence suggest that populations on such plans delay or skip essential care entirely and as a consequence, experience adverse effects.

The Price Problem

On average, the US spends twice as much as other Organization for Economic Cooperation and Development countries on health care without evidence of superior care or health outcomes. In fact, life expectancy is declining in the US while health care costs continue to rise. Grossly inflated drug and device prices, overall health care costs, and surprise billing are big challenges. Substantial administration and advertising costs are a further unintended consequence of the primacy placed on individual choice. Quite simply, everything is more expensive in the United States than it is in our countries.

Drug prices in the US are three to six times higher than in many European countries, despite decades of calls for change. Our countries use Health Technology Assessment (HTA)—a multidisciplinary approach that considers the clinical, economic, legal, ethical, and organizational aspects of new technologies such as drugs, devices, and procedures. The core principle is to determine the added value of new technologies compared to existing alternatives to inform authorities responsible for coverage and reimbursement decisions. Unlike in our countries, there is no single agency tasked with addressing this issue in the US.

The Accountability Problem

In an article recently published in the New England Journal of Medicine, “The Not-My-Problem Problem,” Lisa Rosenbaum provides a persuasive account of the unintended consequences of diffusion of responsibility in a highly fragmented US health care system. According to the World Health Organization’s Health System Framework, well-functioning health care systems share several characteristics, including leadership and governance, factors that play essential roles in achieving the goals of health systems, regardless of how health systems are organized and designed.

In the US, governance is often unclear, and there is no shared understanding of what each actor in the health care system is accountable for (and to whom). At the end of the day, the entire system seems beholden to one thing: the “bottom line.” The lack of a commitment to universal coverage, as well as the many different stakeholders and multiplicity of intermediaries in the supply chain, might explain this phenomenon.

These lessons may not come as a great surprise to the many policy makers and researchers who have long studied and aspired to improve health care in the US. Our hope is that, by highlighting the challenges that stand out most acutely to us as outsiders, this international perspective may provoke thoughtful discussion about how to achieve better health outcomes. Addressing those great challenges is like tackling climate change — it’s both crucial and painful. Taking the necessary steps toward a greater good first requires agreement on what that looks like. The opportunity of the upcoming presidential campaign will undoubtedly make it possible to bring a new vision for the future of US health care.

Author’s Note

Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and should not be attributed to the Commonwealth Fund or its directors, officers, or staff.

2018-2019 Harkness Fellows on health care policy and practice from the Commonwealth Fund:

Angèle Malâtre-Lansac, France
Mary Docherty, UK
Unni Gopinathan, Norway
Cornelia Henschke, Germany
Prakash Jayakumar, UK
Nadine Kasparian, Australia
Grégoire Mercier, France
Huseyin Naci, UK
Andrew Old, New Zealand
Laura Shields-Zeeman, Netherlands

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

This perspective is very helpful to us because it represents the views of highly qualified health policy experts from other nations who have come to the United States to study our system. The objective view they present can be invaluable in our own assessment of our health care system as we consider what can be done to improve it.

Considering our unique culture and politics, it is very difficult to see how we could effectively address the issues discussed short of enacting and implementing a single payer model of an improved Medicare that covered everyone. The sooner, the better.

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

Overlapping payment models: Who gets paid?

Calls mount for CMS to address problem of patient overlap across payment models

By Tara Bannow
Modern Healthcare, September 7, 2019

The problem of overlap in the CMS’ various payment initiatives, including ACOs and bundled-payment programs, can introduce confusion and frustration when it comes to determining which program gets credit for those patients’ care. The CMS wants to avoid double-rewarding for savings on an individual patient’s care, such as if the patient is in an ACO and received qualifying care from a Bundled Payments for Care Improvement Advanced provider. So when it comes down to reconciling who is credited for the savings, things get tricky. And they’re bound to get even more complicated as the CMS adds alternative payment models to the mix.

New research highlights just how sweeping the problem is. More than 1 in every 4 patients receiving care under the CMS’ flagship bundled-payments program, the Bundled Payments for Care Improvement initiative, were also attributed to its flagship ACO program, the Medicare Shared Savings Program, in 2016, according to an August study in the Journal of Hospital Medicine. Conversely, 1 in every 10 MSSP patients received care at a BPCI participating hospital in 2016.

The CMS attempted to clarify things in June when it announced that starting in 2020, providers participating in BPCI Advanced will take precedence over all MSSP beneficiaries—meaning, their savings will be carved out from the ACO’s savings. Currently, this is only the case for certain MSSP beneficiaries, those categorized under the program’s basic track.

On a practical level, the June announcement means if John Doe is a patient in an MSSP ACO, and is admitted to a BPCI Advanced hospital with a clinical episode, such as congestive heart failure, that episode of care will be attributed to the BPCI Advanced provider, said Gina Bruno, vice president of value-based care with naviHealth.

The CMS is also trying to calculate a way to compensate aligned ACOs for their contributions to those patients’ care, Bruno said. “ACOs, especially those that work with BPCI Advanced providers will say, ‘Well, wait a minute. John Doe has been our patient for a period of time. We have a team that follows up with him. We play a part in managing his chronic disease. How do we get credit for our contributions to his outcomes?’ ”

Therein lies the trickiness of overlap. Experts say providers who contributed to a patient’s care often wind up feeling as though they didn’t get the commensurate reward.

“There is a risk of expending resources to support patients who ultimately are not attributed to the model to which that operating expense was aligned,” Bruno said.

At least five CMS payment models could overlap with one another: MSSP, BPCI Advanced, CJR, the advanced primary-care medical home model Comprehensive Primary Care Plus and the Oncology Care Model, said David Muhlestein, chief research officer with Leavitt Partners.

“If everybody is getting credit for it, you could potentially pay the same bonus payment five times,” he said. “Or if everybody does really poorly, all of them would pay the same penalty payment.”

There’s also a broader societal problem with overlap. It makes it difficult for the CMS Innovation Center to study whether its payment model experiments are actually saving money and improving patient outcomes. In that respect, the CMS is between a rock and a hard place, Muhlestein said.

“If they want to test many different programs to find out what works currently and not have overlap, you kind of can’t,” he said.

https://www.modernhealthcare.com…

Comment:

By Don McCanne, M.D.

While the policy community is ignoring the truly effective model of Single Payer Medicare for All, they remain fixated on accountable care organizations (ACOs) and alternative payment models (APMs). Not only has the initial experience with these models been relatively disappointing, the patients may be simultaneously enrolled in multiple models, often without their knowledge, creating confusion as to which entity should be receiving payment or assessed a penalty for falling short on parameters of care.

As David Muhlestein of Leavitt Partners states, “If they (CMS) want to test many different programs to find out what works currently and not have overlap, you kind of can’t.”

Yesterday’s Quote of the Day made the point that we don’t need more policy studies to figure out how we can fix the system. We merely need to enact and implement the single payer model of an improved Medicare for all.

https://pnhp.org…

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Statement on U.S. Census Bureau Health Insurance Report

FOR IMMEDIATE RELEASE, September 10, 2019
Contact: Clare Fauke, Physicians for a National Health Program, clare@pnhp.org

Statement from Dr. Adam Gaffney, president of Physicians for a National Health Program, in response to the U.S. Census Bureau’s 2018 Income, Poverty and Health Insurance Coverage report:

“The number of Americans without health coverage is on the rise, new figures from the Census Bureau show. In 2018, some 2 million people in the U.S. lost coverage relative to the previous year, demonstrating that our current system is not only broken, but getting worse.

“This rise in the number of the uninsured reflects the Trump administration’s ongoing attacks on our health care safety net, specifically Medicaid, a public insurance program relied upon by low-income Americans. Yet these attacks exacerbate an already untenable situation, in which nearly 30 million Americans have been left without health coverage, and many more with inadequate coverage.

“Physicians see daily the harm that this inflicts on our patients. People with asthma or heart disease who don’t take their medications because they can’t afford the prescription; people with multiple sclerosis, diabetes, or cancer who can’t get the care they need because of skyrocketing costs and wind up in the hospital, or worse.

“The only solution is improved Medicare for All — a system that guarantees first-dollar coverage for all medically necessary services to everyone in the U.S. Other patches – like a public option – will invariably fall. A majority of Americans and a majority of doctors now support Medicare for All. It’s time for our elected officials to follow.”

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization whose more than 23,000 members support single-payer national health insurance.

Bio Hackers versus Big Pharma: Tackling the Rising Cost of Insulin

Interview with Dr. Ana Malinow

Making Contact, September 10, 2019

As the cost of insulin continues to skyrocket patients are dying from trying to ration their medication. It’s an extreme example, but not unusual – the cost of insulin mirrors the broader health crisis in the United States. Medicine is too expensive and inaccessible. And as insurance companies continue to raise prices, more and more people are put at risk, especially if they’re uninsured, or under-insured.

Today, we look at ways to combat the health costs associated with diabetes.

First, we hear from a woman living with diabetes about her experience using Insulin. Then, we visit a group of community scientists called the Open Insulin Project, an organization trying to create its own insulin outside the lengthy FDA process and whether it’s worth the associated risks.

And we talk about the benefits of Medicare for All, a policy which would get rid of private insurance and make all medicine and medical care accessible and affordable.

Featuring:

  • Ana Malinow, Former president Physicians for a National Health Program
  • Aura Aparicio, Bay Area resident with Type 1 diabetes
  • Anthony DiFranco, Founder of Counter Culture Labs and the Open Insulin Project
  • Yann Huon De Kermadec, Ph.D., Lead scientist of the Open Insulin Project and Counter Culture Labs
  • Jessica Ching, Member of Open Insulin Project, organizer of the DIY Artificial Pancreas MeetUp for the Bay Area
  • Amy Tenderich, Blogger, founder of diabetesmine.com
  • Brian Roberts, Adult endocrinologist and head of clinical development at Rezolute Bio
  • Jean Peccoud, Professor of chemical and biological engineering at Colorado State University
  • Jenna Gallegos, Post-doctoral researcher in the Peccoud Lab at Colorado State University

https://www.radioproject.org…

Do we really need more policy research before implementing health justice for all?

Which Health Policies Actually Work? We Rarely Find Out.

By Austin Frakt
The New York Times, September 9, 2019

Rigorous evaluations of health policy are exceedingly rare. The United States spends a tremendous amount on health care, but very little of it learning which health policies work and which don’t.

Evaluations of health policy have rarely been as rigorous as clinical trials. A small minority of policy evaluations have had randomized designs, which are widely regarded as the gold standard of evidence and commonplace in clinical science.

Because randomized health policy studies are so rare, those that do occur are influential. The RAND health insurance experiment is the classic example. This 1970s experiment randomly assigned families to different levels of health care cost sharing. It found that those responsible for more of the cost of care use far less of it — and with no short-term adverse health outcomes (except for the poorest families with relatively sicker members).

The results have influenced health care insurance design for decades. In large part, you can thank (or curse) this randomized study and its interpretation for your health care deductible and co-payments.

Problems can also plague rollouts that are voluntary and not randomized. Programs showing promise suffer from diminishing participation as health care organizations drop out. The innovation center’s pioneer accountable care organization program offered health care organizations the opportunity to earn bonuses in exchange for accepting some financial risk, provided they meet a set of quality targets. It started with 32 participants in 2012. Although studies showed it reduced spending and at least maintained, if not improved, quality, only nine remained by 2016 when the program ended.

Beginning in April 2016, Medicare randomly assigned 75 markets to be subject to bundled payments for knee and hip replacements, and 121 markets to business as usual. But the innovation center didn’t maintain the design, announcing in November 2017 that hospitals could leave it. This will greatly limit what can be learned from the program.

Just as in clinical care, there are examples of incorrect thinking based on low-rigor studies that more rigorous ones later overturn. For example, many low-quality studies suggest that wellness programs reduce employers’ health care costs as they improve health outcomes. But when the programs have been subject to randomized controlled trials, none of these findings hold up.

Hospital cost shifting — the idea that shortfalls from Medicare or Medicaid cause hospitals to charge higher prices to private insurers — can also seem commonplace from studies without rigorous designs. But when subject to more careful evaluation, the phenomenon is almost never observed.

It’s hard to rid ourselves of ideas that are little more than wishful thinking or to end policies that don’t work.

NYT Reader Comment:

By Don McCanne, M.D.

Health policy research is potentially beneficial, but it should not distract us from adopting policies that do not require research to know whether or not they work.

Currently much research is directed to studying value over volume, yet the preliminary results have been disappointing, and the response has been to call for more such studies. This is actually harmful when it deters us from adopting policy changes that would be inherently effective. Current research on alternative payment models is largely wasting resources, partly through an increase in useless administrative complexity.

On the other hand, we can enact and implement policies that would automatically include everyone, sharply reduce the profound administrative waste of private insurers and the burden they place on the system, make health care affordable for everyone by financing the system with equitable progressive taxes, and improve access by removing financial barriers to care. You do not need a complex policy study to see whether or not those goals would be realized. They are inherent in a well designed, single payer model of an improved Medicare that covered everyone.

Policy research is fine, but let’s not walk away from common-sense solutions just because the policy community hasn’t done the research yet, when no such research is required.

https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

The granddaddy of health policy research is the RAND health insurance experiment (RAND HIE) which supposedly showed that cost sharing decreased the use of health care without increasing adverse health outcomes (though that’s not quite true, at least for patients with hypertension). Yet commonly ignored is the fact that this study was confined to healthy workers and their young healthy families. That, in effect, excluded most of the 20 percent of individuals who use 80 percent of our health care. Thus the study has intrinsic validity for healthy individuals, but it does not have extrinsic validity for individuals receiving most of the health care in the United States.

Though this study showed that young, healthy people remained healthy (no surprise there), it was nevertheless used to advance the principles of consumer-driven health care – requiring high deductibles to keep people away from health care that they may not need. So today we have high deductibles that keep sick people away from the health care that they should have simply because the policy community ignored the fact that the RAND HIE does not have extrinsic validity. So this greatest health policy experiment of all time has had a detrimental impact on health care in America – the opposite of what policy science should be bringing us.

So what studies do we need to establish health care justice for all?

If we want everyone included, what study would show us how we can do that? Well, you don’t need a study. Simply include everyone.

If we want to reduce the high costs of the profound administrative waste of the private insurers and the burden they place on the health care professionals and institutions, what study would you need to figure out how to do that? How would a study help when what we need to do is simply eliminate the private insurers, substituting a universal, publicly financed and publicly administered program?

What study would you need to make sure that each person can afford his or her share of our national health expenditures? Again, you do not need a study. Simply fund the universal risk pool based on ability to pay by implementing equitable, progressive tax policies.

What study would you need to update the RAND HIE that would remove financial barriers to essential health care services? Again, it doesn’t take a study to conclude that you simply remove the barriers such as high deductibles.

What study would you need to return to the patient choices in health care professionals and institutions beyond the restrictive networks established by the private insurers? By now you’ve gotten the message. Simply eliminate the networks along with the private insurers that established them.

It’s time to reconnoiter and regroup. Let’s chase to the sidelines those in the policy community who just don’t get it and let them watch us fix our system. We don’t need more endless policy studies to figure out how to do that.

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

AMA needs to realize value of Medicare for All, med students say

By Robertha Barnes, Chris Cai, Diana Chang, Ashley Duhon and Michael Zingman
Modern Healthcare, September 7, 2019

Last month, the American Medical Association announced its departure from the Partnership for America’s Health Care Future. While the AMA still does not support improved Medicare for All, this is an important step. Last year, the partnership spent $143 million lobbying against Medicare for All using decades-old scare  tactics like the fear of “socialized medicine,” rising costs and loss of consumer choice.

As future doctors, we know the evidence doesn’t support this. Several studies, including by the libertarian Mercatus Center, show Medicare for All will expand coverage while reducing overall health spending. Over 200 economists agree that Medicare for All would save money for most Americans. Unlike commercial or employment-based insurance, the programwould provide all medically necessary care free at the point of service, including dental, vision, reproductive and long-term care. Finally, a Medicare for All system would not significantly increase hospital use or lower doctors’ incomes.

Why does the AMA oppose Medicare for All? Today the association represents fewer than 25% of physicians and clings to policies that elevate the interests of for-profit corporations and private hospitals over those of patients. The AMA has fought against national health insurance as far back as the 1950s when it opposed Medicare and Medicaid.

That is why Students for a National Health Program co-led a demonstration at the AMA’s annual meeting in June. Our demands were clear: Leave the anti-single payer partnership and end your misguided opposition to single-payer.

While we applaud the AMA for leaving the partnership, we believe this is not enough. If the AMA is truly in favor of healthcare justice, it must support improved Medicare for All.

Robertha Barnes, Chris Cai, Diana Chang, Ashley Duhon and Michael Zingman all are medical students and national board members of Students for a National Health Program.

https://www.modernhealthcare.com…

Medicare-for-All Is Not Medicare, and Not Really for All. So What Does It Actually Mean?

Some candidates use Medicare-for-all to establish themselves as bold progressives or moderate pragmatists. The Trump administration uses it as a point of attack. But voters don’t know what it actually means, and none of the candidates explain it.

By Akilah Johnson
ProPublica, September 6, 2019

GAITHERSBURG, Md. — Ritchard Jenkins reached into the black computer bag he keeps near his workstation at Graceful Touch Barber and Beauty Salon and rifled through medical papers, pulling out an envelope buried deep at the bottom.

It was an unopened medical bill for $971.78, now 17 months overdue, that he had put out of sight and out of mind. Another unpaid bill from May for $447.13 rested in a nearby drawer. Both are the result of an arthritic knee that needs to be replaced and keeps the 55-year-old master barber in near-constant pain.

He makes numerous phone calls to doctors and insurance companies to discuss his coverage. And just when he thought he couldn’t take any more, he fell down the steps, breaking his right wrist, tearing his rotator cuff and kickstarting a new round of hospital stays, tests — and insurance claims.

“Health care is ridiculous. These politicians really need to step their game up,” Jenkins said recently, using his left hand to hold clippers and a comb because his right remains swollen and partially immobile.

But Jenkins shrugged when asked if Medicare-for-all, the slogan that has dominated early campaigning in the 2020 Democratic primary, was the solution to his and America’s health care woes. He mumbled something about being too young for Medicare and laid bare the disconnect between how voters think and talk about health care and how candidates do.

As the Democratic primary campaign heats up, with the third debate scheduled for Sept. 12, candidates have used the slogan to distinguish themselves as bold progressives, moderate pragmatists or, in some instances, a little of both. The Trump administration has made it a point of attack, vowing to create a better system at lower costs. But interviews with voters and research by health policy experts show that the average voter has little idea of what is meant by the phrase that has already become a campaign signpost.

In its broadest terms, Medicare-for-all is what health care experts call single-payer: A system in which a government entity reimburses doctors and hospitals at a set rate. Many of the world’s most admired health care systems, from France to Israel to Canada, use some version of this approach.

Many health care experts argue that single-payer is the most effective way to deliver medical care to the greatest number of people. But until now, it has been politically unimaginable, taken off the table by most candidates seeking national office.

Health care “is the most important issue” of the election, and “single-payer is the right solution for American health care,” said Dr. Adam Gaffney, president of Physicians for a National Health Program and instructor at Harvard Medical School, who supports calling it Medicare-for-all but acknowledges pitfalls with the framing.

This “is an issue that affects, literally, every single person in this country,” he said. “Even putting the medical issues aside, it’s an economic issue. The way we finance health care promotes economic inequality.”

Medicare-for-all, in the purest sense, largely would replace private health insurance with a single, government-run program covering most everyone. It would be similar to traditional Medicare, the current federal health insurance program for most adults over 65 and young people meeting federal disability requirements, hence the name.

Sounds simple? It’s not.

Medicare was signed into law in 1965 after a 50-year effort to create a national health insurance system covering everyone. Opposition was so fierce that President Franklin Roosevelt excluded health insurance from the Social Security Act of 1935, and 13 years later President Harry S. Truman’s efforts to close what he called “the greatest gap in our social security structure” died in committee. The only way to get the law passed was by limiting coverage to older Americans.

And it’s worked, more or less, because of the government’s ability to set payments to health care providers. Still, high-quality, affordable coverage remains out of reach for many Americans, including many on Medicare. (Medicare covers only a portion of medical expenses, with many people buying supplemental plans to mitigate out-of-pocket costs.)

The Affordable Care Act, passed in 2010 during the Obama administration, was seen by many experts as a once-in-a-generation reform. Some argue it didn’t go far enough to provide every American with quality health insurance at a reasonable price. Others say it proves that the government isn’t the solution.

The fight over whether to expand the government’s health care system to cover all Americans has been part of the national conversation for generations, albeit often on the fringes, and was a topic of debate even before independent Sen. Bernie Sanders, of Vermont, made it his campaign rallying cry during his first Democratic primary presidential campaign in 2016.

Only Two Candidates Support Medicare-for-All in Its Broadest Terms

In fact, it was the lessons learned during President Bill Clinton’s failed health care reforms in the 1990s that inspired the term Medicare-for-all. The phrase first appeared in the Congressional Record in 2003 on a House bill introduced by former Rep. John Conyers Jr., of Michigan, and again in 2006 when the late Massachusetts Sen. Edward M. Kennedy, long a proponent of national health insurance, introduced the “Medicare for All Act.”

But it was a former staffer who suggested Kennedy start saying Medicare-for-all instead of single-payer.

“It was too wonky, and no one knew what it meant,” Dr. Philip Caper, a single-payer advocate for nearly 50 years who worked with Kennedy from 1971 to 1976, said during a phone interview from his home in Maine. “I said: What we’re really talking about is expanding Medicare for everybody. I think you should use Medicare-for-all from now on. It’s harder to demonize it … and you don’t have to explain it.”

The senator took his advice, but the bill died in committee.

“This is the first time the notion of Medicare-for-all has really had any political traction” since 1974, Caper said.

It was the subject of the first question asked during the first night of the second Democratic presidential debate in Detroit, where the discussion lasted more than 20 minutes. And a recent Morning Consult/Politico poll showed that 65% of voters say they would support a candidate in the Democratic primary who favors Medicare-for-all over preserving and improving current health care laws.

Still, Caper said, for such a shift to work, there would be a huge need to educate the public and grow a large, active constituency around Medicare-for-all. Elected officials “hate the political pain” that often accompanies large-scale change, he said.

Plenty of people are arguing against Medicare-for-all, urging program reforms but not restructuring. Dozens of health care business groups created the Partnership for America’s Health Care Future to eschew “one-size-fits-all health care … whether it’s called Medicare for all, buy-in, or a public option.” And though the American Medical Association is not listed as a member on the alliance’s website, its president said recently that it too believes in a “pluralistic system.”

“Rather than disrupt what we have now, let’s build up on the progress of it,” said Dr. Patrice Harris, president of the AMA. “Ninety percent of folks have health insurance. It really is about the 10% of folks who don’t.”

Making national health insurance a reality would mean redesigning the country’s health care payment infrastructure. It would involve going from a diffuse network that includes private insurers for those who can afford it and public services for a limited number of those who can’t into a single government-administered system. The role of insurance companies would be vastly reduced. By one estimate, as many 2 million people who are paid to process insurance claims or argue about them would lose their jobs.

Would people get to keep their doctors? Unclear. Would prescription drug costs decrease? Uncertain. Would wait times increase? Unknown. Copays? No, depending on the plan. Increase in taxes? Almost certainly, but again, it depends.

Because the current system doesn’t cover everyone, the government would have to raise money (that is, taxes) to pay for a national health care system. Economists and health experts agree that this would cost significantly more than the $3.5 trillion the nation currently spends on health care, about a third of which is spent on private insurance. And a substantial sum of the nation’s health care costs goes to administering and processing insurance claims.

They disagree on who would get taxed or how much and over whether the trade-off — higher taxes in exchange for limited to no copays, premiums or deductibles — would be worth it. Some experts argue that creating a national health care system would cost the country an additional $32 trillion. Others say it would eventually save $12.5 trillion. Determining who’s right, and by how much, depends on the design of the system which remains a heavily debated point of contention.

“When you say Medicare-for-all, there are eight different flavors,” with each dependent on each presidential candidate’s platform, said John McDonough, a professor at Harvard’s T.H. Chan School of Public Health who was instrumental in both Massachusetts’ universal health care plan and the Affordable Care Act. “It’s an advertising slogan; it’s not a scientific concept.”

A Kaiser Family Foundation report from July found that about three-fourths of the country supports expanding public health insurance programs, including allowing those 55 to 64 to buy into Medicare.

But the report showed that how politicians talk about the issue matters, with 63% responding favorably to the terms “Medicare-for-all” and “universal health coverage.” Those positive feelings begin dissipating when it’s called a “single-payer national health insurance system,” dropping to 49%. They essentially evaporate if it means eliminating private insurance, increasing taxes or disrupting the current Medicare system, with about 60% opposing a national health care plan.

“The problem is: What is Medicare-for-all?” asked Ashley Kirzinger, associate director for the Kaiser Family Foundation’s public opinion and survey research team, which has been polling on the topic since Sanders’ 2016 campaign pushed it into the mainstream. “It’s not Medicare and lots of times it’s not for all, so it’s a little bit of a misnomer.”

Core dimensions of health policy — cost, access, quality and equity — vary wildly depending on factors such as income, geography, race, gender, ethnicity and job type, McDonough said, adding that creating a formula to improve everyone’s health care is “very hard. When you make changes, you will improve it for many but diminish it for others.”

All 20 Democratic candidates say health care is a human right, and universal coverage has been a cornerstone of the Democratic Party’s platform. But universal coverage and Medicare-for-all can be achieved in very different ways — one can include keeping private insurance and the other, in the strictest sense, doesn’t — and are not necessarily synonymous.

Candidates’ health care platforms exist on a spectrum from least to most disruptive, with some calling for building on the current system while others champion its complete dismantling.

Twelve support Medicare-for-all — or something like it — with some, such as Beto O’Rourke, the former Texas congressman, and Mayor Pete Buttigieg of South Bend, Indiana, opposing a single-payer system while trading in the brand recognition that is Medicare-for-all with their respective slogans “Medicare for America” and “Medicare for all who want it.”

The candidates views are not fixed. Some have occupied several positions at once or adjusted their plans to be more mainstream.

Three of the six senators in the race co-sponsored the bill written by Sanders to establish a national Medicare-for-all health insurance program. And until recently he remained the consistent single-payer stalwart, committed to the bill as written. But he, too, reportedly announced compromises for union workers that would allow any employer savings under Medicare-for-all to be passed along to workers in money or other benefits. Others, however, have flirted with — or flat-out embraced — maintaining private insurance.

And Sen. Kamala Harris of California, who calls her plan Medicare-for-all though it includes a mix of public and private insurance, co-sponsored the Sanders bill. She also co-sponsored four other bills along the ideological spectrum currently before Congress.

Then there are candidates such as former Vice President Joe Biden and former Maryland Rep. John Delaney who say Medicare-for-all is too controversial and costly an experiment. Universal coverage can be reached without completely upending the system, they contend.

Caper, the single-payer evangelist who helped popularize the term, said presidential candidates “water it down” and “confuse the issue” by suggesting Medicare-for-all can include commercial insurance.

To him it’s simple: The mission of commercial insurance is to make money while Medicare’s mission is to facilitate care for people. “That’s a fundamental difference,” he said.

Some voters remain unmoved, convinced that the health care debate is little more than meaningless campaign rhetoric.

“Politicians have no clue what it’s like out here,” said Margaret Coates, who, for more than two decades, worked in medical billing for providers and insurers.

Medicare is expensive and confusing, she said, and so is trying to buy health insurance. About two years before she turned 65, Coates said the government began inundating her with a dizzying array of information about Medicare.

“I did not know how expensive these plans were until I reached Medicare age,” she said, sitting in the magazine section of the Gaithersburg library, where signs posted against the back wall ask, “Are you eligible for help with Medicare costs?”

The need for help is widespread. Medicare covers about 80% of the costs of doctor visits and outpatient services; most seniors buy insurance to cover some or all of the remainder.

Coates’ 28-year-old daughter, a cosmetologist, has had her own health care struggles. Last year, she paid more in federal taxes for not having insurance, a penalty that costs at least about $700 per adult. (The Tax Cuts and Jobs Act of 2017 eliminated penalties for taxes filed in April 2020.) To avoid another penalty, she took on the cheapest insurance she could find at a cost of about $120 a month. With a $3,000 annual deductible, she has had to turn to her parents for help with medical bills.

“Everyone is up there cheering and happy because you have medical insurance,” Coates said. “But no one is saying what happens after you get it.”

Much of the conversation about the costs associated with Medicare-for-all include trillion-dollar figures, which does little to explain how it would affect taxpayers’ wallets. What resonates most with voters are not big aggregate numbers, but people’s out-of-pocket costs, said Kenneth Thorpe, an Emory University health policy researcher who worked as a legislative consultant to Vermont during its failed effort to create a single-payer system.

“We spent two years doing estimates, saying if we ran [health care] through the state, what would the state have to raise in taxes?” The answer, he said: Almost a 20% increase in payroll and income taxes. Creating a single-payer plan that would have covered everyone in Vermont would have forced some small businesses to close and put some people out of work.

In the end, he said the trade-off — increase taxes to expand coverage and decrease health care costs — wasn’t worth it, so “they dropped it, one of the most liberal states in the country.”

Charles Blahous, a senior research strategist at the Mercatus Center at George Mason University, and a former trustee of the Medicare and Social Security programs, said it would be an “analytical mistake to say we’re paying for this in other ways.” Because, he continued, “even if you make a very aggressive assumption for substantial administrative cost savings and substantial drug cost savings. It would still be the case that national spending would be higher.”

About 81% of Democrats and left-leaning independents say the federal government has a responsibility to ensure health insurance for all Americans, according to a recent Pew Research Center poll. The opposite is true of Republicans and right-leaning voters, 77% of whom say this is not the government’s responsibility.

Anger over the passage of the Affordable Care Act, which made health care more accessible and affordable for millions of Americans without coverage (though, critics say, not affordable and accessible enough), helped give rise to the Tea Party. Republicans made repealing President Barack Obama’s signature health care legislation central to their party’s effort until the 2018 midterm elections, when voters turned out en masse demanding that key provisions be retained.

Still, the Trump administration said replacing the ACA is key, backing a federal lawsuit seeking to overturn the law and proposing rules allowing individuals to purchase short-term insurance, small businesses to join forces to offer employees health plans, and employers more flexibility in how they fund health insurance.

Health and Human Services Secretary Alex Azar reiterated the administration’s objective of “choice and competition” during a July speech before an advocacy group whose mission is to improve private health insurance options for Medicare beneficiaries while taking aim at the Medicare-for-all debate. He criticized “a total government takeover” as a “reckless” idea.

Taking a seat at an empty barber chair at Graceful Touch, Antonio Dickerson shakes his head in disgust at the idea of government working to improve life for people like him.

“Absolutely not,” said the 50-year-old, rubbing a scar on his shin, a reminder of health care interactions that have left him with a heavy dose of skepticism that Medicare-for-all — or essentially any government action — will result in meaningful reform.

He watched Jenkins, his friend and co-worker, return to work instead of recuperating after surgery because he can’t afford the supplemental coverage that would allow him to take more time to heal.

He watched his grandmother die two weeks after being released from the hospital, saying her insurer would no longer cover the cost of her care.

He watched one nurse’s shift end — and begin again — as he waited, uninsured, in an emergency room for hours, blood oozing from an open wound on his shin that eventually required 32 stitches.

“If you don’t have any money, get to the back to the line,” he said asking if those in the barbershop had ever seen “John Q,” a 2002 movie starring Denzel Washington about a husband and father whose son needs a life-saving operation but insurance won’t cover it.

Washington’s character takes the emergency room hostage, forcing the hospital and doctors to perform his son’s heart transplant.

That, said Dickerson, is “a very understandable situation.”

https://www.propublica.org…

Medical bankruptcy is an American scandal — no debate

Medical bankruptcy is an American scandal — and that’s not debatable

By Michael Hiltzik
Los Angeles Times, September 4, 2019

You’ve got to hand it to Sen. Bernie Sanders for his ability to keep hot-button issues in the forefront of the presidential race.

The latest example is his assertion, made at least twice in the last month, that medical bills drive 500,000 Americans into bankruptcy every year. The Washington Post’s fact-checker column examined the numbers and concluded that Sanders deserved “three Pinocchios” for the statement, which means the Post found it “mostly false” and that Sanders was, basically, lying.

The Post blundered, as the authors of the study on which Sanders based his claim point out. In the real world, Sanders’ assertion that “500,000 Americans will go bankrupt this year from medical bills” is “mostly true.” Medical bankruptcy is an American scandal, and possibly even more common than he or the study’s authors calculate.

“At this point everyone agrees that many thousands of Americans suffer medical bankruptcies each year, but there’s still scholarly debate over exactly how many,” Himmelstein and Woolhandler wrote in response to the Post fact-checking. “Economists and business school professors (including some funded by the health insurance industry) generally offer lower estimates, and medical and legal researchers find higher numbers.”

Unquestionably, the individual burden of medical costs in the U.S. can be unsupportable and, in the richest country in the world, should be unnecessary. Sanders and Warren are right to point the finger at a dysfunctional healthcare financing system. Those who say things aren’t that bad are wrong; it’s worse. Debating whether the number of Americans forced into bankruptcy by medical debt is 500,000 or some other figure is nitpicking, and woefully beside the point. What everyone knows is that the threat is bad enough, and it can strike at anyone.

www.latimes.com…

Sanders’s flawed statistic: 500,000 medical bankruptcies a year

By Salvador Rizzo
The Washington Post, August 28, 2019

This fact check has been updated with a rebuttal response

Sanders’s statements — “500,000 people go bankrupt every year because they cannot pay their outrageous medical bills” and “500,000 Americans will go bankrupt this year from medical bills” — are unambiguous. He’s saying medical debts caused those 500,000 bankruptcies. However, correlation is not causation, and the study he’s citing doesn’t establish causation for all 500,000 bankruptcy cases.

One of the authors sent us rough estimates showing that Sanders might be on target, but those numbers deserve scientific scrutiny before they can be taken as fact.

The omissions and twists are significant enough to merit Three Pinocchios for Sanders.

www.washingtonpost.com…

Medical Bankruptcy is Real, Even if the Washington Post Refuses to Believe it

By David U. Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H

The Washington Post has broken new ground, calling a presidential candidate a liar for citing a statistic from research published in the world’s leading public health journal. The Post’s Fact Checker column labeled Bernie Sanders a “three pinocchio” level liar for saying that 500,000 Americans are bankrupted by medical bills each year. Sanders’ statement relied on research that we and three colleagues published in the American Journal of Public Health (AJPH). Dozens of politicians and publications (including the Post itself!) have cited that study as a reliable source.

Our AJPH study was part of an ongoing research effort by the Consumer Bankruptcy Project (CBP). For decades, the CBP has been surveying debtors about the causes (including medical ones) and consequences of their bankruptcy. In our 2019 research, 37.0% of bankrupts “very much” agreed that medical bills were an important factor, while another 21.5% “somewhat agreed”. Many others cited lost wages due to illness, and overall, two-thirds cited illness-related bills, income loss or both. As we wrote in the AJPH, that’s “. . . equivalent to about 530 000 medical bankruptcies annually.” That figure is in line with estimates based on our earlier CBP studies (carried out with then-Harvard law professor Elizabeth Warren and sociologist Deborah Thorne), which were published in leading medical and policy journals.

But even the 530,000 figure is an underestimate of the number of people affected by medical bankruptcies. Most bankruptcies involve more than one person – an average of about 2.7 people, often including a spouse/partner and children. That means that the 750,000 bankruptcies last year involved more than 2 million people. And even if you use the most restrictive definition of medical bankruptcy – i.e. including only debtors who “very much” agreed that medical bills were a cause of their bankruptcy – Sanders’ 500,000 figure is, if anything, too low. The right number is more like three quarters of a million.

And our studies aren’t the only indicator that many American families suffer a crushing burden of medical bills. A Nobel Prize winner was forced to sell his medal to pay medical bills. More than 250 000 people sought to raise funds for medical bills through GoFundMe campaigns last year. According to the Consumer Financial Protection Bureau, medical bills account for more than half of all unpaid bills sent to collection agencies. And in a New York Times/Kaiser Foundation survey, more than one quarter of respondents said they or someone in their household had a problem paying medical bills, and of them, 11% said they’d declared bankruptcy due, at least in part to medical bills.

So why did the Fact Checker claim that Sanders told a whopper? That claim rests on an econometric study that found only a modest uptick in bankruptcy filings among persons hospitalized in California between 2003 and 2007. But that study appeared tailor made to undercount medical bankruptcies. As we and Elizabeth Warren noted in our response to it in the New England Journal of Medicine, it excluded most people who were frequently hospitalized (a group that’s at high risk of medical bankruptcy); it assumed that anyone not hospitalized could not suffer medical bankruptcy (even though people who aren’t hospitalized in the course of a year account for four-fifths of all out-of-pocket medical bills); that no one is bankrupted by bills for a child’s or partners’ care; and that potentially bankrupting illnesses never start before the moment of hospitalization – an assumption contradicted by the study’s own data.

Yet despite these flaws, the economists behind the study insisted (and the Post believed) that their math was a more reliable indicator of what caused financial ruin than the testimony (and court records that we’ve used as cross-check) from the thousands of debtors surveyed and interviewed by the CBP.

At this point everyone agrees that many thousands of Americans suffer medical bankruptcies each year, but there’s still scholarly debate over exactly how many; economists and business school professors (including some funded by the health insurance industry) generally offer lower estimates, and medical and legal researchers find higher numbers. We’d be happy to see the Post report the facts and nuances of that debate. But instead it’s chosen a side and labeled those on the other side – researchers, public figures who cite their research, and the debtors who shared their painful stories – “liars.”

David U. Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H. are both Distinguished Professors of Public Health, City University of New York at Hunter College and Lecturers in Medicine at Harvard Medical School, and the founders of Physicians for a National Health Program.

www.berniesanders.com… 

Comment:

By Don McCanne, M.D.

The United States is unique in supporting a health care financing system that results in financial hardship for millions of people due to medical bills. Many of those individuals end up in personal bankruptcy whether those bills were a contributor or a “cause” of the bankruptcy.

For many years now, the bankruptcy statistics have been debated, not based on whether medical bills cause financial hardship or contribute to bankruptcy – they clearly do and on a massive scale. Rather, the debate has been over the definition of “cause” when used to estimate the number of bankruptcies “caused” by medical bills. Those who wish to discredit the bankruptcy studies seem to disregard medical debt as “a” cause of bankruptcy and insist that only medical debt as “the” (presumably sole) cause of bankruptcy be counted in the statistics.

David Himmelstein and Steffie Woolhandler, in their response above, set the record straight. Medical debt in the United States is a horrendous problem that creates much hardship, and it is totally unnecessary.

All we need to do is to separate the health care financing system from the delivery of health care. We can finance the entire health care system with equitable taxes that are affordable for each of us without creating any personal financial hardship. Then when individuals need health care they can get it without the necessity of paying insurance premiums nor deductibles, copayments or coinsurance as a condition for accessing health care.

A Single Payer Medicare for All system would ensure health care for everyone without exposing them to financial hardship nor personal bankruptcy due to medical debt. The media and policy community should stick to the issues that actually impact our health care rather than distracting us with their pinocchio mischief.

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

The fallacy of expanding ACA and adding a public option

Who Are the Remaining Uninsured, and Why Do They Lack Coverage?

By Munira Z. Gunja and Sara R. Collins
The Commonwealth Fund, August 28, 2019

In 2018, an estimated 30.4 million people were uninsured, up from a low of 28.6 million in 2016. Coverage gains have stalled in most states and have even eroded in some. In addition, more people have reported problems getting health care because of cost. To examine why so many people remain uninsured, we use data from the 2018 Commonwealth Fund Biennial Health Insurance Survey.

  • Uninsured Working-Age Adults Disproportionately Low-Income, Latino, and Under Age 35
  • Nearly Half of Uninsured Adults May Be Eligible for Marketplace Subsidies or Medicaid
  • One-Third of Uninsured Adults Who Did Not Visit Marketplace to Get Coverage Cited Affordability Concerns
  • One-Third of Adults Who Lost Coverage and Were Previously Covered Through the Individual Market Cited Affordability Concerns
  • Majority of Adults Who Had Lost Coverage and Were Previously Covered by Medicaid Said They Were No Longer Eligible
  • More Adults Had Difficulty Finding Affordable Coverage in the Individual Market in 2018 vs. 2016

Policy Recommendations:

  • Expand Medicaid without restrictions.
  • Lift the 400-percent-of-poverty cap on eligibility for marketplace tax credits.
  • State or federal reinsurance.
  • Reinstate outreach and navigator funding for the 2020 open-enrollment period.
  • Ban or place limits on short-term health plans and other insurance that doesn’t comply with the ACA.
  • Make premium contributions for individual market plans fully tax deductible.
  • Fix the so-called family coverage glitch.
  • Inform people about their options.
  • Reduce churn in Medicaid.
  • Extend the marketplace open-enrollment period.

www.commonwealthfund.org…

Comment:

By Don McCanne, M.D.

In spite of enactment and implementation of the Affordable Care Act, 30 million people remain uninsured and tens of millions remain underinsured. In spite of spending twice the average of other wealthy nations, access to health care and affordability of care remain a uniquely American problem.

The Commonwealth survey quantifies these problems, and then they propose incremental tweaks that would expand access and improve affordability, but they would do so at a cost of increasing our already excessive administrative complexity and increasing further our very high level of spending. Further, they would not eliminate the problems of access and affordability as many would still fall short of qualifying for public programs or of being able to pay for private programs.

Yet many recommend that we build on ACA and add a public option (Medicare buy-in) as another choice. The options listed by Commonwealth are those that would build on ACA, and yet we see that they are costly and increase administrative complexity while falling far short of the goals of universality, accessibility, and affordability. Adding the option of buying a public plan does not work for the great majority of those who would remain uninsured simply because the plan would not be affordable for them.

The single payer model of Medicare for All would recover hundreds of billions of dollars in administrative waste while automatically making health care affordable and accessible for absolutely everyone.

Enough with the deficient tweaks. Let’s go directly to a system that would work for all of us: Single Payer Medicare for All.

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

The role of hospitals in high prices and administrative excesses

That Beloved Hospital? It’s Driving Up Health Care Costs.

By Elisabeth Rosenthal
The New York Times, September 1, 2019

As voters fume about the high cost of health care, politicians have been targeting two well-deserved villains: pharmaceutical companies, whose prices have risen more than inflation, and insurers, who pay their executives millions in salaries while raising premiums and deductibles.

But while the Democratic presidential candidates have devoted copious airtime to debating health care, many of the country’s leading health policy experts have wondered why they have given a total pass to arguably a primary culprit behind runaway medical inflation: America’s hospitals.

Data shows that hospitals are by far the biggest cost in our $3.5 trillion health care system, where spending is growing faster than gross domestic product, inflation and wage growth. Spending on hospitals represents 44 percent of personal expenses for the privately insured, according to Rand.

A report this year from researchers at Yale and other universities found that hospital prices increased a whopping 42 percent from 2007 to 2014 for inpatient care and 25 percent for outpatient care, compared with 18 percent and 6 percent for physicians.

So why have politicians on both the left and right let hospitals off scot-free? Because a web of ties binds politicians to the health care system.

Every senator, virtually every congressman and every mayor of every large city has a powerful hospital system in his or her district. And those hospitals are as politically untouchable as soybean growers in Iowa or oil producers in Texas.

As hospitals and hospital systems have consolidated, they have become the biggest employers in numerous cities and states. They have replaced manufacturing as the hometown industry in a number of rust-belt cities, including Cleveland and Pittsburgh.

Can Kamala Harris ignore the requests of Sutter Health, Kaiser Permanente, U.C.L.A. or any of the big health care systems in California? Can Elizabeth Warren ignore the needs of Partners HealthCare, Boston’s behemoth? (Bernie Sanders may be somewhat different on this front because Vermont doesn’t have any nationally ranked hospitals.)

Beyond that, hospitals are often beloved by constituents. It’s easy to get voters riled up about a drug maker in Silicon Valley or an insurer in Hartford. It’s much riskier to try to direct their venom at the place where their children were born; that employed their parents as nurses, doctors and orderlies; that sponsored local Little League teams; that was associated with their Catholic Church.

And, of course, there’s election money. Hospital trade groups, medical centers and their employees are major political donors, contributing to whichever party holds power — and often to the out-of-power party as well.

To defend their high prices, medical centers assert that they couldn’t afford to operate on Medicare payments, which are generally lower than what private insurers pay. But the argument isn’t convincing.

The cost of a hospital stay in the United States averaged $5,220 a day in 2015 — and could be as high as over $17,000, compared with $765 in Australia. In a Rand study published earlier this year, researchers calculated that hospitals treating patients with private health insurance were paid, overall, 2.4 times the Medicare rates in 2017, and nearly three times the rate for outpatient care. If the plans had paid according to Medicare’s formula, their spending would be reduced by over half.

Most economists think hospitals could do just fine with far less than they get today from private insurance.

While on paper many hospitals operate on the thinnest of margins, that is in part a choice, resulting from extravagance.

It would be unseemly for these nonprofit medical centers to make barrels of money. So when their operations generate huge surpluses — as many big medical centers do — they plow the money back into the system. They build another cancer clinic, increase C.E.O. pay, buy the newest scanner (whether it is needed or not) or install spas and Zen gardens.

If hospitals were paid less via regulation or genuine competition, they would look different, and they’d make different purchasing decisions about technology. But would that matter to medical results? Compared with their European counterparts, some American hospitals resemble seven-star hotels. And yet, on average, the United States doesn’t have better outcomes than other wealthy nations. By some measures — such as life expectancy and infant mortality — it scores worse than average.

As Uwe Reinhardt, the revered Princeton health economist who died in 2017, told me, “If you want to save money, you have to pay less.” That means taking on hospital pricing.

Elisabeth Rosenthal, a former New York Times correspondent, is the editor in chief of Kaiser Health News, the author of “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back” and a contributing opinion writer.

www.nytimes.com… 

Comment:

By Don McCanne, M.D.

Certainly the insurance and pharmaceutical industries are appropriate targets as we try to explain to the public how we can dramatically improve the financing of health care so that it becomes more accessible and truly affordable for each and everyone of us. In this article, Elisabeth Rosenthal explains why we should be looking at the hospital industry as well.

Two of the most important reasons for our high health care costs are administrative excesses and high prices. Hospitals are guilty of contributing to high costs on both counts, primarily because they not only tolerate but actually support our highly flawed method of health care financing, while actively opposing a method that would reduce administrative waste and price gouging.

It is the private insurance industry that has been a major player in tolerating and perpetuating high health care prices, and, of course, their role in increasing the administrative burden for hospitals and the rest of the health care delivery system is infamous. The hospital lobbyists are actively supporting the private insurance industry.

The single payer Medicare for All model of health care financing would change the way we fund hospitals. Instead of paying itemized fees or DRGs for each patient and the various services and products that they utilize, under single payer hospitals would be funded through global budgets, much like we fund the fire department. We would be paying the legitimate costs of operating the facility rather than payments based on driving up both prices and volume of services. Also expansion of system capacity and addition of capital improvements would be separately budgeted based on community need, thus avoiding excess capacity that embodies the Romer rule (if you have an empty bed, it will be filled), while still ensuring adequate capacity for the community.

Right now the opponents to Medicare for All are emphasizing that individuals would lose their choice of private health plans, when that financing model is responsible for much of the waste, deficiencies, and inequities in our system. Our drumbeat needs to be louder on the true sources of high costs and inequities – the perpetrators of the administrative waste and high prices. We will not adequately address those until we change the financing system to single payer through an improved version of Medicare that truly includes everyone.

Why are the hospitals in bed with the insurers instead of with us? Money. They are being paid generously for the services they offer. They seem to dismiss financial hardship and personal bankruptcy for too many of their patients as simply a cost of doing business, but those hardships stem from the fact that they are doing business with the wrong people – the private insurers. That doesn’t mean that they won’t accept funds from the public insurers, especially Medicare and Medicaid, but they don’t see that as a source of huge surpluses that they can plow back into their systems, sometimes surrounding themselves with extravagance.

Of course, there are also hospitals in communities with high rates of poverty and excess numbers of uninsured and underinsured, and many of these hospitals struggle. Single payer Medicare for All would play an important role as the great equalizer, a role that underfinanced Medicaid and charity cannot fulfill.

We can do far better, but the public has to understand how.

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

The Future Of Health Care In The United States

Interview with Dr. Ed Weisbart

By Bente Bouthier
Indiana Public Media, Noon Edition, September 4, 2019

full audio:
https://indianapublicmedia.org…

According to The Washington Post and Politico, thirteen democratic presidential candidates support some form of “Medicare for all,” a proposal that all Americans should automatically be entered into a single-payer government health plan.

Though most Democratic presidential candidates are vocal in their support of expansion of health coverage, many candidates do not agree on the means or time frame for this goal.

According to the U.S. Census, 8.8 percent of Americans did not have health coverage during 2017. Private health insurance is the dominant form of coverage, insuring 67.2 percent of Americans, where government coverage insures 37.7 percent.

Since 2010, 113 hospitals in rural areas have closed their doors. Many attribute this to the lack of expansion of the Affordable Care Act.

The idea for a national health insurance plan in America isn’t new. It was first pushed by President Teddy Roosevelt, and then Harry S. Truman in 1945.

Even then, no bill was passed until 20 years after his presidency, when Americans started to get Medicare health coverage under legislation signed by Lyndon B. Johnson.

Join us this week as we talk about the future of health coverage in the U.S. and what “Medicare for all” means.

Guests

Dr. Kosali Simon, O’Neill School of Public and Environmental Affairs Professor, Journal of Health Economics Co-Editor

Dr. Ed Weisbart, Head of Physicians for a National Health Program Missouri

Dr. Malaz Boustani, Center for Health Innovation & Implementation Science Director

Medical bankruptcy is an American scandal — and that’s not debatable

By Michael Hiltzik
Los Angeles Times, September 4, 2019

You’ve got to hand it to Sen. Bernie Sanders for his ability to keep hot-button issues in the forefront of the presidential race.

The latest example is his assertion, made at least twice in the last month, that medical bills drive 500,000 Americans into bankruptcy every year. The Washington Post’s fact-checker column examined the numbers and concluded that Sanders deserved “three Pinocchios” for the statement, which means the Post found it “mostly false” and that Sanders was, basically, lying.

The Post blundered, as the authors of the study on which Sanders based his claim point out. In the real world, Sanders’ assertion that “500,000 Americans will go bankrupt this year from medical bills” is “mostly true.” Medical bankruptcy is an American scandal, and possibly even more common than he or the study’s authors calculate.

It’s also virtually unique to the U.S. among developed countries; when experts from Japan and Europe were asked by the PBS program “Frontline” about the prevalence of medical bankruptcy in their countries, some had trouble even comprehending the question.

What’s clear about the financial consequences of the American system of healthcare financing, which places much of the burden on households, is that they’re widespread and scandalous. One signpost is the rise of crowdfunding campaigns via platforms such as GoFundMe to raise money for families facing medical bills. In a civilized country, public appeals for help with medical bills shouldn’t exist. Yet GoFundMe reports that it hosts more than 250,000 medical campaigns per year, raising more than $650 million a year.

Even households seemingly well-covered by employer health plans can face financial trouble. A survey conducted jointly by the Kaiser Family Foundation and the Los Angeles Times found this year that among those consumers, “four in ten report that their family has had either problems paying medical bills or difficulty affording premiums or out-of-pocket medical costs, and about half say someone in their household skipped or postponed some type of medical care or prescription drugs in the past year because of the cost. Seventeen percent say they’ve had to make what they feel are difficult sacrifices in order to pay health care or insurance costs; for some, the sacrifices they report making are extreme.”

Still, pinpointing the number of medical bankruptcies in the United States is difficult, because the causes of bankruptcy typically are multiple. To an extent, the Post’s blunder rests in trying to shoehorn a nuanced phenomenon into its Pinocchio scale, which doesn’t much allow for shades of meaning. So let’s take a look at what the research tells us about the devastation that medical bills can bring to household finances.

First, let’s examine the research underlying Sanders’ figure. It comes from a series of studies dating back to 2005, chiefly by David U. Himmelstein and Steffie Woolhandler of Harvard and the City University of New York, with the participation at one point or another of Elizabeth Warren, previously a professor at Harvard and currently a U.S. senator and like Sanders a candidate for the Democratic nomination for president.

In their most recent paper, published in March, Himmelstein, Woolhandler and colleagues explained that they mined questionnaires sent to bankrupt debtors by the Consumer Bankruptcy Project and determined that 66.5% of the respondents “very much” or “somewhat” agreed that medical expenses or illness-related work loss contributed to their bankruptcies. That’s “equivalent to about 530 000 medical bankruptcies annually,” they wrote.

The researchers’ earlier papers triggered a scholarly debate that’s still ongoing over how to define “medical bankruptcy.” Is it enough, for example, that medical bills are a contributing factor, since in a typical bankruptcy there are many factors?

Whatever the definition, the numbers proposed by Himmelstein, Woolhandler and Warren have also come under attack. In a 2006 study funded by the health insurance industry, David Dranove and Michael L. Millenson of Northwestern University asserted that “medical bills are a contributing factor in just 17 percent of personal bankruptcies,” mostly affecting households already near poverty.

Dranove and Millenson scoffed at the argument by Himmelstein and Woolhandler that the solution to the problem is a national health insurance program. (Himmelstein and Woolhandler are co-founders of Physicians for a National Health Program, a leading advocate of single-payer universal health coverage.)

Last year, researchers from UC Santa Cruz, MIT and Northwestern took another crack at the data, examining the finances of patients who were admitted for treatment to California hospitals. They found “compelling evidence of the existence of medical bankruptcies but discovered that medical expenses cause many fewer bankruptcies than has been claimed” (by you-know-who). They estimated that “hospitalizations cause only 4% of personal bankruptcies among nonelderly U.S. adults.”

The dimensions of the debate should be evident by now. Himmelstein, Woolhandler and Warren have sturdily defended their methodology and findings.

Responding to Dranove and Millenson, they observed that narrowing the debts listed in bankruptcy filings to medical bills probably conceals the role of medical expenses in those cases. That’s because families may take intermediate steps to pay those bills before financially throwing in the towel. Responses by families themselves indicate that “medical debts that wound up as credit card balances, second mortgages, payday loans, collection lawsuits, and so on” are “some of the most important indicators of medical bankrupcies …. Medical debt often appears as ‘credit card debt’ or ‘mortgage’ in court records.”

As for the California data, Himmelstein, Woolhandler and Warren responded that the study was flawed in treating hospitalization as “the sole indicator of a medical problem that could lead to financial distress.” Families can be overwhelmed by nonhospitalization bills, including emergency care, physical therapy or prescriptions, not to mention the costs of treating chronic conditions that never result in a hospital stay but drain household accounts year in and year out. (The authors of the California study replied that relying on debtors’ own assessments “is not a credible way to estimate the causes of bankruptcy.”)

That’s where things stand right now. “At this point everyone agrees that many thousands of Americans suffer medical bankruptcies each year, but there’s still scholarly debate over exactly how many,” Himmelstein and Woolhandler wrote in response to the Post fact-checking. “Economists and business school professors (including some funded by the health insurance industry) generally offer lower estimates, and medical and legal researchers find higher numbers.”

Unquestionably, the individual burden of medical costs in the U.S. can be unsupportable and, in the richest country in the world, should be unnecessary. Sanders and Warren are right to point the finger at a dysfunctional healthcare financing system. Those who say things aren’t that bad are wrong; it’s worse. Debating whether the number of Americans forced into bankruptcy by medical debt is 500,000 or some other figure is nitpicking, and woefully beside the point. What everyone knows is that the threat is bad enough, and it can strike at anyone.

www.latimes.com…