PNHP

CMS may be bypassing Congress to shift Medicaid to block grants

CMS may be bypassing Congress to shift Medicaid to block grants

Red states' Medicaid gamble: Paying more to cover fewer people

By Sam Baker
Axios, April 17, 2019

Red states are getting creative as they look for new ways to limit the growth of Medicaid. But in the process those states are taking legal, political and practical risks that could ultimately leave them paying far more, to cover far fewer people.

Why it matters: Medicaid and the Children’s Health Insurance Program cover more than 72 million Americans, thanks in part to the Affordable Care Act’s Medicaid expansion. Rolling back the program is a high priority for the Trump administration, and it needs states’ help to get there.

The big picture: The Centers for Medicare & Medicaid Services, under the leadership of Administrator Seema Verma, has made clear that it wants to say “yes” to new limits on Medicaid eligibility, and has invited states to ask for those limits.

  • But CMS hasn’t actually said “yes” yet to some of the most significant limits states have asked for.
  • In the meantime, states are left either with vague ambitions they’re not sure how to implement, or with risky plans that put their own budgets on the line.

What we’re watching: State-level Republicans are waiting for CMS to resolve two related issues: how much federal funding their versions of Medicaid can receive, and the extent to which they’re able to cap enrollment in the program.

  • “These issues are going to continue to be intertwined,” said Joan Alker, the executive director of Georgetown University’s Center for Children and Families.

Verma has reportedly told state officials that she wants to use her regulatory power to convert Medicaid funding into a system of block grants — which would be an enormous rightward shift and probably a big cut in total funding.

  • CMS probably cannot do that on its own, experts said, but it could achieve something similar by approving caps on either enrollment or spending.

Where it stands: GOP lawmakers in a handful of states are looking to Utah, which has bet big on Verma’s authority, for signals about what’s possible.

  • Utah voters approved the full ACA expansion last year, but the state legislature overruled them to pass a more limited version.
  • By foregoing the full expansion, Utah passed up enhanced federal funding. It’s still asking for that extra money — a request CMS has never previously approved.
  • Utah will also ask CMS to impose a per-person cap on Medicaid spending — a steep cut that was part of congressional Republicans’ failed repeal-and-replace bill, and which may strain CMS’ legal authority.
  • If Utah doesn’t get those two requests, its backup plan is simply to adopt the full expansion.

What’s next: Utah is not the only red state leaning into Verma’s agenda, but it’s further out on a limb than any other.

  • Idaho, like Utah, overruled its voters to pass a narrower Medicaid bill. But it preserved an option for people to buy into the ACA’s expansion.
  • Alaska Gov. Mike Dunleavy has said he wants to take Verma up on her offer of block grants; so have legislators in Tennessee and Georgia. But in the absence of any detail about what that means, or what CMS will approve, that’s all pretty vague right now.

If CMS does move forward on any of this, it could face the same threat of lawsuits that have stymied its first big Medicaid overhaul — work requirements.

  • Those rules are on ice in two states because a judge said they contravene Medicaid’s statutory structure and goals. The same argument could await a partial expansion or tough spending caps.

“There’s a clear agenda here to get a handful of states to take up these waivers, which fundamentally undermine the central tenets of the Medicaid program — which [are] that it is a guarantee of coverage, and a guarantee of federal funding,” Alker said.

https://www.axios.com…

Comment:

By Don McCanne, M.D.

Conservatives in Congress have longed for a conversion of the federal contribution for state Medicaid programs into block grants – a mechanism by which federal spending on Medicaid could be reduced. The states would either have to fund the difference, or, as the conservative states prefer, they would reduce spending on health care for the vulnerable, low-income beneficiaries served by Medicaid. But the resistance to this change has been great. Even with the Republicans in control of both Congress and the White House, they have not been able to enact these changes.

It appears that CMS Administrator Seema Verma is plotting to bypass Congress by using the Medicaid waiver process to allow states to place lower caps on Medicaid spending and on Medicaid enrollment. This would have essentially the same impact as block grants – reducing federal spending while giving the states greater control over their own programs. For a program that is already severely underfunded, this could have a very negative impact on the health care providers who are already struggling to try to make this program work for their indigent patients.

If we had a well designed, single payer Medicare for All program, there would be no need to maintain a separate health care financing program for low-income individuals and families. But since a single payer program could not possibly be enacted in the current session of Congress, it is imperative that we pull all stops to temporarily protect the Medicaid program until we can transition to single payer Medicare for All.

One noted conservative columnist recently condemned some of the progressives for calling the conservative Republicans cruel because of their policies that attempt to take health care away from the people. Well, they could probably escape the label of cruel if only they would quit being cruel.

Speaking of being cruel, what about those Democrats who say that we should reject single payer Medicare for All just so we can protect the employer-sponsored plans for which the 66 million people who leave their jobs each year are not eligible, and for which millions of others lose their continuity of care because of changes in employer plans, and for which tens of millions are potentially exposed to financial hardship because of excessive out-of-pocket spending requirements? That’s not cruel? Democrats and Republicans, shape up!

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Workplace wellness program does not improve health and economic outcomes

Effect of a Workplace Wellness Program on Employee Health and Economic Outcomes

By Zirui Song, M.D., Ph.D. and Katherine Baicker, Ph.D.
JAMA, April 16, 2019

Key Points

Question: What is the effect of a multicomponent workplace wellness program on health and economic outcomes?

Findings: In this cluster randomized trial involving 32,974 employees at a large US warehouse retail company, worksites with the wellness program had an 8.3-percentage point higher rate of employees who reported engaging in regular exercise and a 13.6-percentage point higher rate of employees who reported actively managing their weight, but there were no significant differences in other self-reported health and behaviors; clinical markers of health; health care spending or utilization; or absenteeism, tenure, or job performance after 18 months.

Meaning: Employees exposed to a workplace wellness program reported significantly greater rates of some positive health behaviors compared with those who were not exposed, but there were no significant effects on clinical measures of health, health care spending and utilization, or employment outcomes after 18 months.

From the Introduction

Workplace wellness programs have become increasingly popular as employers have aimed to lower health care costs and improve employee health and productivity. In 2018, 82% of large firms and 53% of small employers in the United States offered a wellness program, amounting to an $8 billion industry. This growth has been aided by public investments such as the Affordable Care Act, which included funds to promote the development of workplace wellness programs.

Conclusions

Among employees of a large US warehouse retail company, a workplace wellness program resulted in significantly greater rates of some positive self-reported health behaviors among those exposed compared with employees who were not exposed, but there were no significant differences in clinical measures of health, health care spending and utilization, and employment outcomes after 18 months. Although limited by incomplete data on some outcomes, these findings may temper expectations about the financial return on investment that wellness programs can deliver in the short term.

https://jamanetwork.com…

Comment:

By Don McCanne, M.D.

With the very high costs of health care in the United States, it is no wonder that businesses latched onto products offered by the purveyors of wellness programs that promised lower costs for their employer-sponsored health plans, not to mention the benefit of having a healthier workforce. Great concept, so how is it working out?

Roughly a tenth of the employees in this meticulous study of a wellness program reported that they were more attentive to their personal exercise and weight management programs, “but there were no significant differences in clinical measures of health, health care spending and utilization, and employment outcomes after 18 months.” It did not produce the outcomes the employer was promised.

Employers have tremendous problems with their health benefit programs. The costs continue to increase. Employment is unstable with 66 million leaving their jobs each year. Continual changes in insurers, provider networks and benefits covered increase the instability of health care for the workers and their families. And now this desperate attempt to create “wellness” is failing them.

Quite a few years ago, I co-authored a paper with the chairman and CEO of a Fortune 100 company who was also the chair of the Health Committee of the Business Roundtable. The topic was Medicare for All. The intent was to show that an icon of the business world and a health care justice activist could come together to support health care reform that would work well for all of us. Although the article was encouraged by the editor of the leading health policy journal, a junior editor was assigned to send us the rejection notice. The medical-industrial complex was simply not ready for a single payer model of reform.

But look at the wealth of health policy knowledge that has continued to spring up. By any objective criteria, the single payer Medicare for All model is vastly superior in that it achieves all essential goals of reform while using a financing system that is equitable and affordable for each of us. About that last point, none of the other models come close on affordability for all individuals and families, yet, with our three and a half trillion dollar health care bill, we absolutely have to get that one right. Besides, enacting and implementing a health care financing system that works for all of us sounds to me like a pretty good start to a universal wellness program.

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

I agree with Angus King on health care — sort of

By Philip Caper, M.D.
Bangor (Maine) Daily News, April 17, 2019

I agree with Sen. Angus King’s frustration, expressed in his March 31 BDN OpEd, with the seemingly endless debate about how best to provide access to health care to all Americans. I have known King for more than 40 years, dating back to the time we were both on the staff of the U.S. Senate. In general, I agree with King’s politics, and admire his skills as a politician. But in the case of the debate about health care, I disagree with his analysis.

In his OpEd, King decries the Groundhog Day nature of our national health care debate, yet advocates putting yet another patch on the Affordable Care Act rather than replacing it with something better.

He writes, “The ACA isn’t perfect, but it’s made people’s lives better, and that’s worth building on by making simple fixes around the edges rather than tearing it apart or repealing it entirely.” His sentiment is a noble one. But, as Albert Einstein once put it, “The definition of insanity is doing the same thing over and over again and expecting different results.” There have been many attempts to patch up our insurance-and-market-based system. All have failed.

In Maine, Dirigo Healthcare is a prime example. It was launched in 2003 by then-Gov. John Baldacci but never achieved its coverage goals and was allowed to sunset in 2014 by Baldacci’s successor, Gov. Paul Le Page — with hardly a whimper from the public.

In Massachusetts, Romneycare achieved better coverage than did Dirigo, but it has failed to reign in out-of-control health care costs. As a result single-payer health care bills have once again been introduced in the Massachusetts Legislature.

Patching our fundamentally flawed insurance-based system will not solve our health care problems. The problem is not one of designing better insurance, because insurance itself is the problem.

Medical underwriting, the fundamental business of commercial insurance, is all about finding ways to discriminate against sick people or those who are likely to become sick, in order to increase shareholders’ profits. Do we really want a health care financing system that discriminates against sick people? We need to create a system better than insurance.

The ACA lacks adequate cost controls when we’re already spending too much and getting poor results for our money. Furthermore, patches to the ACA will do nothing to fix the extreme fragmentation of our current health care system. That would only contribute to the ongoing confusion and polarization about health care reform that have created our current political gridlock.

Improved Medicare for all would introduce sorely lacking budgets into every level of the system, going a long way toward controlling out-of-control health care costs. And a gradual transition to a new and better system can limit the disruption that is inevitable with any change of this magnitude.

King is a very smart and thoughtful politician with a sophisticated understanding of the complexities of American health care. But on this issue he’s a bit too cautious. He has yet to endorse improved Medicare for all, the one solution that would put an end to his Groundhog Day.

Winston Churchill once said, “Americans will always do the right thing, once they’ve exhausted all alternatives.” Now is the time.

Dr. Philip Caper is an internist and founding board member of Maine AllCare.

https://bangordailynews.com…

Employer coverage provides the least financial protection for lower-wage workers

For low-income people, employer health coverage is worse than ACA

By Drew Altman
Axios, April 15, 2019

There has been appropriate handwringing since 2010 about the affordability of Affordable Care Act plans in the marketplaces. But new data show that health insurance is decidedly less affordable for lower income people who get coverage at work than for their counterparts with similar incomes in the marketplaces.

Why it matters: It’s another example of how, when we focus so much on the ACA markets, we lose sight of problems in the employer-based health system where far more people get their coverage. For lower-wage workers, their coverage is decidedly worse than ACA coverage is.

The details: A low-income family with a marketplace plan pays 8.4% of their income on premiums and out-of-pocket costs, compared to 14% for a lower-wage family with employer coverage (those with incomes below twice the poverty level).

  • That’s based on Current Population Survey data on what people at that income level paid for employer coverage, plus exchange premium data collected from Healthcare.gov and state-based ACA marketplaces.

How it breaks down:

  • For low-income families with marketplace plans, the out-of-pocket costs are 4.7% of their income, while the premiums are just 3.7% of their income.
  • For those with coverage through work, the out-of-pocket costs are 5% of their income, roughly the same as the families with marketplace plans.
  • The big difference is in the premiums — because the low-income families with workplace coverage pay about 9% of their income to cover those payments.

The largest share of group insurance premiums, paid by employers, also depresses wages for lower-wage and other workers.

Between the lines: It’s not really surprising that marketplace enrollees do better. The ACA provides financial protections for lower-income people enrolled in subsidized health plans in the marketplaces or in Medicaid, and there are no similar income-based subsidies that apply to employer plans.

  • In fact, as employers shift more costs to employees, low and moderate-income families face several thousand dollars in premium contributions and cost sharing.
  • For firms that employ disproportionately low-wage workers, it can simply be too expensive for employers to provide good coverage. Premiums averaged $6,896 for a single policy and $19,616 for a family plan in 2018.

We tend to think of everyone with employer coverage as one big group, but it’s really lower wage workers — and, while it’s a different subject, also people with major illnesses — who take it on the chin in the current private health insurance system. They are also the group with employer coverage who would benefit the most from a Medicare-for-All style plan.

The bottom line: Employer-based coverage is by far the largest source of health insurance, and it now provides the least financial protection for lower income workers who need it most. We debate affordability in the ACA marketplaces a lot, but we don’t talk about this far larger problem much, if at all.

Drew Altman is President and CEO, Kaiser Family Foundation.

https://www.axios.com…

Peterson-Kaiser report:
https://www.healthsystemtracker.org…

Comment:

By Don McCanne, M.D.

The war cry to protect employer-sponsored health plans by rejecting single payer Medicare for All is growing louder each day. Little does it matter that 66 million people leave their jobs each year and lose their employer-sponsored insurance, if it had even been offered. But look at what Drew Altman has to say about employees who have low incomes or major illnesses:

“We tend to think of everyone with employer coverage as one big group, but it’s really lower wage workers — and… also people with major illnesses — who take it on the chin in the current private health insurance system. They are also the group with employer coverage who would benefit the most from a Medicare-for-All style plan.”

Get that? They take it on the chin from private insurance, and they would benefit the most from a Medicare-for-All style plan.

Moderate politicians and the media are so sure that the threat of losing employer coverage will cause individuals to reject single payer Medicare for All that they keep repeating it, over and over.

Yesterday presidential candidate and single payer advocate Bernie Sanders held a town hall on enemy territory – Fox News. Fox host Brett Baier set Sanders up by asking the audience, “How many people get their insurance from work, private insurance, right now?” Most hands went up. He then asked, “Of those, how many are wiling to transition, to what the Senator says, a government run system?” expecting most hands to go down. Not only did most hands go back up, the response was accompanied with cheers. Not even the Fox News audience is buying the baloney that people don’t want single payer Medicare for All if it means eliminating insurance through work. For a 21 second video of this highly instructive moment:

https://splinternews.com…

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‘Medicare for All’ the moral choice

By Dr. Tom Hayhurst
The (Fort Wayne, Ind.) Journal Gazette, April 16, 2019

I note that a federal judge recently made a decision potentially invalidating the Affordable Care Act. President Donald Trump subsequently stated he fully supported repeal of the ACA. He went on to tout what he described as a much better health care plan but offered no details.

Repealing the ACA would leave more than 20 million of our currently insured fellow citizens without adequate health insurance. Having reviewed his website, I am not aware of the position of Rep. Jim Banks regarding this matter, which is important to many citizens of northeast Indiana.

Independent studies indicate that thousands of our fellow citizens die each year because they do not have health insurance. As a doctor, I am the volunteer director of the Multi-County Medical Outreach Clinic in Columbia City. With vigorous support from Parkview Health and many agencies and individuals throughout the region, we provide free health care for the working poor (from any county) who are either uninsured or underinsured.

In that setting I have seen many who have been driven into bankruptcy by large medical bills after hospitalization for serious illness. I am also aware of others who have died because of a lack of health insurance. For example, I cared for a 41-year-old man who presented to a local emergency department at 3 a.m. gasping for air with a temperature of 104 and almost no detectable blood pressure. He had extensive pneumonia, did not respond to vigorous treatment and died a few hours later in the intensive care unit. He had delayed seeking medical care because he had lost his job and his health insurance.

Many of our current 30 million (50 million if the ACA is repealed) uninsured fellow citizens face this choice every day. Some are lucky enough to avoid serious consequences of their decision. Many others suffer death or disability or bankruptcy. I have seen it firsthand.

So where do we go from here? At the least, we need to make sure that every citizen has affordable health insurance. The most efficient way to do this would be to gradually expand Medicare to include every citizen.

Medicare has been around since the 1960s and has many advantages over other forms of health insurance. Cost controls have gradually been put into place which help verify that costs are necessary and sensible and appropriate. Pharmaceutical costs will decrease significantly when the government allows competitive bidding for medications under Medicare Part D – which it has blocked for more than a decade. Medicare overhead is much less than that of private sector health insurance companies – 4% to 5% as opposed to 20% to 25% for the private health insurance industry.

The high overhead typical of private health insurance results in billions of wasted dollars. How else would the private health insurance industry afford $100 million+ bonuses for their executives?

There are many who make gloom-and-doom predictions for government health care programs, including U.S. and Canadian Medicare. They complain continually about rationing of health care in Canada. Recently I spoke with a Canadian visitor who had presented to a Canadian hospital with chest discomfort and a possible heart attack. That gentleman was seen by a cardiologist within minutes after arrival.

There is already extensive health care rationing in the USA. The patient I described earlier suffered from health care rationing as a result of poverty. I should add that essentially all Medicare services in the USA are provided by the private sector; the government acts only as an efficient insurance agent.

The Feb. 26 issue of the Journal of the American Medical Association contains an excellent article: “Rationing of Health Care in the United States.” The article concludes: “It has been said many times that in the richest country in the world, in which many of the greatest scientific and medical advances are developed, it is a blight on the U.S. soul that each of its residents does not fully benefit from available health care.”

That quote touches on the aspect of the health care debate that concerns me greatly – the immorality of needless death, disability and financial ruin in our country, which declares it is a God-fearing, “religious” country. Some faith leaders speak out on this moral issue.

But why aren’t we hearing an outcry from more religious leaders to solve this moral and economic “blight on the soul of America”?

Our goal should be eventual “Medicare for All”; it surpasses all other options for making affordable quality health care available to every U.S. citizen.

Dr. Tom Hayhurst is a physician and former member of Fort Wayne City Council.

http://www.journalgazette.net…

Don’t believe the lies about single-payer health care

By Garrett Adams, M.D., M.P.H.
Louisville Courier Journal, April 15, 2019

American health care is in continuing crisis. Access is declining, and costs are out of control. Medical bankruptcies, unheard of in other developed countries, still plague us. Even though the U.S. spends nearly twice as much per capita on health care, our health outcomes are far worse than other comparable nations. For example, way more American women die of pregnancy-related complications than in any other developed country, and the rate is rising.

Statistics are people with the tears wiped dry.

What’s wrong? Corporate profiteering. Corporations squeeze the insured, you, for every nickel to pay their dividends and increase cash value. Insurance companies raise premiums, deductibles and co-pays; they deny claims and contrive to insure only healthy (cheap) people.

The patchwork of private insurance costs our nation billions in administration, billing and collecting — amounting to a full third of health care expenditures. Hospitals track every pill and bandage and charge patients and hundreds of different insurers for each item. Physicians spend an average of nine hours a week with a jumble of plans for billing, preapproval and payment. It is taking a toll on the profession in burnout, early retirement, depression and suicide. Patients are angry and frustrated by the bureaucratic maze of filing claims, with justifiable claims often rejected.

Medicare Advantage, which privatizes Medicare, is burdened with fraud and poor cost control. Insurance companies selling Advantage plans bilked the government for an estimated $70 billion between 2008 and 2013.

The U.S. system isn’t about improving health care; it’s about profit. Single-payer changes the dynamic; with single-payer the system becomes patient-oriented, not profit-oriented.

Single-payer means ONE payer, the government, pays the bills while health care delivery (doctors and hospitals) remain in private hands. The wasteful bureaucracy of private health insurance goes away. The government becomes the insurer. Coverage is unhooked from employment, allowing workers to change jobs or start new businesses.

What about workers for insurance companies, such as Humana, when single-payer replaces private insurance? The new system will need their administrative experience. Moreover, single-payer legislation specifies that displaced workers be provided retraining and two years of salary. Many, who are health care workers themselves, will move back to actually providing care. And, like all of us, they and their families will have all medically necessary care as a right!

In 2003 the first single-payer bill in the U.S. Congress was tagged the Medicare-for-All bill. The name stuck. Today there are many “Medicare-for-All’s.” However, only two are single-payer plans, one House and one Senate version. They provide for publicly financed, nonprofit national health insurance that fully covers medical care for all Americans.

Drug companies, for-profit hospitals, insurance companies and others invested in profit-based care are campaigning vigorously against single-payer, spreading misinformation and fearmongering. Industry-aligned anti-single-payer individuals are posing as ordinary citizens spreading misinformation about single-payer.

Don’t believe the lies. National health plans work extraordinarily well in every other industrialized nation. Canada, Scotland, Sweden, Taiwan, and Japan (among dozens of others) cover their entire population for a fraction of what the U.S. spends (wastes!) and enjoy longer lifespans and better health outcomes. How will we pay for it? An American single-payer plan will pay for itself by redirecting wasted administration and profiteering funds into patient care. Consider the vast difference in cost: From 2007 to 2014, spending in private plans grew nearly 17 percent per enrollee, while Medicare spending decreased 1.2 percent per beneficiary.

Congressman John Yarmuth has represented the 3rd District of Kentucky in the House of Representatives with honor and distinction since 2006, and he has always been a single-payer champion. As chairman of the budget committee, he called for Medicare-for-All hearings. He knows that a majority of Americans support single-payer, but he has recently withdrawn his support. Chairman Yarmuth should continue to represent the will of the people and give single-payer his wholehearted endorsement.

Single-payer will have an immediate healing effect on all our people, and it will arrest our surging wealth inequality. Rev. Dr. Martin Luther King, Jr. said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” With single-payer, in one transformative action, on at least one level, everyone becomes the same, and we seriously commit to a true democracy with justice for all.

Dr. Garrett Adams is a founding member of Physicians for National Health Program – Kentucky and a member of the group’s national board.

https://www.courier-journal.com…

Sanders town hall audience cheers after Fox News host asks if they’d support ‘Medicare for All’

By Brooke Seipel
The Hill, April 15, 2019

The audience at a Fox News town hall erupted in cheers and applause when asked by moderator Bret Baier if they would support Sen. Bernie Sanders‘s (I-Vt.) “Medicare for All” proposal.

“I want to ask the audience a question here. … How many are willing to transition to what the senator says, a government-run system?” Baier asked before the crowd burst into cheers.

The question comes a week after Sanders introduced updated Medicare for All legislation in the Senate.

His proposed bill would largely eliminate private insurance and institute a single-payer system managed by the government.

The updated version would also include coverage for long-term care, such as nursing homes, which is  not covered by Medicare currently. Home- and community-based care would also be covered.

A number of other 2020 Democratic candidates, including Sens. Kamala Harris (D-Calif.) and Elizabeth Warren (D-Mass.), have endorsed Sanders’s legislation.

The White House blasted Sanders’s proposal, however, adding to its past criticism of single-payer plans.

Press secretary Sarah Huckabee Sanders called the plan a “total government takeover of health care that would actually hurt seniors, eliminate private health insurance for 180 million Americans, and cripple our economy and future generations with unprecedented debt.”

Republican leaders have also blasted the bill, with Senate Majority Leader Mitch McConnell (R-Ky.) saying it won’t happen under a GOP-controlled Senate.

Despite criticism, a number of polls have shown both Democratic and Republican voters support Medicare for All. One such poll conducted by The Hill in October showed a majority of Republicans supported single-payer health care. Another poll conducted in January showed that 56 percent of American voters supported such an insurance system.

The video of Sanders on Fox quickly gained attention online Monday, with many pointing to the applause and past polling as examples of support among even conservatives for Medicare for All.

Sanders agreed to a Tax Day town hall on the network, moderated by the “Special Report” anchor Baier and “The Story” anchor Martha MacCallum.

In March, Democratic National Committee Chairman Tom Perez announced that the network would be barred from hosting any of the party’s primary debates. Democratic presidential candidates are not precluded from appearing on Fox News for interviews or town halls, however.

https://thehill.com…

Medicare for all is not scary, but a great idea

By Jack Bernard and William Elsea, M.D.
Georgia Health News, April 15, 2019

The following statistic shocked us, even as jaded as we may be:

The U.S. 2014 infant mortality rate was 70 percent higher than that of other wealthy nations, all of which have national health care. It also indicated that American children had a 57 percent greater risk of death here, though that is partly caused by high mortality in the United States related to automobiles and guns.

The primary job of a Georgia local health director is to define the health needs of our community and then ensure that these needs are met. A closely related task is to inform the community of these health care needs and systemic shortfalls.

One key to success is ensuring that our residents are aware of problems so they can take unified action to resolve issues and ameliorate mortality and morbidity issues. In a democracy known for its high ideals, permitting innocent children to suffer and die because their families cannot afford care is simply inexcusable. This unacceptable situation goes directly against our basic sense of morality as Americans.

But the problem is far broader than just children. Our adult population has a higher morbidity and mortality rate than those in other countries. In general, U.S. health care lags far behind other democracies in regard to access, as well as cost containment.

Just as disturbing is the fact that Georgia and other Southern states have an even worse health status than the nation as a whole. We must recognize this fact before we can solve the problem.

It’s disturbing to have prominent people state that U.S. care is the best in the world, ignoring facts, and that “socialized medicine” as practiced in every other democracy is somehow lacking.

There would be no communistic takeover of medicine under Sen. Bernie Sanders’ recently revived Medicare for All Act of 2019 program, as some legislators have implied in the past. Sanders is a supporter of the democratic socialism seen in advanced countries, not the repressive form imposed in dictatorships.

Under the Sanders plan, you could still go wherever you wished for treatment, with the vast majority of physicians and hospitals accepting government reimbursement and a small number accepting only private pay (similar to U.S. “concierge medicine’’ now). That’s why the bill is co-sponsored by 14 of Sanders’ colleagues and endorsed by 65 organizations.

Let’s look at some other mistaken notions that many politicians promulgate about single payer (expansion of Medicare to cover all ages), starting with cost. We can’t just continue with what we have now, as industry interest groups would have you believe.

In the 1970s, health care spending as a portion of total GDP was 7 percent. It is now an astounding 18 percent and expected to hit 20 percent by 2026.

Clearly, spending under our current system is out of control. In part, rising costs are due to our citizens delaying necessary preventive and primary care until an expensive medical crisis arises.

To give us perspective, let’s look at the figures for other major nations, all of which have universal coverage. In 1970, their average spending was 5 percent of GDP, relatively close to our 7 percent. In 2017, it was 11 percent compared to 18 percent here.

Increased health care spending is causing our nation to delay vital public/private investments in education, roads, bridges, technology and other areas. All the while, our mortality and morbidity rates surpass those of other developed nations. Isn’t it time to try another approach, like Sanders’ Medicare for All?

There are a variety of ways to finance single payer that will make it actually less expensive overall than what we have now. First, Medicare administrative costs are only 2 percent to 3 percent versus 12 percent or more for private insurance firms.

Yes, taxes will go up for some, but there will no longer be deductibles and premiums off-setting expenses for many citizens. Plus, there will no longer be medical bankruptcies, the largest cause of total bankruptcies.

Under Medicare for all, our overall national health care would improve, via better access, planning, and standards. Further, with the future addition of universal budgeting and cost control in areas like drug pricing, costs will be contained while everyone is covered. Now it is up to each of us to pressure our state and national elected officials to understand the facts and act now, not later.

Jack Bernard, former Georgia Director of Health Planning, is a retired senior vice president with a national health care corporation and a Fayette County Board of Health member. Dr. William R. Elsea was Fulton County health commissioner, president of the National Association of County and City Health Directors, and a professor at Emory Medical School.

https://www.georgiahealthnews.com…

Medicare for All Explained Podcast: Episode 10

Interview with Alex Lawson

April 15, 2019

Alex Lawson, the Executive Director of Social Security Works, encourages seniors currently on Medicare to demand improved Medicare for All with dental, vision, long-term care, and zero cost-sharing. Hosted by Joseph Sparks. Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

AMSA endorses the Medicare for All Acts of 2019

Future Physicians Endorse Medicare for All

AMSA (American Medical Student Association), April 12, 2019

The American Medical Student Association (AMSA) stands in strong support of Rep. Pramila Jayapal’s Medicare for All Act of 2019, H.R. 1384, and of Sen. Bernie Sanders Medicare for All Act, S. 1129. As an organization of future physicians, AMSA seeks to improve the health and enhance healthcare access for everyone in America, true healthcare for all; and the federal single-payer system proposed in the Medicare for All Act would be a momentous step toward that vision.

The current system creates a huge administrative burden that takes physicians away from patient care, allows pharmaceutical companies to drive up costs of medicines, and makes essential healthcare services unaffordable for many. As AMSA National President Perry Tsai, M.D., Ph.D., remarked at the introduction of Sen. Sanders’ bill, “For each thing we learn on our way to becoming physicians who care for patients, we find one more thing that will prevent us from caring for our patients…Our dream [of caring for patients] is turning into a nightmare, and we will not stand for it.” Comprehensive health coverage through Medicare for All would result in lower administrative costs, increased healthcare access for everyone regardless of employment, and reduced burdens on physicians such that they can spend more energy on patient care.

“As medical trainees, we have witnessed on multiple occasions how the current healthcare system fails to provide affordable, high quality, comprehensive care to all patients and their families,” Avanthi Jayaweera, AMSA’s Education and Advocacy Fellow, said. “We are inheriting a system that puts profits over our patients’ lives. The next generation of physicians want Medicare for All to allow for a future where we can put our patients first just as we are taught in our clinical training.”

AMSA is proud to support these bills to establish Medicare for All and is organizing a Health Care for All Week of Action, April 15-19, in order to educate and engage medical trainees to ask their members of Congress to support Medicare for All. Hanan Rakine, co-chair of AMSA’s Health Care for All Campaign, stresses, “It is our role as future health care professionals to advocate for our patients’ well-being and right to health care.”

Through our Health Care for All Campaign, AMSA has over 50 years of experience fighting for equitable, efficient and quality universal health care coverage. Unburdened by conflicts-of-interest, medical students are fighting for the healthcare system that our nation and our communities need, not the system pharmaceutical and insurance companies have created. As the largest body of future doctors in the U.S., AMSA is fighting for a future that puts patients ahead of special interests. AMSA believes that no person should go without needed emergent or preventive health care services. AMSA believes that these proposals released by Rep. Jayapal and Sen. Sanders will address the current inequities of the U.S. healthcare system by ensuring every individual living in the U.S. has access to comprehensive health care benefits.

About the American Medical Student Association:

AMSA is the oldest and largest independent association of physicians-in-training in the United States. Founded in 1950, AMSA is a student-governed, non-profit organization committed to representing physicians-in-training, advocating for quality and affordable health care for all, and building the next generation of physician leaders.

https://www.amsa.org…

Comment:

By Don McCanne, M.D.

With AMSA’s endorsement of both Rep. Pramila Jayapal’s and Sen. Bernie Sanders’ Medicare for All Acts of 2019, we know that the future of health care is in very good hands.

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Medicare for All could have been on standby for the Paradise fire

Why Butte County needs Medicare-For-All more than ever

By Paul O’Rourke-Babb
Enterprise-Record, April 7, 2019

New Medicare-for-All legislation (The Medicare for All Act of 2019, HR 1384) was just introduced in the U.S. House of Representatives by Rep. Pramila Jayapal (D-Wash) with 103 cosponsors. I’m for it. Our nation has another, better, chance to fix our broken health insurance system.

As a retired Nurse Practitioner and a long-time Butte County resident, I strongly believe Medicare for All will give our communities the health care security that we desperately need. Here’s why.

Whether you’re a patient, a health care provider or a hospital, I don’t need to tell you the health care challenges we were facing before the fire just got a whole lot worse. You already know.

Fifty thousand people have been displaced. Adventist Hospital, doctors’ and therapists’ offices, and clinics have been damaged or destroyed by fire. If you owned your business and lost it, you also lost your ability to pay for private insurance. If your employer was burned out, you lost your job and if your employer was sponsoring your health insurance, you lost that too.

Getting health care was a problem before the fire, but it’s even worse now. No matter whether you get insurance through work, Covered California or Medicare, the scarcity of primary care doctors was already a problem. If you’re on Medi-Cal, almost no physician would accept you as a patient. At the same time that the number of people who qualify for Medi-Cal will likely rise, the ability of doctors to hire staff and see those people will worsen.

That’s because many patients and their doctors lost their homes and businesses and had to move away to find shelter. The Butte County vacancy rate was already critical at around 2%. Then the fire took out an estimated 6.5% of the county’s housing units.

On top of that, our communities have been traumatized. Month-long waits or long drives to access mental health care were common before the fire. Today it’s worse.

Affording health care remains another big problem. Over 21% of Butte County households were living in poverty before the fire. But even at higher incomes, the costs of health insurance prevented 4 in 10 of us from seeking the care we need.

Now it’s worse. Insurance premiums, deductibles and co-pays don’t magically disappear during disasters. But the money to pay them has to compete with the need to rebuild our lives from scratch.

Area hospitals, greatly impacted by the fire, are also disproportionately burdened by having to deal with multiple insurance companies and this adds a layer of completely unnecessary expense to our health care.

Medicare for All would make health care more affordable. Here’s how:

It would reduce the cost of billing.

Medicare for All would dramatically reduce the average $99,581 that physicians spend each year on billing and insurance-related work just to get paid. It would save hospitals millions of dollars on redundant and often competing billing administration, up to 25% to 30% of their budgets.

Reduced billing costs means savings for you and for a public insurance system.

It would finance health care in a completely different way.

A public Medicare-for-All system will eliminate upfront costs like premiums, deductibles and co-pays. A combination of taxes, based on one’s ability to pay, would ensure that everybody would pay their fair share for the same comprehensive policy. And universal coverage would ensure that the system would remain solvent and financially stable.

It would cost you less.

The savings from a more efficient health care system means that we would pay less in taxes than we are now paying in premiums and out-of-pocket costs.

We would all have the same comprehensive, high-quality health insurance no matter what circumstances change in our lives.

You could see the doctor of your choice, even if your doctor had to set up a new practice in another area or gave up private practice and took a job at a hospital.

When I moved to Butte County many years ago for work, the active arts community and beautiful environment attracted me. Life here should be peaceful and uncomplicated. When it comes to our health care, it’s anything but. It doesn’t have to be this way. Contact your congressional representatives and voice support for Jayapal’s new bill. At the same time, let your state legislators know that you also support California Medicare for All. We need it now, more than ever.

Paul O’Rourke-Babb is a retired Nurse Practitioner and longtime member of Physicians for a National Health Program. He lives in Chico.

https://www.chicoer.com…

Comment:

By Don McCanne, M.D.

The Butte County fire in which the beautiful town of Paradise was destroyed was a heart-wrenching experience for my wife and me, especially wistful since we had visited our dear friends there frequently in years past. Our friend and health care reform colleague, Paul O’Rourke-Babb, describes in his article what this meant to so many residents of Butte County. It was a terribly tragic event that only those who were there to experience it can truly comprehend.

So why does this belong in a blog on single payer Medicare for All? Paul tells us. Although they lost their hospitals and clinics, the surrounding communities were there to help. But they were restricted by the deficiencies in our highly dysfunctional health care financing system. Imagine if, instead, everyone was covered by a single payer Medicare for All program. All attention would be directed to providing the care needed, with no concerns about insurance coverage, cost sharing, provider networks, prior authorization requirements, or any of the other cruel, parsimonious features of our current system.

When the fire and forest services were battling the blazes destroying the homes, they did not first check to see if the homes were registered to qualify for fire services nor did they have to obtain prior authorization to extinguish the blazes. We have often said that health care should always be there for you just as the fire department is when you need it. We would have that with a well designed, single payer Medicare for All.

Maybe it would not have made much difference during the urgent moments of the fire, but it can make a very big difference now for those who lost their work and the health insurance that went with it and are now facing medical bills that compound the financial hardships that they are facing. We can do only so much to try to console those facing grief, but at least we can take worries about paying for health out of any future tragedy like this – by enacting and implementing single payer Medicare for All.

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Can the 66 million people who leave their jobs keep their insurance?

Job Openings and Labor Turnover Summary (JOLTS): January 2019

Bureau of Labor Statistics, March 15, 2019

Separations

Total separations includes quits, layoffs and discharges, and other separations. Total separations is referred to as turnover. Quits are generally voluntary separations initiated by the employee. Therefore, the quits rate can serve as a measure of workers’ willingness or ability to leave jobs. Layoffs and discharges are involuntary separations initiated by the employer. Other separations includes separations due to retirement, death, disability, and transfers to other locations of the same firm.

Annual Levels and Rates

In 2018, there were 68.9 million hires, an increase of 3.3 million from 2017. Total separations (the sum of quits, layoffs and discharges, and other separations) rose by 2.6 million in 2018 to 66.1 million. Quits rose for the ninth consecutive year reaching 40.1 million in 2018, up by 2.4 million. Quits comprised 61 percent of total separations. Layoffs and discharges edged up by 307,000 in 2018 to 21.9 million and comprised 33 percent of total separations. Other separations edged down by 44,000 in 2018 to 4.1 million and comprised 6 percent of total separations.

The annual hires for 2018 was 46.3 percent of the annual average CES (Current Employment Statistics) employment level. This rate has been trending upwards since 2009. The annual total separations rate for 2018 was 44.3 percent. The annual rates for the components of total separations were 26.9 percent for quits, 14.7 percent for layoffs and discharges, and 2.8 percent for other separations.

https://www.bls.gov…

Comment:

By Don McCanne, M.D.

We are being told repeatedly that we should not enact a single payer Medicare for All program because people like their insurance they get at work, and they should be able to keep it if they want. Yet in 2018, 66 million individuals left their employment – a turnover rate of 44 percent!

For those 66 million separations from work, employer-sponsored plans did not prove to be the stable coverage that most of us want. Sure, many of these individuals were not even offered coverage at work, but that is more evidence that the employer-sponsored plans that the Affordable Care Act was designed to protect often do not provide reliable, stable coverage.

Of course there are other problems with employer-sponsored plans. They frequently have excessive cost sharing requirements, especially high deductibles, that can create financial hardship and impair access to care. Provider networks frequently prevent access to the patients’ choices of health care professionals and facilities, and often even fail to include much choice for highly specialized problems (though some larger employers may have special programs for centers of excellence). With change of employment, provider networks, benefits covered, and cost sharing requirements may change dramatically, potentially creating instability in the individual’s health care.

So who are these individuals who are so pleased with the health insurance that they get at work? Well, the workforce is a relatively healthy population that on average does not require much health care. Many feel secure with the financial protection that they believe their plan is providing even though they may have little experience with the system because of their good health. Some do have more significant medical problems and many of them do find professionals with whom they are pleased, and so the system works fairly well for them. But what about those who can’t go to their established care sources, or who cannot afford the out-of-pocket cost sharing, or who cannot afford the medications on which they have been maintained, or are one of the 44 percent with employment turnover and find that their new employer does not provide coverage, yet they earn too much for ACA subsidies? How can you say that employer-sponsored plans work well for them?

Another thing, employers insure predominantly the healthy workforce and their young healthy families. Those with more significant and costly medical problems tend to receive their care from government programs – Medicaid, Medicare, the VA system, safety-net institutions, and cost shifting by the uninsured (disproportionate share payments, etc.) – financed by us, the taxpayers. Pooling risk is one of the most fundamental functions of health insurance, so why are we granting employers favorable selection in their risk pools while passing adverse selection onto the taxpayers? Obviously it would be much more equitable to have one universal risk pool under single payer Medicare for All. Insurance premiums paid by employees along with forgone wage increases to cover the employer’s contribution are a form of regressive financing of health care – the opposite of the more equitable progressive financing of a tax-funded single payer system.

Next time you are told that we have to reject single payer Medicare for All because it would not allow individuals to have the choice of remaining enrolled in a health plan at work, point out that last year the 66 million people experiencing work separations did not have that choice, even if they previously had been offered insurance at work.

Addendum: About that 66 million job turnover

Quote of the Day, Addendum for April 11, 2019

About that 66 million job turnover each year, Dr. Ed Weisbart makes a very important point:

“I’ve been using numbers like this for a while but to make a different point — that the ~1.3M job displacements from single payer are a single bump in the road, with mitigation strategies, compared to the unending sea that is our current culture. 60M every year, for decades before and decades to come, vs 1M in a single planned way.”

Comment:

By Don McCanne, M.D.

Thus not only can we use this number of a 66 million job turnover each year as as an argument against “you can keep your insurance,” but also as an indication that the job displacement caused by eliminating private insurance does not create a formidable employment nightmare for the one million or so that might be displaced. We can do it.

Another addendum: About that 66 million job turnover

Quote of the Day, Second addendum for April 11, 2019

About that 66 million job turnover each year, UMass economics professor Gerald Friedman makes another very important point:

“Excellent note! To these 66 million need to be added all those whose employers change their insurance plan. And this is a growing problem because of narrow insurance plans where people need to change their primary care provider.”

Comment:

By Don McCanne, M.D.

None needed. This thing has a life of its own.

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