May 1, 2019

On April 30, 2019, the House Rules Committee held a historic hearing on H.R. 1384, the Medicare for All Act. This podcast highlights major arguments (for and against) from the hearing. 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

By Farzon Nahvi, M.D.
U.S. House of Representatives, Rules Committee, April 30, 2019

Thank you Chairman McGovern and thank you Ranking Member Cole for inviting me to be here today. My name is Farzon Nahvi. I’m an emergency medicine doctor in New York City and I support Medicare for All.

As an ER doctor, I have the opportunity to help all sorts of people in all sorts of ways. I get to save investment bankers from heart attacks and strokes and homeless veterans from hypothermia in the winter.

That’s what I love about my job — the idea that I can help anyone with any problem at any time is what attracted me to medicine in the first place.

But over the years, I’ve learned that it becomes impossible to care for someone when our medical system forces them to fear things like bankruptcy and foreclosure when they seek medical care.

If you ask any ER doctor, any ER nurse, or any ER janitor in this country, you will hear countless stories of patients who came to seek medical care only to walk out in the middle of their treatment “AMA,” or against medical advice. Patients often walk out Against Medical Advice out of concern for the cost of their treatment.

The reality for many people in this country is that seeking medical care means weighing their health against their wallet.

You all already know all the statistics. You already know that 41% of Americans have skipped a visit to the ER in the past 12 months because of cost concerns. And you already know that 45% of Americans live in fear that a health event could lead to bankruptcy.

But I see this every day on the ground level, I have to look these people in the eye, and I want to put some faces on those numbers that you all already know so well.

A few weeks ago, I took care of a patient who I was sure had appendicitis. I recommended a CT scan and we discussed IV antibiotics and possibly an operation. But a short while later this patient flagged me down and pulled me aside and asked me to pull out her IV so she could go home.

This patient wasn’t stupid. She was not crazy. Nor was she distrustful of physicians. She was simply concerned about the cost of her treatment. She did some research on her phone, learned that in some rare cases appendicitis can be treated with antibiotics alone and without an operation, and she asked me if I could just discharge her with a prescription. Of course, you don’t need to be a doctor to know that this is far from the standard of care for appendicitis and an incredibly risky idea. I told her that there were too many things that could go wrong and I strongly recommended against it.

She asked me the risks of her plan and I told her the truth. I told her about the possibility of a perforation of her bowels, an abscess formation, sepsis from her infection, and even death. This wasn’t an exaggeration, this was simply the truth. She sat back, asked for some time, thought about it for a long while but she eventually did decide to leave. In her own words she said, “Thanks doc, I appreciate all you’ve done, but I just don’t know if I’ll be able to afford this — I’m going to take my chances.”

In my line of work I often have to tell people that their spouse, their parent, or their child has died — but I can tell you that watching someone sick walk out the door with something that is completely treatable right here in the richest country in the world is just as awful of a feeling.

About one year ago I took care of a young lady who came in for an overdose on fish antibiotics. She had had a fever, could not afford an ER visit, so decided to go to a local pet store to buy fish antibiotics for her symptoms. The antibiotics came as a packet of powder and the directions were designed for a fish tank. There were no instructions for human consumption. She accidentally overdosed by an order of magnitude, the side effects ended up affecting her brain, she ended up falling down a staircase while on a job interview, and needed to be admitted to the the ICU.

Twenty one years ago, when she was ten years old, my fiance lost her mother because her mother decided to delay medical care for her abdominal pain until only after her stomach cancer had already spread beyond any hope for treatment. A housekeeper raising two daughters, my fiance’s mother was worried about the cost of her care and she paid for it with her life.

I’m here today because my patients and my fiance deserve better. These stories and countless others are absolutely ridiculous to be taking place here in the richest country in the world.

All I want is to practice medicine in a world where I no longer have to watch a patient walk out of the ER without medical care that could save their life because they are worried about going bankrupt. All I want is to never see another patient who thinks their best option for medical care is to go to their local pet store. To simply treat someone for a problem so simple as appendicitis and to have human patients take human antibiotics from a human pharmacy are not radical ideas.

From my perspective on the ground, the solution has to involve approaching medical care in just the same way we approach educating our children, maintaining our roads, and supporting our armed forces. This means simply treating healthcare like any other public good and creating a universal healthcare system like Medicare for All so that when they’re at their most vulnerable, my patients never have to make any consideration except to simply do what they need to do in order to get better.

Once again, thank you Chairman McGovern, Ranking Member Cole, and the Rules Committee for allowing me to testify. I’m looking forward to any questions you may have.

https://www.c-span.org…

By Matt Bruenig
The New York Times, April 29, 2019

As the national debate about health care kicks off ahead of the 2020 presidential election, we’re going to be hearing a lot about the costs of increasingly popular progressive proposals to provide universal health care, like Bernie Sanders’s Medicare for All plan.

One common refrain on the right and the center-left alike: Since the rich can’t foot the bill alone, are middle- and working-class supporters of a more socialized health care system really ready to pay as much for it as people do in some of the high-tax nations that have one?

The problem is, we already do, and we often pay more.

It’s true that by conventional measures, taxes on workers’ wages in the United States are comparatively very low and even very progressive, affecting the lowest-earning workers the least and taxing those who can afford it more.

But these measures obscure an important fact of American life: Unlike workers in many other countries, the vast majority of American employees have private health insurance premiums deducted from their paychecks.

If we reimagine these premiums as taxes, we’d realize that Americans pay some of the highest and least progressive labor taxes in the developed world.

Just how heavy is the burden placed on American workers by employer insurance premiums? By combining data from the O.E.C.D. Taxing Wagesmodel with data from the Medical Expenditure Panel Survey, we can see what percentage of each worker’s compensation — a figure that includes cash wages as well as the taxes and benefits employers pay on behalf of their employees — goes toward taxes and health care, and how progressive these payments really are.

What this data shows is that lower-income workers, higher-income workers, single workers, and married workers with children all contribute around 40 percent of their pay toward taxes and health premiums. And when those health care costs are taken into account, the less well off no longer pay less than high-earners, as they do in taxes alone.

So, while opponents of comprehensive plans like Medicare for All claim those plans will greatly burden middle-class families, the truth is that we already have an unfair system. Middle-class workers in America are charged the same health insurance fees as upper-class workers despite the vast income differences between the two groups, and pay more of their earnings toward taxes and health care than workers in many wealthy countries.

By Sarah Kliff
Vox, April 29, 2019

Adam Gaffney is the president of the Physicians for a National Health Program (PNHP) — and a single-payer advocate whom I’ve found to be especially clear-eyed about what a single-payer system in the United States can and can’t do.

Gaffney works as a critical care doctor and supports Medicare-for-all for lots of reasons. He thinks it will improve access to medical services and make the United States a more equitable place to live.

But he also doesn’t expect that Medicare-for-all would amount to huge cost savings for the United States, at least in the short-run. He isn’t sure whether we can ratchet down our current health care spending (17 percent of the economy) down to the same level as Canada (where they spend about 10.5 percent of gross domestic product on health care).

“It would make my position as a single-payer advocate a lot easier if I could say, ‘hospital spending will fall 50 percent with Medicare-for-all,’” Gaffney says. “But that’s not realistic.”

I saw Gaffney make a short version of this argument in a New York Times article last week, and knew I wanted to get the long version. So I gave him a call and we spoke about what cost-savings he thinks are realistic, how we get there, and how his views on this have changed in the past decade.

What follows is a transcript of our discussion, lightly edited for length and clarity.

Sarah Kliff: Let’s start with something you said to the New York Times for an article last week, that I thought was pretty interesting. This was for an article about possible funding cuts that hospitals might face if we moved to a Medicare-for-All system. And the thing you told the Times was, “We don’t need the insurers, but we do need the hospitals.” Essentially saying, you can’t get too aggressive on cutting hospital revenue. Explain to me why you think that is, and what kind of cuts would be realistic in a Medicare-for-all system?

Adam Gaffney: It would make my position as a single-payer advocate a lot easier if I could say, hospital spending will fall 50 percent with Medicare-for-all, but it’s not realistic. I think there are savings that hospitals can achieve through efficiencies. If we move toward a global budget system, which is what is described in the Jayapal bill, you maximize the administrative savings.

We should be talking about the things we want hospitals to spend less of their revenue on, rather than focusing on the individual prices of services. If we’re going to say, we want to shrink hospital budgets, well, what things do we want the hospital to spend less money on? If you just take the average hospital and simply shrink its budget, you have to make sure it’s happening in the right way.

The way I think about it is we need a new way to finance hospitals. We need to transform them. We can achieve savings in administration costs, and we can finance new capital projects from a different source that isn’t hospital profits. But beyond that I think it’s not feasible to make claims about more dramatic reductions in national health expenditures.

Sarah Kliff: What do you think are the risks of getting budgeting wrong in a Medicare-for-all system? You mention the global budgets that are in the Jayapal bill, which are pretty similar to Canada, and essentially give a hospital a lump sum to take care of patients. How do you decide how big that budget is — and know that it’s the right amount to pay the hospital? Is there a risk of some hospitals closing?

Adam Gaffney: I don’t think that’s going to happen. When Medicare-for-all is passed, it’s not going to happen in a way that causes hospitals to close, or close down certain wings. I think we’ll get the payment structure right, because hospitals will have similar amounts of money to what they had in the year prior to reform. If you slashed hospital budgets after a military coup, sure, hospitals could close. But this nightmare scenario of hospitals closing and doctors fleeing the country, it’s not going to happen that way. We’re going to pass a law that ensures hospitals have the resources they need.

Sarah Kliff: I think something you said just there, that hospitals will have similar amounts of money the year after Medicare-for-all passes, that would surprise a lot of people who support Medicare-for-all and believe that hospitals should face big budget cuts.

Adam Gaffney: It might. And if I think I were speaking to you 10 years ago, I would have said something different. I would have thought well, hospitals in Canada can do this for half as much, why don’t we just do that. But it’s just not realistic.

Sarah Kliff: What changed your mind?

Adam Gaffney: I think awareness of the fact that every dollar spent on health care is being spent on something, so you have to be willing to put your finger on where do I want the reduction to come from. We can eliminate profits. Fire departments don’t have profits, schools don’t have profits. We can get rid of advertising, we can get rid of bonuses, about 50 percent of administrative spending. But beyond that, I’m not going to claim they can produce the same amount of health care for less. I can’t say when that will happen.

Sarah Kliff: Do you see a path for the United States to spend the same amount of money on health care that Canada does? Can we have Canadian prices here?

Adam Gaffney: I don’t know the answer to that question. I know the answer is no in the short-term. If you study other universal health care transitions, there has never been a case where they created a system and suddenly slashed spending in half. I’m not sure any country has reduced their spending in half overnight.

We’re getting into a new stage of the single-payer discussion. At first the emphasis was getting the idea out there, and pushing it into the center of the policy discussion. We weren’t quite as focused on some of the details of how the system would run, and that is what we’re working out now.

Sarah Kliff: I know another way that the plans that your group and Sen. [Bernie] Sanders support differ from many other countries is that they have no type of co-payments or cost-sharing for medical care. When you go to the doctor, you don’t pay a fee. How important is that element of the plan to you? Is that something you could see changing in negotiations?

Adam Gaffney: Ten years ago, I would have said co-pays would be fine. I wouldn’t have been in favor, but I would have thought, what’s the big harm.

Since then I’ve come to realize there are two possible ways to do cost-sharing. It can be set so low that it has no effect on people’s use of health care. You could have a co-pay that costs a nickel. That won’t deter anyone from going to the doctor, so what function is it serving? Then you need a guy to collect all the nickels and carry them down to the bank, and that costs more in terms of administering the nickel co-pays.

If the co-pays are going to be high, then you start asking, why are we trying to make a financial barrier to people using health care? There are decades of data that show that cost-sharing makes people use less health care, but it doesn’t just reduce low-value care. It reduces high-value care, too. There was a recent study showing that high deductibles caused women to have a delay in breast cancer diagnoses.

I could go on and on about this but the point is it just reduces care indiscriminately. That’s how I view it: that cost-sharing reduces use. It keeps people from getting the medicines that they need.

Sarah Kliff: Let’s talk about another design choice in the plans from PNHP and legislators: the set of benefits. The plans you all are proposing cover a wide array of benefits including long-term care, vision, dental. Do you think it’s realistic to build a system like that? Or at some point, in the political process, we’ll see some benefits drop off because a system with more benefits costs more money?

Adam Gaffney: There is no question that, the more you cover, the more expensive it’s going to be. I do think that given how rich our country is, we can afford universal dental care. There are other countries that have universal long term care, like Germany and Japan. But obviously we’re going to have to push to keep it comprehensive.

When they created the National Health Service in Britain, it included dental and vision and all sorts of medical services. But then they added co-pays back for prescription drugs. It was thought the costs were getting excessive. I think co-pays should be kept out of this entirely, but it’s not going to be easy, there is a big health care fight ahead.

https://www.vox.com…