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House Democrats on key committees receive funding from anti-single payer groups

House Democrats on key committees receive funding from anti-single payer groups

Special interests try to sway Democrats.

By Amanda Michelle Gomez
Think Progress, April 1, 2019

Medicare for All has attracted widespread support in the Democratic Party. But the ambitious overhaul of the nation’s health care system faces a major threat: big spending by health care and insurance interests determined to preserve the status quo.

A ThinkProgress analysis found that those industries, part of a coalition called the Partnership for America’s Health Care Future, donated nearly $1.2 million in the 2017-2018 election cycle to Democratic members of four key House committees that could determine the fate of Medicare for All.

Asked at a recent press conference about the greatest hurdle facing her bill, the most far-reaching Medicare for All proposal out there, Rep. Pramila Jayapal (D-WA) replied, “the money, money, money, ain’t it funny of the industry groups that are going to fight us every step of the way.”

The Jayapal bill, H.R.1384, would radically transform the health care system by abolishing virtually all private insurance and moving everyone into one government-run program.

Sen. Bernie Sanders (I-VT), a 2020 Democratic presidential candidate who popularized the idea during the last presidential campaign, shares her concern.

“This is not going to be an easy fight,” he said in a conference call after the midterms. “You’re taking on the drug companies, you are taking on the insurance companies, and these people have unlimited amounts of money — unlimited. They buy and sell politicians every single day.”

Jayapal and Sanders have reason to be worried.

Last summer, leading pharmaceutical, insurance, and hospital interests formed the Partnership for America’s Health Care Future to curb favor for Medicare for All in the Democratic Party. And they’ve been donating a lot to get their views across.

ThinkProgress analyzed political action committee (PAC) contributions to Democratic members on four key House committees — Ways and Means, Energy and Commerce, Budget, and Rules — on the website Political Money Line as of March 2019.

House Energy and Commerce Committee Chairman Rep. Frank Pallone (D-NJ), who has declined to hold any Medicare for All hearings, received $56,000 from partnership members — the most of any chairman of those committees. Notably, he received thousands more than committee chairmen who promised to hold Medicare for All hearings, jump-starting conversations about the future of health reform. Pallone did not respond to a request for comment.

But even co-sponsors of the Jayapal bill have received donations from partnership members. Rep. Jimmy Gomez (D-CA), who is a co-sponsor, received $66,769 — more than any other member on the four committees.

The partnership has been waging a quiet war to shape the national conversation around single-payer health care and to ensure Medicare for All isn’t part of the Democratic Party platform in 2020. The coalition intends to do this by “engaging stakeholders
including key committees and staff on the Hill,” as the coalition put it in documents obtained by the Intercept. In other words, the partnership will try to meet with and influence congressional lawmakers responsible for health reform. The coalition does not lobby directly, but it does have “a diverse set of members who do lobby, raising concerns about Medicare for All proposals,” a spokesperson for the partnership, who wished to remain anonymous, told ThinkProgress.

The Federation of American Hospitals, America’s Health Insurance Plans, and the Pharmaceutical Research and Manufacturers of America created the coalition last June. By August, when the Hill first reported the coalition’s formation, the partnership had 16 organizations. Today, nearly 30 organizations belong.

Of the partnership’s early members, 11 operate a PAC that donated more than $7.5 million to congressional candidates during the midterm elections, when the Medicare for All rallying cry was prevalent. House Speaker Nancy Pelosi (D-CA) received $27,500 from partnership members, but that’s far less than the $60,000 her Republican counterpart, House Minority Leader Kevin McCarthy (R-CA), received.

Republicans aren’t interested in Medicare for All; in fact, the Trump administration is more concerned with repealing Obamacare, a goal laid bare when it supported a federal judge’s decision to declare the entire health law unconstitutional last week. But many Democrats are open to the idea of Medicare for All, so are more susceptible to persuasion.

The 11 PAC members of the partnership are the National Association Of Insurance And Financial Advisors (NAIFA), the Council Of Insurance Agents & Brokers, the American Medical Association, the American College Of Radiology Association, the National Association Of Health Underwriters, the Blue Cross Blue Shield Association, the Federation Of American Hospitals, the National Retail Federation, the Pharmaceutical Research and Manufacturers of America (PhRMA), America’s Health Insurance Plans, and the Association For Accessible Medicines.

“Like most Americans, we are concerned with Medicare for All-style proposals that would scrap our current health care system and start from scratch with a one-size-fits-all program run by the government, and we strongly believe that approach would cause more harm than good for patients throughout our country,” said Lauren Crawford Shaver, executive director of the Partnership for America’s Future, who also served in Hillary Clinton’s 2016 presidential campaign and as a health advisor in the Obama administration.

The statement to ThinkProgress echoes the group’s past talking points — but in reality, the partnership isn’t against only single-payer health care. It’s against any proposal to expand access to federal health programs like Medicare and Medicaid. For example, earlier this year, the partnership opposed a modest bill that would allow people to buy into Medicare beginning at age 50.

PhRMA and NAIFA were the only partnership members to respond to ThinkProgress, but neither spokesperson would comment on PAC contributions.

“We believe that the current health care system must be improved to help patients achieve affordable and accessible health care that fits their unique health needs. We joined this coalition to contribute to policy conversations that look to deliver affordability, expand options, improve access and foster innovation,” PhRMA spokesperson Holly Campbell said in a statement.

“NAIFA routinely meets with Members of Congress on a variety of issues including health reform,” said NAIFA spokesperson Sheila Owens in an email.

“NAIFA strongly supports the employment-based private sector health insurance system which provides quality health insurance coverage to millions of individuals and businesses in the small and large group markets. We believe any expansion of government programs should be narrowly limited to those persons who are not appropriate candidates for private coverage, and it should expressly authorize the use and compensation of agents in placing insureds in such coverage,” she added.

With Republicans controlling the White House and the Senate, Medicare for All is unlikely to become law any time soon. But activists who support it stress that this moment is about starting the national conversation on where the country should go next on health care reform. The House committees on Energy and Commerce, Ways and Means, Budget, and Rules will oversee any reform legislation, which is why members of the partnership have given contributions to these lawmakers.

“We know for a fact that corporate opposition to Medicare for All has deep pockets and they wouldn’t be giving this money to Congress if they didn’t think it would have its desired effect
 it should raise people’s skepticism about the motivations of leaders,” said Dr. Adam Gaffney, the president of the single-payer advocacy group Physicians for a National Health Program.

“It’s sort of like when people talk about pharmaceutical companies giving money or gifts to physicians — they wouldn’t be doing it if it didn’t matter.”

Rep. Richard Neal (D-MA), the chairman of the other critical House committee, Ways and Means, received slightly less than Pallone, $54,500.

Meanwhile, the chairmen of the Budget and Rules committees, Reps. John Yarmuth (D-KY) and James McGovern (D-MA), received $5,000 and $3,500 respectively.

The House Budget Committee has six members who received no contributions from partnership members — the most of any of the four committees — including Jayapal, Reps. Ro Khanna (D-CA), Sheila Jackson Lee (D-TX), Steven Horsford (D-NV), David Price (D-NC), and Ilhan Omar (D-MN). The NAIFA PAC sent $2,000 to the Khanna campaign, but the campaign did not accept it. “We just pledged to be completely PAC free,” said Khanna’s campaign manager, Cooper Teboe. Horsford and Price aren’t cosponsors of the Jayapal bill.

Two members of the Rules Committee, Reps. Alcee Hastings (D-FL) and Jamie Raskin (D-MD), received no contributions from partnership members. Only one member of Energy and Commerce and one of Ways and Means — Reps. John Sarbanes (D-MD) and Steven Horsford (D-NV), respectively — received no money from these special interests. The Energy and Commerce and Ways and Means committees are usually comprised of more seasoned lawmakers who are also more likely to receive more industry money.

Two of the four committees (Budget and Rules) have announced plans to hold hearings on single-payer health care — but there’s a catch.

Jayapal told The Washington Post in January that she secured Pelosi’s commitment to hold the first-ever hearings about Medicare for All legislation in those two committees. But a Budget Committee spokesperson told ThinkProgress that the chairman, Yarmuth, would hold a hearing on “various approaches” to making coverage more accessible. “It will not be a hearing on any specific proposal,” said a spokesperson who asked to remain anonymous.

The Rules Committee is the only panel that has committed to a hearing focused on Jayapal’s Medicare for All legislation, though a committee spokesperson who asked to remain anonymous said no date has been set yet.

Neal, chairman of House Ways and Means, is open to holding a hearing on the issue but nothing’s scheduled yet, said committee spokesperson Erin Hatch.

The Energy and Commerce Committee, meanwhile, will be “focused on legislation that will reverse the Trump administration’s sabotage of our health-care system, protect people with pre-existing conditions, and make health care and prescription drugs more affordable,” a committee spokesperson who asked to remain anonymous said. The partnership has reportedly been encouraging lawmakers to focus on shoring up the Affordable Care Act, or Obamacare, instead of adopting single-payer health care.

The partnership denies that campaign contributions will stand in the way of Medicare for All. Shaver, the executive director, asserted that the obstacles to passage are the plan’s cost and a lack of public support. (In reality, support fluctuates based on how the argument around Medicare for All is framed). She added that the midterm elections weren’t a referendum on Medicare for All, but on Obamacare.

“It would be worth going back to Rep. Jayapal and asking her to explain why she thinks so many members of her own party – especially her own House Democratic Caucus colleagues – are not with her on this,” said Shaver.

Supporters of Medicare for All counter that health care industries always have fought proposals to change the status quo.

“The corporate opposition is unquestionably the biggest obstacle ahead of us — that’s been the case throughout the history of the fight for universal health care in America and this stage is not different,” said Gaffney, of Physicians for a National Health Program.

“But look back at history and you see grassroots movements succeeding when they are able to change the conversation around an issue,” he said. “We’ve already seen that — look at where we’ve come in the last two years.”

Medicare for All supporters have also been trying to meet with lawmakers to build support for the Jayapal bill. Activists with the Center for Popular Democracy, for example, tried to meet with lawmakers on the first day the new Congress convened, but typically just left information packets at the front desk. Even so, they’re optimistic.

“Health insurance companies, the pharmaceutical industry, and other corporate players make billions of dollars off of America’s illness — and they want to keep it that way,” said Jennifer Flynn Walker, director of mobilization and advocacy at the Center for Popular Democracy, an advocacy group that promotes progressive policies.

“Corporations prioritize profits over people, which keeps health care out of reach for millions,” she said. “We will win because the time has come for a change. We are organized in a way that we never have been before.”

Josh Israel, Ryan Koronowski, and Diana Ofosu contributed to this story. 

https://thinkprogress.org…

Medicare for All Explained Podcast: Episode 9

Interview with Gerald Friedman (Part Two)

March 31, 2019

Economist Gerald Friedman argues that, if we can afford our current, inefficient (and deadly) health care system, then we can certainly afford something that’s both cheaper and better: improved Medicare for all. Hosted by Joseph Sparks. Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Misinformation About Single Payer Medicare for All

A rebuttal to David Brooks' “Undo the Revolution”

By Joel A. Harrison, Ph.D., M.P.H.
East County Magazine (San Diego), March 30, 2019

Unfortunately, our media is dominated by misinformation designed to protect our private for-profit health insurance industry. One of the latest, by syndicated columnist David Brooks, was published in the San Diego Union-Tribune on March 6th. Since that newspaper reaches over 1 million San Diegans, I hope those reading this article will agree and share it with others. At the bottom I list several articles/papers that give a more comprehensive detailed discussion of why a single-payer system designed to benefit people trumps a for-profit health insurance industry designed first and foremost to enrich corporations.

According to Brooks, “Patients would have to transition. Right now, roughly 181 million Americans receive health insurance through employers. About 70 percent of these people say they are happy with their coverage.”

Since most of the 70 percent have NOT experienced a major illness or injury, only when they, their loved ones or close friends do, will they discover too late the high cost of pharmaceuticals, non-covered care, fighting with insurance companies to get the care they need, inundated with paperwork, and facing bankruptcy (75% of bankruptcies in US involve medical care).

The enrollment will be almost automatic. It will NOT cost people more and in most cases less. Instead of premiums, copays, deductibles, out-of-pocket additional costs, all will be covered, mainly through the equivalent of an increased Medicare payroll tax. In addition, one’s kids will be covered, even when in college, and whether between jobs, early retirement, etc. one and ones loved ones will ALWAYS be covered and ALWAYS be able to keep the doctors they choose. With single-payer, when facing some illness or injury, dealing with it, not fighting with insurance companies and an inundation of paperwork.

Brooks states: “The insurance companies would have to transition. Lots of people work for and serve this industry. All-inclusive public health care would destroy this industry beyond recognition, and those people would have to find other work.”

Insurance company employees include doctors and nurses who would much better serve us working in actual health care. Proposals for a single-payer health-care system all contain provisions for training and helping insurance company employees find other jobs, jobs not designed to increase health insurance profits by minimalizing expenses, that is, the care we get. As discussed below, the for-profit insurance companies actually decrease our choices, often delay care, and the quality of care we receive, so, bottom line, keeping them in business makes no sense for the vast majority of Americans, unless the vast majority prefer the current nightmare that is our fragmented, dysfunctional for-profit health care system for the benefit of a few corporations at our expense, economically and health-wise.

Brooks says: “Hospitals would have to transition. In many small cities the local health care system is the biggest employer…If you live in a place where the health system is a big employer, think what happens when that sector takes a sudden, huge pay cut.”

More than 10% of hospital costs are for the excess administration necessary to deal with the private for-profit health insurance industry. Hospitals will either continue to be paid fee-for-service or given global budgets. Again, any employees losing jobs will receive retraining. Not one doctor, one nurse, one medical staff employee will lose their jobs nor see substantial pay cuts.

Brooks claims: “Doctors would have to transition. Salary losses would differ by specialty, but imagine you came out of med school saddled with debt and learn that your payments are going to be down by, say 30 percent. Similar shocks would ripple to other health care workers.”

American doctor’s bills include approximately 10% administrative overhead just to deal with the insurance companies. American doctors devote approximately 15 hours or more to filling out excess paperwork and on the phone fighting to get a patient a referral or other care compared with doctors in Canada and other nations. Since everyone will be covered, lawsuits will not include health care cost, the major portion of doctor’s liability insurance, so their insurance costs will be much less (and because we will be covered, we will get the care we need, not delayed in hopes of winning a lawsuit). In the U.S. approximately 30% of doctor bills are denied by insurance companies, while, for instance, in Canada approximately 2%. With an average of 15 minutes per doctor visit in U.S., the additional 15 hours would allow doctors to see and bill for up to 60 more patients per week.

Neither will surgeons face substantial reductions in income. So, the vast majority of doctors will see little to no reduction in income and have the satisfaction of taking care of people, not functioning as bureaucrats. And studies have found that the excess administrative efforts doctors are forced to endure actually affects them, their stress level, some often considering leaving the profession. They devoted many years and effort into learning to help people, not the time and stress of excessive paperwork and fighting with insurance companies.

Brooks states: “The American people would have to transition. Americans are more decentralized, diverse and individualistic than people in the nations with single-payer systems. They are more suspicious of centralized government and tend to dislike higher taxes.”

Under single payer each American will be able to choose his/her doctor and hospital. Much more individualistic than allowing a for-profit insurance company with their often-limited network of doctors and hospitals to decide. And without copays and deductibles, Americans will be able to do so. Currently, under our current system, with some plans having high deductibles and copays, people delay seeking care, ending up using emergency departments, and with their condition more serious, more costly, often less successful, care. And those getting care often face restricted networks, sometimes not with the specialist they need or want.

Brooks claims: “The Sanders plan would increase federal spending by about $32.6 trillion over its first 10 years.”

Yep; it will increase federal spending, but not the total amount going into health care. As discussed above, mainly one simple tax, rather than premiums, copays, deductibles, out-of-pocket will result in the monies we pay into health care actually going to health care and NOT costing us more. Brooks ignores that given current projections using our present system, the total amount will be considerably higher. Brooks omits compared to what! Quite simply, the reduction in administrative costs alone will be substantial, together with bargaining with drug companies. Despite what they claim, there is ample data showing the costs of developing drugs is exponentially less than claimed and, in fact, much of it funded by the taxpayers.

Brooks further claims: “The government would also have to transition. Medicare for all works only if politicians ruthlessly enforce those spending cuts. But in our system of government, members of Congress are terrible at fiscal discipline.”

Given that everyone will be in the same system, including our politicians and their families, and that it will be transparent, this is unlikely. However, for those afraid of government insuring health care, NOT running it, do they really trust private for-profit companies more?

Single-payer is NOT socialized medicine. Doctors will not be employed by the government and hospitals will not be owned nor run by the government, simply an expanded version of Medicare, our most successful and popular healthcare program, with no need for supplemental insurance, no deductibles, no copays, and including dental, vision, long-term care, and home health care.

Sooner or later most families will need either home health care or nursing home care—finding out too late how expensive both are and that to be eligible for various Medicaid programs having to spend down, basically reach the level of impoverishment. And poor dentition leads to poor nutrition which leads to poorer health, so covering dental care saves money.

Brooks opines: “Patient expectations would have to transition. Today, getting a doctor’s appointment is annoying but not onerous. In Canada, the median wait time between seeing a general practitioner and a specialist is 8.7 weeks.”

Wait times in Canada for life-threatening and disability threatening conditions is as short as here and international studies show Canada has longer life-expectancy, lower infant mortality, and equal to better outcomes for many chronic diseases and illnesses, despite having a higher percentage of immigrants and refugees than the U.S. And, of course, Brooks ignores the wait time for the un- and underinsured in the U.S., eventually costing our system more with worse outcomes. More importantly, Canada spends only about 2/3 of what we do for health care and over the past couple of decades they have been working to shorten wait times for non-emergency care.

Currently, in the U.S., over 30 cents on the dollar goes to the excess administration, profits, and bloated salaries of health insurance executives. And what most people don’t understand, our taxes, including from those uninsured and underinsured, fund approximately 65% of health care, as much as the next most expensive system in the world which covers everyone with high quality care. So, we fund health care and the 30 cents on the dollar goes to for-profit insurance companies benefit, which results in deductibles, copays, limited doctor networks, fighting with insurance companies, and often bankruptcy.

In other words, the 30 cents on the dollar actually impedes choice and care, certainly nothing that fits any free market model I know of. Thus, the amount we have available for health care, including the 30 cents on the dollar wasted by our for-profit health insurance industry will be more than enough to ensure ALL Americans get timely care.  A simple question is: does anyone believe that this 30 cents on the dollar, this money ensures as good or better care than putting it directly into health care?

Every technologically advanced, industrialized democracy in the world has some form of universal health care coverage which international studies have found to rank far better on a multitude of measures than the U.S. And they do it for less, allowing more monies to be used in the economy for consumer spending, investment, infrastructure, and research and development. And our current system puts American industry at a disadvantage in international competition because of the high cost of health care and the wasted administrative costs of either dealing with for-profit insurance companies or running their own “in house” insurance.

Don’t be fooled by opinion pieces such as David Brooks. And don’t be fooled by anecdotal evidence how one or a few cases in another country didn’t receive the care they should. Anecdotal evidence is used to arouse emotion and short-circuit thought; but no system is perfect and one should always ask the question: Compared to what? The answer is that for every anecdotal case in another country, we have hundreds if not thousands here.

Addendum

After finishing the above, I came across a San Diego Union-Tribune Letter-to-the-Editor, “Single-payer not the panacea it seems to be” (San Diego Union-Tribune, March 29, 2019 which states: “Eliminating the private insurance industry takes monies out of research for medical innovation . . . European health care is barely adequate, and there are few specialists to treat specialties. We have personal experience with this where in a London hospital, for two weeks, a diagnosis couldn’t be made, putting my wife’s life in serious jeopardy. With an emergency flight back to the U.S., in 10 minutes a specialist diagnosed and put her on a course to resolve the issue . . . The government cannot efficiently run any program (see U.S. Postal Service).”

First, almost all medical research in the U.S. is grant funded, carried out in medical schools and universities, in-house by our National Institutes of Health, FDA, and Centers for Disease Control. For the most part, the research conducted by for-profit health care companies is marketing research and devising plans to save money/increase profits. A few non-profits like Kaiser Permanente do conduct quality “legitimate” research. I repeat “non-profits”; but even Kaiser has much higher administrative costs than Medicare. Second, the UK has contributed a heck of a lot to medical research, also, mainly paid for by government. And, despite having comparable stats on infant mortality, life-expectancy and other measures, the UK spends less than many other universal health care systems, partly still trying to undo the extreme cuts by the right-wing anti-government Margaret Thatcher.

Second, yep, an anecdote about a bad experience. I am currently watching for the second time a series on Animal Planet, streamed online for free, called “Monsters Inside Me.” What is fascinating is that every case presented starts with the patient getting one, two, or even more misdiagnoses. Of course, in some cases, the signs and symptoms are quite similar so the doctor didn’t do anything wrong; but in other cases, the doctor simply decided without hearing the patient out or running the extra labs, just jumped to a conclusion, which in some cases caused serious hardship. In the U.S. the number of autopsies performed on hospital deaths has declined precipitously, partly because of our for-profit health care system not wanting to pay for them and partly because families refuse to allow them. The problem is that when autopsies have been performed, up to 25% of the diagnoses were wrong. This doesn’t automatically mean if the diagnoses had been correct the patient would have survived; but certainly they didn’t get the correct treatment. Without autopsies, doctors can’t learn about their mistakes and, thus, may repeat them  (Baumgartner, 2016; Combes, 2004; Groopman, 2007; Pastores, 2007; Reichert, 1985; Wittekind, 2018). And I have personally been misdiagnosed on several occasions; but before going on meds with significant side-effects, did my own research and then got a second opinion.

I’m glad the Letter-to-the-Editor writer’s wife finally received a correct diagnosis and was successfully treated; but one anecdote doesn’t prove anything. Not every UK hospital is equally good, so had they used another hospital the result may have been quite different, just as in the U.S. we have excellent hospitals; but not all are and even two equally competent doctors may each misdiagnose a case where the other would have gotten it correct. Medicine involves a very complex set of variables. And it is obvious the writer knows nothing of the funding of research nor international comparative statistics.

As for the remark about the U.S. Post Office, an oft used trope that is both wrong and insulting to those who work for the Post Office. And Medicare, with administrative costs much lower than that of the for-profit health insurance industry is a very popular program. Yep, they sometimes makes mistakes; but compared to what?

References

Baumgartner A, Anthony D (2016 Oct). The Decline of the Autopsy in Rhode Island and Nationwide: Past Trends and Future Directions. Rhode Island Medical Journal; 99(10): 36-38.

Combes A, Mokhtari M, Couveland A et al. (2004 Feb 23). Clinical and Autopsy Diagnoses in the Intensive Care Unit: A Prospective Study. Archives of Internal Medicine; 164: 389-392.

Duffy D, Milani K (2019 Feb 20). Profit over Patients: How the Rules of Our Economy Encourage the Pharmaceutical Industry’s Extractive Behavior. Roosevelt Institute.

Groopman J (2007). How Doctors Think. Houghton Mufflin Company.

Harrison JA (2008 May). Paying More, Getting Less: How much is the sick U.S. health care system costing you? Dollars & Sense.

Harrison JA (2018 Aug 10). The Case for A Non-Profit Single-Payer Healthcare System. Physicians for a National Health Program.

Kemp E (2019 Feb 4). The Case for Medicare-for-All. Public Citizen.

Pastores SM, Dulu A, Voigt L et al. (2007). Premortem clinical diagnoses and postmortem autopsy findings: discrepancies in critically ill cancer patients. Critical Care; 11(2): R48.

Reichert CM, Kelly VL (1985 Summer). Prognosis For The Autopsy. Health Affairs; 4(2): 82-92.

Witteking C, Gradistanac T (2018). Post-Mortem Examination as a Quality Improvement Instrument. Deutsches Ärzteblatt International; 115: 653-8.

Dr. Joel A. Harrison is a retired epidemiologist who has studied and worked in several countries, including Sweden (where he earned his doctorate) and Canada (where he earned a Master’s degree). Dr. Harrison is a long-time member of Physicians for a National Health Program.

https://www.eastcountymagazine.org…

Milliman footnote on ‘disruptive’

Congress asked nine questions about single payer. Here are 27 answers.

Milliman, March 2019

At its core, a single-payer system is one in which the system’s primary financing (and oftentimes the primary enrollment) comes from a single payer, which is typically the government. Reflecting the many unique ways that the federal and state governments fund and regulate American healthcare, we have identified three different single-payer scenarios, ranging from least disruptive to most disruptive compared to the status quo. (See footnote 2)

Footnote 2: The word “disruptive” was once largely pejorative, but has recently become synonymous with game-changing innovation. For the sake of our discussion, both meanings may apply.

http://us.milliman.com…

Comment:

By Don McCanne, M.D.

This Milliman white paper is not particularly helpful in defining the ideal single payer model of reform since it asks more questions than it answers. It may be useful in reviewing potential questions about single payer to prepare answers as to why a model such as that supported by Physicians for a National Health Program is the ideal which we should be pursuing. But this isn’t why this paper was chosen for today’s message.

In reaction to the newfound popularity of single payer Medicare for All, supporters of lesser measures, such as a Medicare public option, have claimed that the single payer model of Medicare for All would be too disruptive, implying that disruption is undesirable. But in the footnote quoted, Milliman (business advisers “with no agenda other than getting it right”) indicates that “disruptive,” though formerly a pejorative, “has recently become synonymous with game-changing innovation.”

Innovation is praised in the business world. In fact, those who insist that we must perpetuate the private health insurance industry state that innovation is one of the more important reasons to continue to support their industry. However, their innovations, such as restrictive provider networks, higher deductibles that impair access to care, ineffective and intrusive pay-for-performance schemes, upcoding to obtain unwarranted risk adjustment bonuses, and the like, are measures that suggest that “innovation” has become a pejorative when applied to the private health insurance industry.

Maybe in our messages we need to add two adjectives – “beneficial” and “detrimental” – as in, “It’s time for us to replace detrimental innovation with beneficial disruption.” That should be our message whether or not the rhetoric gains traction.

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

Dr. Paul Song on “Rising Up With Sonali”

PNHP national board member Dr. Paul Song appeared on “Rising Up With Sonali” on Free Speech TV and Pacifica radio stations on March 28, 2019. He discussed the Trump Administration’s decision to seek to invalidate the entire Affordable Care Act through the courts, as well as other detrimental policies such as Medicaid work requirements. He cautioned Democrats not to settle for defending the ACA, but to advance a popular policy that would more fully address our health care crisis: improved Medicare for all.

The fundamental flaw in the Trump Administration’s approach to health care

Economic Report of the President

The Annual Report of the Council of Economic Advisers, March 2019

As shown in the Report that follows, we are ushering in an era of renewed dedication to our citizens. It is my great honor to champion the American people and to make their success and well-being my top priority. This pro- growth, pro-opportunity agenda celebrates the irreplaceable value of America’s working families and embraces the extraordinary possibilities for American ingenuity to improve the human condition. It is an economic agenda that lays the foundation for the future of American greatness.

Donald Trump

Chapter 4 – Enabling Choice and Competition in Healthcare Markets

The dominant theory in economics for centuries in the Western world has been the efficiency of the free market system. For a free market to be efficient, free choice and competition must exist in the market to allow consumer demand to be met by suppliers.

Of course, many markets deviate in substantial ways from the conditions under which markets are perfectly efficient. Market failures occur to a greater or lesser extent throughout the economy. The important question is what to do about them.

Following the research of Kenneth Arrow (1963), many economists and policymakers have argued that unique features of healthcare make it impossible for competition and markets to work. They claim that uncertainty in the incidence of disease and in the effectiveness of treatment, information asymmetry between providers and consumers of healthcare, barriers to provider entry, and the critical importance of and inelastic demand for health services all interfere with market function and justify government intervention in—or even its takeover of—healthcare markets. Some members of Congress have proposed nationalizing payments for the healthcare sector (which makes up more than a sixth of the U.S. economy) through the recent “Medicare for All” proposal. This policy would distribute healthcare for “free” (i.e., without cost sharing) through a monopoly government health insurer that would centrally set all prices paid to suppliers such as doctors and hospitals. Private insurance would be banned for the services covered by the “Medicare for All” program.

This chapter begins by critically examining the rationales offered for the government’s intervention in healthcare. We find that though some characteristics of healthcare may present obstacles to a perfectly functioning market, these are not insurmountable problems that mandate the government’s intervention in healthcare and can be overcome by market and nonmarket institutions. Moreover, these problems also occur in markets for many other goods without calls for government takeovers and the suppression of consumer choice and competition. Government intervention in healthcare is only clearly warranted where the political process has made a determination that some level of healthcare for low-income people is a merit good—a beneficial good that would be underconsumed, justifying replacing consumer sovereignty with another norm—so that government redistribution programs to provide health- care in kind for low-income people might enhance efficiency.

We next critique the “Medicare for All” proposal. This plan would eliminate choice and competition—everyone would be forced to participate in the same insurance, with mandatory premiums set through tax policy and without the option of choosing an alternate insurance if they dislike the government’s plan. Our analysis shows that the proposal would reduce longevity and health in the U.S., decrease long-run global health by reducing medical innovation, and adversely affect the economy through the large tax burden required to fund the program.

In contrast to proposals that diminish health and damage the economy by curtailing market forces, the next section of this chapter details the Trump Administration’s efforts to improve choice and competition in health insurance markets so as to help them better serve low- and middle-income people. The Administration has reduced the penalty associated with the Affordable Care Act’s (ACA’s) individual mandate to zero, so consumers can decide for themselves the value of purchasing health insurance. We analyze this deregulatory reform and find that it will generate $204 billion in value over 10 years. In addition, the administration has increased the choices and affordability of available health insurance plans by expanding association health plans and extending the available terms and renewability of short-term, limited-duration insurance plans. As opposed to sabotaging healthcare markets, conventional incidence analysis by the CEA implies that these three deregulations of health insurance markets together will benefit Americans by $453 billion during the next decade.

Finally, the last section discusses the Administration’s reforms to enhance choice and competition in biopharmaceutical markets by streamlining the drug application and review process in a way that effectively lowers barriers to entry while ensuring a supply of safe and effective drugs.

We conclude that the market for health insurance and healthcare should be supported through increased choice and competition, not hampered by increased government intervention. Competitive markets for healthcare services and insurance—whether privately or publicly funded—can and do work to provide high-quality care for people at all income levels.

Conclusion (Chapter 4)

The U.S. economy generally relies on free markets to maximize benefits for U.S. citizens. The hallmarks of any free market are consumer choice and competition. Although some have claimed that healthcare is an exceptional case that cannot be produced and allocated through the market, we argue that these claims are exaggerated and that the costs of market failure are often lower than the costs of government failure. Deviations from perfect market conditions are present in healthcare and many other markets, but promoting choice and competition is the appropriate way to maximize efficiency and consumer welfare.

The recent push in Congress to enact a highly restrictive “Medicare for All” proposal would have the opposite effect—it would decrease competition and choice. The CEA’s analysis finds that, if enacted, this legislation would reduce longevity and health in the United States, decrease long-run global health by reducing medical innovation, and adversely affect the U.S. economy through the tax burden involved.

The Trump Administration has instead concentrated on deregulatory reforms that will increase choice and competition in the health insurance markets and pharmaceutical drug markets. Bringing the ACA’s individual mandate penalty down to zero will allow consumers to choose how much health insurance they desire. Expanding the availability of association health plans and the duration and renewability of short-term, limited-duration health plans will increase consumers’ options and spur competition. Finally, the FDA’s initiatives to speed drug approvals have already had tangible benefits in record numbers of drug approvals and increased pharmaceutical competition. All these reforms are expected to bring down prices, encourage continuing innovation, and maximize consumer welfare.

The Annual Report of the Council of Economic Advisers (705 pages):
https://www.whitehouse.gov…

Comment:

By Don McCanne, M.D.

President Trump’s Council of Economic Advisers begins their report on health care by dismissing the seminal work of Nobel Laureate Kenneth Arrow demonstrating how markets do not work in health care – a concept that has been confirmed by many decades of non-structured natural experiments. Ignoring facts, they then move into a magical world crafted from wishes derived from their ideology of free markets, competition and choice.

There is no way that this approach can lead to sound decisions in health policy if our goal is to ensure affordable, accessible, and equitable health care for everyone.

President Trump announced this week that he intends to terminate Obamacare by supporting the lower court decision declaring the entire Affordable Care Act to be unconstitutional, while at the same time promising that “we will have a plan that’s far better than Obamacare.” He has never explained what that better plan he keeps promising us would be, but by using advisers that reject Kenneth Arrow’s fundamental premises, we can conclude that our health care financing system is not in good hands. We have to do something about that.

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The free market is bad at providing health care

By Ken Lefkowitz
The Washington Post, Letters, March 27, 2019

Regarding the March 24 editorial “The demagoguery of Medicare”:

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

Rather, single-payer universal health care is quite cost-effective. Expressed as a percent of gross domestic product, it has proved to be less costly in other countries. It will wring out the wasteful administrative costs of the free marketplace and provide negotiating leverage to stabilize medical provider and pharmacy costs.

A University of Massachusetts study demonstrated that a single-payer system, or Medicare-for-all, could cover all citizens, including today’s uninsured, eliminating deductibles and co-pays, and still save $592 billion. Reduced absenteeism and increased labor productivity in the workplace would be an additional cost advantage.

So let’s move to Medicare-for-all and ditch our ineffective free marketplace.

The writer, who designed health insurance plans for major corporations, is a member of Physicians for a National Health Program and the New Jersey Universal Healthcare Coalition.

https://www.washingtonpost.com…

Spending growth greater in employer-sponsored, private plans than in Medicare

Variation In Health Spending Growth For The Privately Insured From 2007 To 2014

By Zack Cooper, Stuart Craig, Charles Gray, Martin Gaynor, and John Van Reenen
Health Affairs, February 2019

Abstract

We examined the growth in health spending on people with employer-sponsored private insurance in the period 2007–14. Our analysis relied on information from the Health Care Cost Institute data set, which includes insurance claims from Aetna, Humana, and UnitedHealthcare. In the study period private health spending per enrollee grew 16.9 percent, while growth in Medicare spending per fee-for-service beneficiary decreased 1.2 percent. There was substantial variation in private spending growth rates across hospital referral regions (HRRs): Spending in HRRs in the tenth percentile of private spending growth grew at 0.22 percent per year, while HRRs in the ninetieth percentile experienced 3.45 percent growth per year. The correlation between the growth in HRR-level private health spending and growth in fee-for-service Medicare spending in the study period was only 0.211. The low correlation across HRRs suggests that different factors may be driving the growth in spending on the two populations.

From the Discussion

US health spending has increased steadily since 1960. In this study we analyzed growth in health spending on Medicare beneficiaries and people with employer-sponsored private health insurance in the period 2007–14. Whereas Medicare spending per fee-for-service beneficiary decreased by 1.2 percent in real terms during this period, spending per private insurance enrollee increased by 16.9 percent. Of note, there was substantial variation in the growth rates for private health spending across HRRs (less so for Medicare spending). This variation suggests that some regions are more successful than others at constraining health spending growth. This is particularly apparent in HRRs where there were negative growth rates in both Medicare and private spending.

This divergence in growth rates suggests that at least during our study period, different factors were driving health spending growth in the Medicare and privately insured populations. Prior work has demonstrated that there is a low cross-sectional correlation between HRR-level health spending on fee-for-service Medicare beneficiaries and that on people with private health insurance. One driver of this low correlation is the low correlation between the regulated payments in fee-for-service Medicare and the prices that health care providers and insurers negotiate for care. It is likely that differences in growth rates between regulated fee-for-service Medicare provider payments and providers’ negotiated transaction prices are also driving some of the difference in the growth in spending across these two populations. Indeed, recent work has found that in the short run, growth in providers’ prices is driving growth in private health spending.

This research has one very clear implication for public policy: Given the low correlation between the growth in private health spending on people with employer-sponsored coverage and the growth in spending on fee-for-service Medicare beneficiaries, separate policies will be necessary to curb spending growth in the two populations.

Abstract:
https://www.healthaffairs.org…

Full article (behind a paywall):
https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

Growth in health spending on people with employer-sponsored commercial health insurance from Aetna, Humana, and UnitedHealthcare, three of the five largest health insurers in the US, was compared with growth in health spending in the traditional fee-for-service Medicare program which excluded the private Medicare Advantage plans.

There were two important observations. Spending growth in the employer-sponsored commercial plans was much greater than spending growth in the traditional Medicare program, with private spending growing 16.9 percent over 2007-14 and Medicare spending actually decreasing 1.2 percent (during SGR years). The other observation is that there was tremendous variation in private spending between hospital referral regions which had a very low correlation with Medicare spending in those regions.

The authors note, “One driver of this low correlation is the low correlation between the regulated payments in fee-for-service Medicare and the prices that health care providers and insurers negotiate for care. It is likely that differences in growth rates between regulated fee-for-service Medicare provider payments and providers’ negotiated transaction prices are also driving some of the difference in the growth in spending across these two populations. Indeed, recent work has found that in the short run, growth in providers’ prices is driving growth in private health spending.”

Thus the traditional, public fee-for-service Medicare program has been much more effective in controlling spending than have the large, private commercial insurers which have operated more as a loose canon in cost containment.

Since the study was done while the the Medicare sustainable growth rate formula was in effect, it may be that the negative spending growth for Medicare was too severe at that time (since abandoned), but it does show that public policies are more effective than the private market in controlling and stabilizing health care spending growth.

Regardless, this study does support enactment and implementation of the single payer Medicare for All model as a method of achieving a more sustainable growth in health care spending in the future.

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Dr. Adam Gaffney on “WBUR CitySpace”

PNHP president Dr. Adam Gaffney participated in a WBUR CitySpace discussion titled, “Single Payer: The Pros, The Cons And What’s Possible” on March 26, 2019. (Click here to view our live tweet of the event.) He was joined by Profs. John E. McDonough and Anya Rader Wallack to discuss the policy and political implications of improved Medicare for all.

The U.S. Healthcare Cost Crisis

Discover how the high cost of healthcare impacts Americans' personal finances, individual healthcare choices and perceptions of the U.S. healthcare system. A new survey from West Health and Gallup reveals financial hardships but gaps between political parties on the overall quality of the system.

Gallup, March 26, 2019

Every day, Americans are burdened by the strain and fear of ballooning healthcare costs. Yet despite the hardships many Americans endure, 64% say they are “completely” or “mostly” satisfied with their personal experience of the healthcare system.

Additionally, one in four skipped a medical treatment because of cost, and in the past year alone, Americans collectively borrowed an estimated $88 billion to cover healthcare costs.

Partisan divides split Americans’ perceptions of the healthcare system’s quality. While 48% of the general population believes that the quality of care in the U.S. is the best or among the best in the world, this swells to 67% among self-identified Republicans, compared with just 38% among Democrats.

Other key findings in The U.S. Healthcare Cost Crisis include:

  • the sacrifices Americans make, and the tradeoffs they are willing to accept, to offset the impact of high healthcare costs
  • Americans’ concerns about the damage rising healthcare costs could do to the U.S. economy and to their own personal finances
  • Americans’ expectations about their healthcare costs over the next two years
  • the extent to which Americans defer or forgo care or medicine due to high costs
  • Americans’ understanding of their out-of-pocket costs before receiving care

https://news.gallup.com…

Democrats bailing on real health care reform

House Democrats to Unveil Plan to Expand Health Coverage

By Robert Pear
The New York Times, March 25, 2019

On Tuesday, Democratic leaders, including Speaker Nancy Pelosi, will put aside, at least for now, the liberal quest for a government-run “Medicare for all” single-payer system and unveil a more incremental approach toward fulfilling those campaign promises. Building on the Affordable Care Act, they would offer more generous subsidies for the purchase of private health insurance offered through the health law’s insurance exchanges while financing new efforts to increase enrollment.

They would also reverse actions by the Trump administration that allow insurance companies to circumvent protections in the Affordable Care Act for people with pre-existing conditions. Insurers could no longer sell short-term health plans with skimpy benefits or higher premiums for people with chronic illnesses.

Ms. Pelosi said the legislation would “strengthen protections for pre-existing conditions, reverse the G.O.P.’s health care sabotage and lower Americans’ health costs.”

The legislative package… seems to answer a question facing Democrats since they took control of the House: How would they balance the expansive demands of their most liberal members with the needs of more pragmatic Democrats elected in seats that were held by Republicans?

Ms. Pelosi, the committee chairmen and many other House Democrats see the new legislative package as a more efficient way of achieving universal coverage, a goal shared by champions of “Medicare for all,” led by Representatives Pramila Jayapal of Washington and Debbie Dingell of Michigan.

The House Democrats’ bill would…

…turn back the president’s action by stipulating that short-term plans are included in the definition of “individual health insurance coverage” under the Affordable Care Act and therefore must comply with coverage requirements of the health law…

…would revise the law to provide more of both types of assistance.,, tax credits to help them pay premiums, and cost-sharing reductions to lower their deductibles, co-payments and other out-of-pocket costs…

…make subsidies available to some working families who are now ineligible… eliminate this quirk in the law, sometimes called the family glitch…

…provide money to publicize the insurance options and subsidies available under the Affordable Care Act and to help people enroll…

…block guidance issued by the Trump administration under which states can get waivers allowing them to use federal funds to subsidize insurance that does not comply with coverage requirements in the Affordable Care Act…

…seeks to lower premiums by setting up reinsurance programs…

…would provide federal money to states that want to set up their own insurance marketplaces but have yet to do so.

https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

So what do we know about politics?

Because of the persisting deficiencies in our overpriced and underperforming health care financing system, the majority of the people are now ready for the vastly superior model of single payer Medicare for All which would ensure affordable health care for everyone. But the Democratic leadership that now controls the House of Representatives is more politically astute than us so they will put aside single payer and move ahead with fine tuning the mediocre Affordable Care Act (ACA) with the dubious claim that it will move us closer to the deferred goal of Medicare for All. What could be wrong with this logic?

The number one rule is do not ever give away anything before you sit down at the negotiating table. With this maneuver they have given away everything except for a few tweaks to the Affordable Care Act. Oh my. But they’re master politicians.

Okay. It is agreed that if the House passes the Medicare for All Act of 2019 in this session of Congress it will be blocked in the Senate and would be vetoed by President Trump anyway. But would that be a futile gesture?

Let’s assume that the House does manage to pass a modest package of ACA tweaks and sends it on to the Senate. Isn’t that the deliberative body controlled by the party that has vowed for years to repeal Obamacare, i.e., the Affordable Care Act? Also, when the president has been busy slashing and burning ACA and only yesterday requested the courts to declare the entire Act unconstitutional, does anyone believe that he will sign on to a package of tweaks that move slightly in the opposite direction of where he has been headed? So wouldn’t the House passing a few ACA tweaks also be a futile gesture?

If the House Democratic leadership is honest about their claim that the ACA tweaks will eventually lead to single payer Medicare for All (a proposition that is very difficult to accept at face value) then which futile gesture should they choose, since either will be defeated?

The House can use the legislative process to further educate the nation on the reasons for the high costs and the cruel deficiencies in our system while demonstrating the solutions that will bring us the reform that we desperately need. The ACA tweaks barely touch on the problems and are even somewhat arcane from the public’s perspective, so this legislative package has virtually no instructive value that would help to increase the passion needed to push forward the movement for reform.

Contrast that with the Medicare for All Act. It is easy for people to understand what is meant by everyone being included (unlike the Affordable Care Act). They can understand what is meant by being affordable for everyone (unlike the Affordable Care Act). They can understand what is meant by health care being free at the point of service (unlike the Affordable Care Act). They understand that equitable means fair (unlike the Affordable Care Act). They understand what it means to have a program that covers you for your entire life (unlike the Affordable Care Act). And on and on.

The Senate and the White House remain barriers to any health care reform in this session of Congress. The plot of the Democrats seems to be to offer legislation that the Republicans will block so that they can use that in the 2020 elections, claiming the Republicans don’t care about your health care. But look at the measures listed above in the excerpts from the New York Times article. What percentage of the voters are going to be passionate about electing candidates that promise to pass those tweaks? Well, all we can say for sure is that it is not less than zero.

This is the time to greatly expand our educational efforts on single payer Medicare for All. We can do that by bringing the Medicare for All Act of 2019 to the committees that actually have the power to move the bill to the floor (instead of the committees that do not have that power), and then bring it to the House floor so that the nation can see on C-Span and cable news channels just what health care justice is all about. The policies are powerful and have tremendous support throughout much of the nation.

Think of entering the voting booth in 2020. Which is more apt to drive your vote? Comprehensive, affordable health care for everyone forever? Or excluding short-term health plans from the ACA exchanges?

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How ‘Medicare for All’ went from pipe dream to mainstream

Universal health care debates could shape the 2020 election — and the future of the Democratic Party

By Mary Ellen McIntire
Roll Call, March 26, 2019

Political candidates and activists in Maine, especially in rural areas, often got a sharp reaction five years ago when they knocked on doors to promote universal health care.

“The reaction was, ‘Oh, you’re a commie,’” said Phil Bailey, who back then advocated for various Democratic causes.

Now, voters in those same conservative areas have a different take.

“Of course” is a common response to calls for universal coverage, said Bailey, now executive director of Maine AllCare, part of a national coalition campaigning for single-payer health care. The organization saw enough growing momentum and received enough financial support to justify hiring Bailey and another full-time staffer last summer for the previously volunteer-led group.

What was once seen as a long-shot pitch from Vermont independent Sen. Bernie Sanders during his 2016 presidential campaign is now a proposal that at least four of his Senate colleagues also vying for the party’s 2020 nomination supported during the last Congress. The issue is driving the national political health care debate.

But to succeed in enacting a single-payer system such as the “Medicare for All” plan that Sanders backs, liberals would need an unprecedented grassroots movement propelling the effort forward and would have to work out complicated policy details affecting nearly one-fifth of the nation’s economy.

Democrats are already contending with industry groups hoping to shift the focus back to strengthening the current system. Most drug companies, hospitals and insurers oppose Medicare for All, which undoubtedly complicates progressives’ efforts. The party’s left wing is pushing a bold, pricey plan carrying political risks that make Democratic leaders shudder. Despite all the inevitable political hurdles, getting a single-payer law enacted may look easy compared to implementing it.

The most ardent advocates for a government-run, single-payer system are not content with incremental steps. They are seeking a wholesale reorganization of the nation’s health care system.

The proposed two-year transition may be too fast for the entire industry to adapt to in an overhaul that experts warn would displace workers and jolt the economy.

“It is going to be a big administrative and logistical challenge. When you’re talking about moving everyone in the country into a new health insurance program, that is not a small feat,” said Linda Blumberg, an institute fellow at the Health Policy Center at the left-leaning Urban Institute.

Upending the industry

A single-payer health care plan would significantly change every sector of the health care industry. Hospitals and doctors would need to adjust to a new payment system, the insurance industry would shrink to a fraction of its size, and the government would bring drug companies to the negotiating table to determine prices.

The 2010 health care law left in place most of the existing health care infrastructure in the U.S. Still, experts warn that the lessons from that more incremental transition show how dramatic it would be to shift to a single-payer system.

Supporters aren’t intimidated by the seismic nature of the change. The hope is not just to ensure that everyone has coverage, but also to take on health care companies seeking to maximize their profits, said Adam Green, a co-founder of the Progressive Change Campaign Committee, a political action committee that supports liberal candidates.

“Medicare for All boils down to two things,” Green said. “One is universal coverage. The other is corporate accountability.”

Setting up a single-payer system would most likely require creating a new government program to serve as the payer and oversee the system. A House bill by the co-leader of the Progressive Caucus, Pramila Jayapal, would also establish a national health care budget to cap costs.

The Washington Democrat’s bill, like Sanders’ plan, doesn’t envision a large role for supplemental insurance.

It would be permitted, but aides say it would likely be unnecessary and used only to cover medically unnecessary treatments, such as cosmetic surgery. Unraveling the current insurance system is a Gordian knot-style task all its own.

Even public entitlement programs are often administered through private plans, with 68 percent of people in Medicaid and 34 percent of those in Medicare using comprehensive managed care plans.

Granddaddy of 2020 issues

The role of private insurance in a single-payer system has already emerged in the fledgling Democratic presidential primary race.

California Sen. Kamala Harris sparked the debate over the survival of private insurance earlier this year, saying she favors a single-payer system that would eliminate it. Harris has also backed other proposals, but called the single-payer plan her top choice.

Minnesota Sen. Amy Klobuchar said such a move is not feasible and supports a bill by Hawaii Democratic Sen. Brian Schatz to let people buy into Medicaid. Similarly, former Texas Rep. Beto O’Rourke, who previously supported a single-payer system, now says another path to universal coverage may be more efficient.

The single-payer bills introduced so far would not be based on the current Medicare program, but instead would greatly expand the program’s benefits.

Jayapal and Sanders both say the national health program would cover all medically necessary treatments. Those could be determined by a doctor or a newly formed national health program, said Jodi Liu, a RAND Corp. associate policy researcher.

Adam Gaffney, president of Physicians for a National Health Program, which supports a move to single-payer, said those decisions could resemble the way Medicare determines what care is medically necessary. He supports a national list of covered drugs.

Advocates for a single-payer system say that enrolling people in the program may be the easiest part. After all, decades ago, the government signed up seniors in the newly created Medicare program the year after it was enacted. Unenrolled patients could be signed up at a doctor’s office or hospital when they receive treatment, said Gaffney.

“Once you say you’re going to enroll everyone, it actually takes a lot of the administration out of it,” Gaffney said.

Compensation questions

One major challenge under a single-payer system would be how to pay medical providers. Advocates propose different types of plans, such as paying all providers at the same rate, possibly based on current Medicare rates, or global budgeting, through which institutions would regularly receive a lump sum of money as reimbursement for treatments.

Payment changes could benefit some doctors, such as those who currently treat many Medicaid enrollees and receive lower rates than Medicare. But providers who see mostly patients covered by commercial insurance could see payments fall.

The same goes for access to providers, said Liu. Since not all providers accept Medicaid, many patients would likely have an easier time finding doctors.

The government would face significant pressure to ensure that providers were compensated at the “right” rate, said Blumberg. Controlling health costs would be one goal, but the government would not want to skimp on quality or access to a sufficient number of providers.

In making decisions that affect the entire health care system, selecting the wrong payment rate could have serious ramifications, said Blumberg. “That process in and of itself is going to require a huge amount of attention and analysis and monitoring.”

Under the Jayapal bill, hospitals and the government would negotiate a budget based on factors like the historic volume of services over three years, a hospital’s normal expenditures and standard payment rates.

Hospitals would also get funding to cover their uncompensated care costs under an all-payer system.

Global lump-sum budgeting, which would give institutional providers an amount of money for health care services over a set amount of time, could contain costs, which advocates call a key benefit.

“If there was a national global budget, that’s certainly a direct lever to address how much spending there is on health care, but of course, there’s a lot of political issues that would come up,” such as budgetary pressures, Liu said.

While hospitals and other institutions would be paid quarterly through a capped budget under Jayapal’s proposal, individual doctors would be paid through a fee-for-service system for every procedure. The Health and Human Services secretary would have one year to set those providers’ fees. Hospitals are already sounding the alarm about receiving lower payments under Democratic proposals.

Whether Jayapal’s two-year transition is feasible is another question. A Jayapal aide said a fast transition provides less time for the industry to push back.

Still, Blumberg suggests a 10-year transition is more feasible. “The change for a lot of providers could be very substantial, and doing that in a very short period of time may have implications for disrupting the operation, the ability for these providers to continue to operate and the access for the patients,” she said.

Although the challenges are great, Medicare for All advocates note that other large developed countries ensure all citizens can access health care.

“Across industrialized countries, the hallmark of the health care system is universal coverage,” said Robin Osborn, a Commonwealth Fund vice president and director of international health policy and practice innovations.

Where’s the funding?

For all the questions around a single-payer system, the biggest question may be how to pay for it. Neither Jayapal or Sanders included a financing plan in their bills, although Sanders released a list of possible ways to pay for his.

The price tag for Sanders’ vision would be roughly $32 trillion over 10 years, according to two outside analyses of proposals Sanders put forward in 2016 and 2017, the first from the Urban Institute and the latter from the libertarian Mercatus Center.

That’s an eye-popping balance, although Sanders emphasizes findings that the U.S. would actually save money on health care spending over a decade. Single-payer advocates argue that the U.S. health care system is already the most expensive in the world and would be more efficient under a new program.

“When you think about the fact that people are already paying, you have to recognize that this is just a scare tactic, primarily from the right, saying you’re going to end up paying much more,” Jayapal said.

Still, asking taxpayers to pay the whole bill causes even some Democrats to balk.

Speaker Nancy Pelosi of California said in a recent Rolling Stone interview that a single-payer system may be easier administratively than other ways to reach universal coverage, but questioned how to pay for it.

Pelosi insists that Democrats should build on the 2010 health care law, which she helped shepherd through Congress a decade ago. Expanding the current Medicare program would not be as beneficial to Americans as that law, she argues.

“All I want is the goal of every American having access to health care,” she told the magazine. “You don’t get there by dismantling the Affordable Care Act.”

Critics will likely highlight the lack of a financing plan — and the expected high tax increase — that would come with implementing a system that covers essentially all medical expenses.

Sanders’ financing options include ending tax breaks that would become obsolete under a single-payer plan, adding a 4 percent income-based premium paid by households, imposing a wealth tax or a more progressive personal income tax, or leveraging fees on corporations, such as a one-time tax on offshore profits.

Other possibilities include sunsetting parts of the Republican 2017 tax overhaul or creating a tax on employers, which could mean that employers would not see much savings from not providing coverage to workers.

High-income earners are particularly at risk, said Larry Levitt, senior vice president for health reform at the Kaiser Family Foundation. “Depending on how it’s financed, high-income people could end up paying much more in taxes than they now pay for health care,” he said.

Because a transition to a single-payer plan would effectively eliminate most of the insurance industry, possibly 1 million to 2 million people who work in that industry would be displaced, according to Jayapal. Both Jayapal and Sanders proposed assistance for those workers with new job training, education or other programs.

Jayapal’s bill introduction in February led health insurance stocks to slip, although analysts did not express much concern. Spencer Perlman, director of health care research at Veda Partners, wrote to clients that he did not believe the bill to be a risk to managed care.

“The only conceivable analogues for the approach envisioned by House Progressives are the Medicare Act of 1965 and the ACA, each of which were generational policies that nevertheless largely left intact the commercial insurance paradigm and private control of healthcare services,” he wrote. That could be partially because a Medicare for All debate would draw in essentially every sector of the economy.

“It’s hard to imagine a bigger and more all-encompassing debate than over Medicare for All,” Levitt said. “Health care is such a big part of the economy, and you would just have every business and health care group weighing in.”

Political calculus

Some Democrats doubt that a Democratic president and Congress would implement a single-payer system.

Bob Kocher, a partner at Venrock and former senior Obama administration health care official, said actions in office typically don’t match the aspirations candidates invoke while campaigning.

“When you try to do it, the details matter and are hard and are often less disruptive and ambitious than what your poetry was,” he said.

Liberals insist that a single-payer system is the only path forward. “This is not a messaging event. We are going to get health care for every American,” Rep. Debbie Dingell, a Michigan Democrat, said at an event for the House bill.

If lawmakers were going to march toward a single-payer system, a massive shift in public opinion over a relatively short period of time would be needed.

Recent polls show that support for Medicare for All falls when people learn it would eliminate private insurance companies or raise taxes.

Whether Democrats decide to take up a single-payer plan would depend on how much a president campaigned on it, said Green.

A political boost could come if Medicare for All brought down “an old timer” who doesn’t support the policy, such as Ways and Means Chairman Richard E. Neal of Massachusetts, Green suggested.

“Now what we’re experiencing is there’s a lot of candidates who campaigned and won on Medicare for All, including flipping red seats blue, but ironically, there’s others who didn’t campaign on Medicare for All, got attacked anyway and won, but were kind of spooked from the whole experience,” Green said.

Still, Green added that if a “true progressive” wins the White House, he expects Medicare for All to be a priority.

Advocates hope that Medicare for All hearings in the coming months in the Rules and Budget committees will help the public understand the plan. Those hearings could also be a chance for single-payer opponents to raise concerns.

“Democrats are once again proposing fiscally irresponsible policies that will radically alter how hundreds of millions get their health care,” Rep. Steve Womack of Arkansas, the Budget Committee ranking Republican, said when Jayapal’s bill was released.

Mark Peterson, a political science professor at the University of California at Los Angeles, said historically, Americans have consistently said the health care system needs improvements, but they’re also afraid of what they don’t know.

“To the extent that what progressives are doing will stimulate that kind of action at the public level to really create that wave, a groundswell of support the way Social Security had, that can make an enormous political difference,” he said.

http://www.rollcall.com…