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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Comment:

By Don McCanne, M.D.

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

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

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

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

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

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By Yusra Murad
Morning Consult, July 11, 2019

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

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

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

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

https://morningconsult.com…

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Republicans make U-turn on health care

By Alexander Bolton
The Hill, July 14, 2019

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

https://thehill.com…

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Comment:

By Don McCanne, M.D.

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

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

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

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

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

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

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

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

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

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

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

Getting in the Door

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

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

Waiting to Be Seen

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

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

Weighing Health Against Your Wallet

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

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

Paying for Value

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

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

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

Conclusion

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

https://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

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

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

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

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

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

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

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

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

Abstract

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

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

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

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

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

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

From the Discussion

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

Conclusions

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

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

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

Shocking! Shocking! Absolutely shocking!

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

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

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

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

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

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By Michael D. Frakes, Jonathan Gruber, and Anupam Jena
National Bureau of Economic Research, July 2019

Abstract

Stemming from the belief that the key barrier to achieving high-quality and low-cost health care is the deficiency of information and medical knowledge among patients, an enormous number of health policies are focused on patient education. In this paper, we attempt to place an upper bound on the improvements to health care quality that may emanate from such information campaigns. To do so, we compare the care received by a group of patients that should have the best possible information on health care service efficacy — i.e., physicians as patients — with a comparable group of non-physician patients, taking various steps to account for unobservable differences between the two groups. Our results suggest that physicians do only slightly better in adhering to both low- and high-value care guidelines than non-physicians – but not by much and not always.

Introduction

There is widespread belief in health care that the deficiency in information and medical knowledge among consumers is the key barrier to achieving high-quality health outcomes and lower costs of care. An enormous number of health policies follow from this assumption, including efforts to educate patients about health, both at a population level through large-scale public health campaigns (e.g., campaigns to encourage exercise and healthier diets) and at an individual level through provider-led patient education (e.g., education of patients about the inappropriateness of antibiotics for the common cold, the importance of vaccination, etc.), decision-making support, and so on. In addition to information-based policies intended to improve health, other important demand-side approaches intended to improve the efficiency of health care (e.g., high-deductible health plans) focus on increasing direct consumer engagement in the purchase of health care, relying heavily on the notion that informing patients about the costs and benefits of health care services can steer patients towards higher-quality, more efficient care.

The widely prevailing view that information scarcity is a key obstacle to achieving high quality health outcomes raises the basic question: is it simply inadequate medical knowledge and information among patients that has limited the utility of various demand-side approaches to health improvement? If so, it remains possible that improvements could be made along both cost and quality lines should policymakers and providers encourage even greater levels of information disclosure to patients, a point not only stressed by patient-centered health care enthusiasts promoting shared decision-making models, but also intrinsic to the many public health efforts that aim to use patient education as a primary way to improve health. In this paper, we attempt to shed light on whether eliminating the scarcity of information in medical knowledge – an extreme form of information disclosure – could plausibly lead to the delivery and receipt of higher value patient care.

A natural way to explore the importance of scarcity of medical knowledge and information is to look at the care received by a group of patients that should have the best possible information on health care service efficacy: physicians. The decisions of physicians about which type of health care to receive would likely place an upper bound on how well non-physicians could do in selecting their health care treatments if fully informed about the costs and benefits of different types of health care interventions. With the exception of Johnson and Rehavi (2016), who focused on a single health care service – cesarean sections – there is no work which has been able to study the role of physicians as patients.

We are able to address this shortfall by using a source of data previously unexploited in economics research: data on physicians in the Military Health System (MHS). The MHS provides health insurance for all active duty military, their dependents, and retirees. Care is provided both directly on military bases and purchased from an off-base network of contracted providers. The MHS is one of the largest sources of health care spending in the U.S., with spending of over $50 billion per year. We have gathered data on the complete claims records for all MHS enrollees over a ten-year period. Importantly, this includes the claims data for MHS physicians when they are treated as patients themselves (drawing from records of over nearly 35,000 military physicians). The ability to observe physicians as patients provides us with a unique and powerful opportunity to answer the question: do especially well informed patients elect to receive higher value medical services?

For these purposes, we evaluate the quality of health care services received by physicians and non-physicians, focusing on a set of services for which objective, evidence-based standards exist. In particular, we assess whether physicians receive more services deemed “high value” by the relevant medical literature and fewer services deemed “low-value,” in each case relative to the less-informed comparison group of similar non-physician patients. An example of low value care is a chest x-ray before eye surgery, a very low risk procedure for which pre-operative diagnostic testing is not recommended. An example of high value care would be statin therapy for patients with cardiovascular disease. If deficiency of medical knowledge and information is an important reason why demand-side interventions to improve patient health have met with limited success, we should expect that physicians as patients would exhibit markedly higher levels of adherence to high-value health care services and lower levels of low-value care compared to otherwise similar non-physician patients.

Our results suggest that physicians do only slightly better than non-physicians – but not by much and not always. Across most of our low-value settings, physicians receive less low-value care than do non-physicians, but the differences are modest, and generally amount to less than one-fifth of the gap between what is received by non-physicians and recommended guidelines. The results are slightly more mixed in the case of the high-value care analysis, with some evidence suggesting that physicians appear to receive high-value care at roughly the same rate received by non-physicians and some evidence suggesting that physicians do slightly better than non-physicians. These results provide a rough boundary on the extent to which additional information disclosure (beyond prevailing levels) can be expected to improve the delivery of health care in the U.S. Relatedly, these findings suggest that, despite the threat to the optimality of the health care system posed by information asymmetries between physicians and patients (Arrow 1963), most of the explanation behind the over- and under-utilization of low- and high-value services likely arises from factors other than informational deficiencies of patients.

Moreover, in the case of low-value care—where we do find modest physician effects — we attempt to shed light on the mechanisms underlying any information channel. We do not find consistent evidence to suggest that the observed average physician effects arise from the patient’s choice of a low-intensity physician or from a reduced scope for physician induced demand. Given these findings, it is likely that some of the modest physician effects we estimate arise simply from informed patients making higher quality choices at the moment of the care decision itself.

Our paper proceeds as follows. Part II reviews the existing literature on the impacts of health care information initiatives and provides a conceptual overview behind our approach of observing physicians as patients as a means of exploring the bounds of the quality gains that may arise from greater information disclosure. Part III provides a background on the Military Health System and discusses our data and empirical methodology. Part IV presents the results of our analysis and Part V concludes.

Discussion and Conclusion

We attempted to explore the upper bounds of the gains that may ensue from consumer-driven health care approaches that draw upon greater information-disclosure to patients by exploring the care choices of physicians when acting as patients themselves relative to the clinical choices of non-physician patients. In an attempt to isolate the information-component to the differences between these two groups of patients, we took various approaches to ensure comparability between physician and non-physician groups. Our results consistently suggest that, at most, superior patient knowledge is associated with only modest improvements in the quality of care selected during medical encounters. Perhaps one interpretation of these findings is that patients remain generally deferential to the care recommendations of their treating physicians, even in the case of near fully-informed patients. This interpretation would be consistent with other recent findings in the health economics literature, including recent research by Chernew et al. (2018) showing that referring physicians are dramatically stronger determinants of where patients receive MRIs relative to patient cost-sharing factors. Should concerns over the quality of care received by patients remain—as is suggested by the large gaps demonstrated between prevailing rates of adherence to high- and low-value care guidelines and recommended rates of adherence — our results are informative on the limitations that may come with information-focused, demand-side solutions.

Despite our efforts to ensure comparability across our treatment and control groups, concerns may remain over the generalizability of our findings. In particular, among other external validity issues, some may be concerned that we tested for the impacts of information in an environment characterized by very low levels of cost-sharing. The influence of information, however, may interact with financial considerations of this nature. Consider, for instance, preoperative testing and assume, as is the case with the Military Health System beneficiaries, that copayments for these diagnostic procedures are negligible. Even though such tests may render insufficient benefits to justify their full social costs and even if patients are aware of this, informed patients may nonetheless undertake the tests anyway given the negligible financial implications. In contrast, informed patients may decide to forego these tests when cost-sharing is more substantial.

This consideration does not necessarily threaten the external validity of our low-value care findings—at least not overly so—in light of the fact that the costs to undergoing low-value care extend beyond just direct financial outlays. For instance, in the case of pre-operative testing by the patients in our sample, we demonstrate in the Online Appendix that much or most of these instances of pre-operative testing necessitate an entirely separate visit to a medical provider on a separate day, an outcome that likely imposes costs and inconveniences of another nature on the affected patient. Accordingly, if we still estimate modest physician effects in the face of low-value care decisions that carry potentially significant non-cost-sharing consequences, such modest findings may indeed generalize to populations facing higher levels of cost-sharing.

Further reinforcing this point, the costs associated with receiving low-value care may extend beyond cost-sharing dollars in light of the possibility of physical harms and discomfort associated with the care itself. This is very likely true with the case of cesarean delivery, especially considering the recovery period involved. These physical consequences are, of course, likely to be far less significant in the preoperative testing setting, especially in the case of blood draws.

Finally, it is important to note that this particular generalizability concern does not extend to the high-value care analysis. If anything, the fact that cost-sharing is lower in the MHS should only elevate the role of information in encouraging greater guideline adherence. In this light, our finding of little to no improvements in high-value-care adherence in fully-informed patients is likely to generalize to settings with higher levels of cost-sharing.

The entire 49-page paper can be downloaded for free at the following link:
https://www.nber.org…

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Doctors aren’t much better at picking the best medical treatments than laypersons

By Michael Hiltzik
Los Angeles Times, July 8, 2019

In recent years, the idea has spread that forcing consumers to pay more for healthcare — giving them “skin in the game” is the usual mantra — will prompt them to become more discerning medical shoppers.

The goal is to improve the efficiency of the healthcare system by saddling consumers with higher costs if they opt for less useful or more overpriced services. Experts have identified numerous flaws with this concept, as we’ll get to in a bit.

But a new paper by Michael D. Frakes of Duke, Jonathan Gruber of MIT and Anupam Jena of Harvard raises an important and oft-overlooked point: Even if consumers have better information about the efficacy of particular treatments, will they be any good at using that information?

The answer is: probably not.

The authors tested the theory behind “consumer-driven healthcare” by examining the behavior of the best-informed consumers of all: doctors. (Their sample of physicians as patients came from the massive Military Health Service.) What they found was that doctors are better at picking high-value treatments and avoiding low-value care — but “not by much and not always.”

The message is that “purely relying on consumer cost-sharing and high deductibles won’t get us to the best outcome,” Gruber says.

The authors’ examples of low-value care included caesarean sections, which are judged by experts to be vastly overused; and pre-operative diagnostic tests for low-risk surgeries, such as chest X-rays prescribed for patients undergoing eye operations. The high-value examples included comprehensive diabetes care, statin use for patients with cardiac risk, and child vaccinations.

“There really should be 100% consumption of high-value and 0% of low-value care,” Gruber told me. “On those benchmarks, doctors don’t do a whole lot better than non-doctors.”

The finding is important because it suggests there’s a limit on how much more efficient the healthcare system can become by making consumers better informed. If doctors, the best-informed medical consumers, can’t consistently be steered to the most cost-effective treatments, then obviously average consumers will do much worse.

“If our approach is just to get more information to patients,” Frakes says, “that may not give us a great deal of return.”

This study isn’t the first to cast doubts on the theory that high deductibles and co-pays alone will lead consumers to make better and more cost-effective choices on healthcare. In 2015, a team from UC Berkeley and Harvard examined what happened when a large company shifted from an all-expenses-paid health plan to a high-deductible plan in a single year.

They found that total medical spending fell by as much as 13.8%, but that consumers cut spending on “potentially valuable care” such as preventive services as well as potentially wasteful care, such as X-rays and scans. They found “no evidence of consumers learning to price shop after two years in high-deductible coverage.” That confirmed a 1993 study by the Rand Corp. that also found that consumers reduced spending on good treatments and bad alike.

The latest study found that physician families did reduce their rate of C-sections, but only modestly and not enough to bring the rate into line with what medical experts say is proper. (Medical professionals say the rate, which is about 30%, should be only 10% to 15%.) Physician patients received unnecessary pre-surgical diagnostic tests nearly 20% of the time, less than non-physicians but still much too often.

That led the authors to conclude that “even the best informed patients do not make any less use of low-value health services.”

As for high-value care, physician patients failed to receive comprehensive diabetes care 30% of the time. There was virtually no difference between doctors and laypersons in receiving post-cardiac care, or in vaccinations for diphtheria/tetanus/pertussis and hepatitis. There were “small improvements” in compliance for child vaccinations for chicken pox, polio and measles/mumps/rubella.

The findings don’t show that there’s no place for deductibles and co-pays in the U.S. healthcare system. “There’s no step forward in healthcare that doesn’t have pros and cons,” Gruber says. “Absent any consumer cost-sharing, healthcare will be overused; the potential con is that people will forego both more valuable and less valuable care.”

That points to a more nuanced system of deductibles and charges, he says. Often this is termed “value-based healthcare,” in which flexible cost-sharing steers consumers to more effective care. That means lower co-pays for generic drugs, higher charges for unnecessary tests or higher-cost treatments not shown to have better results than lower-cost alternatives.

“The right answer for our system is not to tell patients they can’t have service X,” Gruber says, “but to say service X isn’t cost-effective — if you want it you have to pay for it. That’s controversial and hard, but the lesson from this paper is that we should bring expert analysis into cost sharing, rather than relying on consumers to figure it out.”

https://www.latimes.com…

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Comment:

By Don McCanne, M.D.

Please excuse the fact that today’s Quote of the Day selections are relatively long, but they are because it is imperative that we clearly understand the fundamental health policy implications that can be extrapolated from this NBER report.

For a few decades much attention has been directed to the concerns about the very high health care costs in the United States in a system that is delivering mediocrity. The debate has centered around whether public policies – the government – or consumer-directed health care – the market – can deliver greater value in health care – higher quality at lower costs.

This study is important because it places the provider of health care – the physician – in the role of the health care consumer – the patient. Nobel laureate Kenneth Arrow showed us long ago that information asymmetry – the fact that the health care provider has information that the health care consumer does not – is a major flaw in the theory that free markets are more effective in improving quality and reducing costs when it comes to health care. The fact is that free markets do not work effectively in health care.

Government regulation and public administration have been shown to be effective in improving value in health care, much to the chagrin of conservative/libertarian ideologues. To counter the perceived “government takeover” of health care there have been efforts to reinforce the effectiveness of markets, especially though consumer-directed health care policies that theoretically place the patient in charge.

One major effort has been to place more information in the hands of the patient to enable informed decisions to be made by the patient in the health care marketplace. This landmark NBER paper is important because it essentially eliminates information asymmetry as a significant factor by observing the behavior of the most informed of patients – physicians themselves – in the health care “marketplace.” They show that these highly informed health care shoppers – physicians – do not do much better than comparable uninformed laypersons. The minimal benefit, if any, is so small that we cannot rely on expanding available information for the patient-consumer to use the market more effectively to improve quality and reduce costs. This study shows that giving every single patient a medical school education would not have much of an impact.

Another effort to increase the effectiveness of health care shopping in the marketplace has been to increase price sensitivity of the patients. Supposedly, when all things are otherwise equal, the patient will go for lower prices. Here we run into real problems.

Health care has become too expensive. Patients need some form of health care coverage to prevent financial hardship. Insurance products have been designed to expose patients to costs through deductibles and other cost sharing. This really doesn’t have much impact on health care prices since the ultimate costs are not determined by the patient-consumer but rather by nontransparent business arrangements between the health care providers and the third party payers such as the private insurers. The patients may not even be aware of the actual prices unless they eventually see them in the insurers’ explanation of benefits.

So since the deductibles and other cost sharing arrangements do not have much influence actual prices, then what impact do they have? Deductibles do cause patients to forgo some recommended care. It is often glibly stated that, since both low-value care and high-value care are forgone because of cost sharing, it is a trade-off, as if that is perfectly acceptable. Well, it isn’t. Forgoing high-value care is always wrong and indicates that the health care financing system is not functioning properly. So what about low-value care? By definition, it is not care that is totally without value, so it is care that should be seriously considered in the management of the patient. It is only no-value care that should never be rendered. More about this in a moment.

The consumer-directed advocates have recommended health savings accounts to increase the shopping power of the patient-consumer. But they are a gimmick that unfairly provides regressive tax benefits to higher-income individuals. More important, families with inadequate disposable income cannot benefit from an empty health savings account. They are not a satisfactory solution to the financial barriers created by high deductibles.

There is considerable talk today about value-based health care. It is often suggested that the patient should pay more for low-value care, but less or nothing at all for high-value care. Obviously this is an attempt to counter the negative impact of high deductibles. So let’s look at this.

A high performance health care system should be designed to enable people to get the care they should have. Thus high-value care should have no financial barriers, thus no deductibles or other coast airing. Care that is of no value should never be offered and thus no payments should ever be made for it. Regarding the more difficult problem of low-value care, which may be entirely appropriate, some would suggest that patients should pay larger amounts out-of-pocket for lower-value care. But rather than the patients making those decisions based on the amount of out-of-pocket spending, the providers are in a better position to decide the value based on cost effectiveness. (Conservatives often say that cost effectiveness should never enter into the decision, but they are wrong. You cannot give the health care delivery system a blank check, where anything goes.) Regardless of high-value, low-value, or no-value, if pricing decisions were left to patients, they would price high-value and low-value care too low and no-value care too high. If pricing decisions were left to providers, everything would be (and already is) priced too high.

The beauty of a well designed single payer financing system is that it uses very effective tools to get pricing right (global budgets, negotiated rates, bulk purchasing, etc.). Today’s lesson is that if physicians are not much better health care shoppers than anyone else then it is time to dump the consumer-driven market ideology and move forward with a proven method of financing health care equitably so that we all receive the care we should have: single payer improved Medicare for all.

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