By Reed Abelson and Margot Sanger-Katz
The New York Times, March 23, 2019

At the heart of the “Medicare for all” proposals championed by Senator Bernie Sanders and many Democrats is a revolutionary idea: Abolish private health insurance.

Proponents want to sweep away our complex, confusing, profit-driven mess of a health care system and start fresh with a single government-run insurer that would cover everyone.

But doing away with an entire industry would also be profoundly disruptive. The private health insurance business employs at least a half a million people, covers about 250 million Americans, and generates roughly a trillion dollars in revenues. Its companies’ stocks are a staple of the mutual funds that make up millions of Americans’ retirement savings.

Such a change would shake the entire health care system, which makes up a fifth of the United States economy, as hospitals, doctors, nursing homes and pharmaceutical companies would have to adapt to a new set of rules. Most Americans would have a new insurer — the federal government — and many would find the health insurance stocks in their retirement portfolios much less valuable.

“We’re talking about changing flows of money on just a huge scale,” said Paul Starr, a sociology professor at Princeton University and author of “The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry.”

“There’s no precedent in American history that compares to this,” he said.

Most other countries with single-payer systems allow a more expansive, competing role for private coverage. In Britain, for example, everyone is covered by a public system, but people can pay extra for insurance that gives them access to private doctors. Most countries in Europe don’t have single-payer systems, but instead allow private insurance companies to compete under extremely tight regulations.

Legislators writing the bills acknowledge that people in the health insurance industry would lose their jobs. Proposals in the House and Senate would set aside large funds to help cushion the blow to displaced workers, offering them training, benefits, and income supports.

The health insurance industry is now composed of a mix of for-profit and nonprofit companies of various sizes. About 155 million Americans get private health coverage through an employer, but the reach of the industry extends into publicly funded insurance programs.

A third of Americans enrolled in Medicare, which insures older and disabled people, and four-fifths of those in Medicaid, which covers the poor and disabled, now get their benefits from a private insurer.

Many supporters of this approach see elimination of private insurance as a key feature, not a bug, meant to improve the program’s efficiency and equity by streamlining the health care system and weakening profit motives. With a single insurer covering every patient, hospitals and doctors could spend less time and money complying with differing policies, negotiating contracts, and filing forms to get paid.

“It’s worth it,” said Adam Gaffney, the president of Physicians for a National Health Program, which supports single-payer health care and helped design Ms. Jayapal’s bill. “Because we are not going to get to true universal health care without the greater efficiency of a single-payer system.”

The concept, in broad strokes, appeals to many Democratic voters. But overall support diminishes by a third or more when people are told that the plan would involve eliminating private insurance, raising taxes, or requiring waits to obtain medical care, according to surveys from the Kaiser Family Foundation.

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NYT Reader Comment:

By Don McCanne, M.D.

Before expressing concern about the loss of the private insurance industry, it is crucial to understand the single payer model of Medicare for All. It truly reduces administrative waste by hundreds of billions of dollars while using public policies to finally price our health care services appropriately. The funds recovered are more than enough to fill in the voids in coverage for the uninsured and underinsured. The Affordable Care Act with the public option Medicare buy-in models forgo that efficiency and still leave tens of millions uninsured or underinsured.

The insurance industry is very expensive, yet it interferes with care through restrictive provider networks, financial barriers to care, and prior authorization requirements, while providing no direct health care for the hundreds of billions of dollars it consumes. Reform models include job retraining and transitional compensation for displaced workers, so they can engage in more productive occupations of greater benefit to our economy.

In any other industry, accolades are awarded for disruption of a system with very high costs and poor value, when it is replaced by products and services of greater value. Our sympathy for the insurance industry will evaporate once we finally experience affordable health care for all.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

The promise of affordable care for everyone has helped to popularized the concept of single payer Medicare for All. However, those opposed either because of their conservative ideology or because of the disruptive impact this would have on the private insurance industry are now telling the public that this would take away the freedom to choose a private health plan, especially a plan offered through employment. The media has been particularly helpful to the insurance industry by making sure that people understand that Medicare for All threatens to take away their option to continue with the health plans they have.

What much of the public does not understand is that the single payer model of Medicare for All would recover close to half a trillion dollars of administrative waste – funds that when combined with the current spending level on actual health care would make it possible to pay for comprehensive health care for everyone. When they decide that they want to have the option of obtaining a health plan through work, they have a total disconnect with understanding the profound administrative waste that preserving such a health care financing system entails.

Keeping in place the private health plans forgoes this savings. The continued high costs would keep pressure on the payers to reduce spending which they do by erecting administrative and financial barriers to care (narrow provider networks, high deductibles, prior authorization requirements, etc.). Preventing people from getting the health care that they should have is the opposite of what a high performance health care system should be doing, and that is particularly shameful when we are paying the system so much more money for these intrusive measures that are superfluous to the provision of actual health care.

As I mentioned in my comment on the NYT website, “In any other industry, accolades are awarded for disruption of a system with very high costs and poor value, when it is replaced by products and services of greater value. Our sympathy for the insurance industry will evaporate once we finally experience affordable health care for all.”

Disruption is good if it’s beneficial disruption.

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By Hannah Fingerhut and Andrew Taylor
Associated Press, March 21, 2019

A growing majority of Americans want greater government spending on health care, and the increase is being driven by both Democrats and Republicans.

That’s according to new data from the General Social Survey, a widely respected trend survey that has been measuring views of government spending since the 1970s. An analysis by The AP-NORC Center for Public Affairs Research and General Social Survey staff reveals that Americans want to spend more money on a wide range of government functions.

The findings come as President Donald Trump’s latest budget plan proposes to cut many programs that are popular with the public, including alternative energy, the safety net for the poor, and health care.

Support for more government spending on health care has been on the rise since 2014. Seven in 10 consider the government’s spending on improving national health to be too low, up from 62 percent in 2016 and 56 percent in 2014. While Democrats are more likely than Republicans to say spending on health is too little, there has been a sharp increase across party lines. The poll finds 80 percent of Democrats say there is too little spending, up from 66 percent in 2014, and 59 percent of Republicans say the same, up from 42 percent four years ago.

https://apnews.com…

Since 1973, more than half of Americans have said that the United States is spending too little on health and improving and protecting the nation’s health. The percentage peaked in 2004, when 77 percent of Americans said we’re spending too little, and then steadily declined to 56 percent in 2014. Since 2014, the percentage of Americans who say we’re spending too little has been on the rise, climbing to 62 percent in 2016 and 70 percent in 2018.

http://www.apnorc.org…

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Comment:

By Don McCanne, M.D.

Seventy percent of Americans believe that the government should be spending more on health care. That includes 80 percent of Democrats and a majority of Republicans as well – 59 percent – and the numbers have been increasing recently.

That does not seem to be consistent with the stated views of the politicians who are telling us that people would prefer to keep their private employer-sponsored health plans, so we should not enact a single payer Medicare for All program. In contrast, other polls have also confirmed the popularity of single payer.

By asking questions about your taxes and about freedom to choose your health plans, pollsters can make it appear that the support for single payer is malleable. But this AP-NORC poll is quite straightforward; there is a bipartisan consensus that the people want a publicly-funded health system. You won’t get that through a health plan offered at your place of employment.

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By Patrick Svitek
The Texas Tribune, March 17, 2019

Beto O’Rourke has long advocated for “universal, guaranteed, high-quality health care for all.”

But O’Rourke has a less-than-straightforward history with Medicare for All, and he continued to keep it at arm’s length in Iowa, saying at one point that he is “no longer sure that that’s the fastest way” to achieve universal health care. Instead, he arrived in the Hawkeye State ready to talk about a different health care proposal: Medicare for America.

Introduced in December by U.S. Reps. Rosa DeLauro of Connecticut and Jan Schakowsky of Illinois, the legislation would set up a government-run health care program — like Medicare for All — but aims to let people keep their employer-sponsored insurance if they have it and like it.

“It responds to the fact that so many Americans have said, ‘I like my employer-based insurance. I want to keep it. I like the network I’m in. I like the doctor that I see,'” O’Rourke said.

https://www.texastribune.org…

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Comment:

By Don McCanne, M.D.

In my presentations in years past, I frequently asked audiences to think back to twenty years ago. Think about the insurance you had then. Now, how many here still have that same insurance? No hands go up. That is, except for people over 85 on Medicare, and except for a Kaiser Permanente physician who had worked for Kaiser for over twenty years.

The obvious point is that people do not have stable health care coverage throughout their lives. There are many reasons. To mention just a few: employment is not stable and individuals lose their coverage when they leave a job; moving to a new location usually results in loss of prior coverage, employers may change their employee benefits or change their insurers; frequent changes in insurer provider networks may cause individuals to lose their usual sources of care; low-income individuals may lose their Medicaid with a modest increase in income or a change in state eligibility policy; individuals with long term disabilities or end-stage renal disease may be shifted to Medicare; individuals on Medicaid have frequently been transferred into restrictive Medicaid managed care plans; states may have overly stringent eligibility requirements for Medicaid, such as the work requirements that are causing many to lose their coverage; patients in traditional Medicare may transfer to private Medicare Advantage plans with provider network restrictions; Medicare Advantage plans may withdraw from selected markets; unless grandfathered, as of 2020 individuals will no longer be able to enroll in more comprehensive Plan C and Plan F Medigap plans and may be subjected to underwriting requirements; plans in the individual market are quite unstable with frequent changes in benefits, in provider networks, and in the plans themselves since they are subject to cancellation; bankruptcies may impact retiree benefits including pension and health benefits; premiums may become truly unaffordable resulting in loss of coverage due to inability to pay; and, of course, at any given time tens of millions of people face being uninsured. There are endless other reasons for lack of continuity of coverage, but it is the norm.

And now many politicians besides Beto O’Rourke are telling us that we should not enact the single payer model of Medicare for All because it would not allow people to keep the insurance they have. Memory must be very short. Not too long ago President Obama received the Politifact Lie of the Year award for saying, “If you like your health care plan, you can keep it.”

So then they say, well, you can have your choice of plans. What choices? The most common coverage is through employer-sponsored plans, but you do not have the option of choosing one of the millions of plans offered by other employers, only that from your own employer, if one is even offered. You cannot choose Medicare or Medicaid plans if you have not met the eligibility requirement. Your only option may be to choose a plan in the individual market, but you may find that you have a very limited choice of highly restrictive plans that may not cover your physician or hospital. Some choice.

Besides, the choice you want is that of your health care professionals and hospitals, not a choice of your supposedly beloved health plans, even if mediocre. Under Single Payer Medicare for All you do have total free choice in your health care, choices that are being taken away by the private health insurers.

When you are told that you get to keep your health plan, you don’t have to respond by calling the person a liar (as was disrespectfully done with our president at the time). “Fallacy” is a less pejorative term than “lie” so you can emphatically respond with, “THAT IS A FALLACY; NOBODY GETS TO KEEP THEIR SAME INSURANCE THROUGHOUT LIFE; INSURANCE CHANGES ALL OF THE TIME!”

If you have the opening, you can go on with, “WHAT I WANT IS MY CHOICES IN HEALTH CARE. THE INSURERS ARE TAKING THAT AWAY FROM US WHILE WASTING OUR MONEY ON ADMINISTRATIVE EXCESSES.”

Anyway, we need to bring to an abrupt end the fallacy that you can keep the insurance you have, especially when it is being used to dismiss the great opportunity we have to bring health care to everyone in America by enacting and implementing SINGLE PAYER MEDICARE FOR ALL!

This is a time for PASSION. We have to get this message out there.

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By Jennifer Wagner
Center on Budget and Policy Priorities, March 19, 2019

A large majority of the more than 18,000 Arkansas Medicaid beneficiaries who lost their Medicaid coverage since the state began implementing a first-in-the-nation Medicaid work requirement in June not only haven’t found jobs, but they also probably don’t have health insurance, new state data suggest.

Those who lost their Medicaid last year could have re-enrolled effective January 1, but only about 2,000 have done so. Some federal and state officials have argued that such low re-enrollment means that most who lost Medicaid have found jobs with health coverage, but there are no data to support the claim.

Asked what happened to the 18,000 Arkansans who lost coverage due to the work requirement, Health and Human Services (HHS) Secretary Alex Azar told a House hearing last Tuesday that “we do not yet have data as to why they fell off the program.” At the Senate Finance Committee two days later, Azar pointed to the low share of people who lost coverage last year and re-enrolled in January and said, “That seems a fairly strong indication that the individuals who left the program were doing so because they got a job.”

But state data released on Friday show that very few beneficiaries who lost coverage found jobs. Of the 18,164 beneficiaries who lost coverage in 2018 for not complying with the work requirement, 1,981 had matches in the state’s New Hire Database, indicating they found new work. That means that for the more than 16,000 others who lost coverage, there is no evidence that they found new work.

https://www.cbpp.org…

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Ruling on Medicaid work requirement expected by end of March, judge says

By Benjamin Hardy
Arkansas Times, March 14, 2019

(U.S. District Judge James E. Boasberg) in the District of Columbia heard oral arguments Thursday morning in a lawsuit challenging Arkansas’s work requirement for certain Medicaid expansion beneficiaries.

“Congress has made its intent clear — Medicaid is a medical assistance program, not a work program,” the plaintiffs argued in a brief submitted in November. The purpose of the Medicaid program is “to furnish health care coverage to people who cannot otherwise afford it,” it says.

“It’s easy to talk about [the work requirement] in broad strokes that this will improve people’s lives, and that’s not for me to say. But that’s not the purpose of Medicaid,” the judge said in reply to government attorneys at one point during Thursday’s hearing.

https://www.arktimes.com…

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Comment:

By Don McCanne, M.D.

What kind of policy is it that when low-income individuals are unable to find jobs, the state punishes them by taking away their health care? The judge hearing the Medicaid work requirement case in Arkansas agrees, “that’s not the purpose of Medicaid”

Shouldn’t we instead have a public policy that says that anyone who needs health care should be able to receive it? That is not the case now, even though we are already spending enough to guarantee health care for everyone. We could do that merely by enacting and implementing a single payer Medicare for All program, and it doesn’t have to cost us any more than we are already spending.

It would be great if our government also supported more effective policies to ensure that every capable person has employment opportunities, but depriving people of their health care is not an effective work program, as Arkansas has demonstrated.

How can it be that we even tolerate such a cruel government policy?

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By Keoni Everington
Taiwan News, March 18, 2019

The popular antidepressant Prozac is to be permanently removed from pharmacy shelves this April in Taiwan, announced the drug’s Taiwanese manufacturer Zuellig Pharma (裕利藥廠) last week, reported CNA.

Claiming to be unable to cope with frequent price cuts by Taiwan’s National Health Insurance (NHI), the local Taiwanese maker of the Prozac 20 mg, Zuellig Pharma, announced last week that it will stop selling the antidepressant in Taiwan on April 1. The company said that it will completely withdraw the drug from the Taiwan market, but all orders received before March 29 will still be fully supplied.

On March 13, the company sent a letter to all hospitals announcing that due to the annual reduction of drug prices by the National Health Insurance Administration, along with an increase in raw material and transportation costs in recent years, it will be ceasing the supply of Prozac. The company also mentioned the rising costs of following the Pharmaceutical Inspection Co-operation Scheme (PICS) and Good Manufacturing Processes (GMP) to ensure the quality of the medication.

Zuellig Pharma said that after taking the above-mentioned factors into an actuarial analysis, it was notified by Eli Lily Taiwan, the owner of Prozac, to cease production on April 1 and withdraw the product from the Taiwan market. In order to ensure the rights of hospitals and patients, the company said that orders received before March 29 will be fully supplied.

In an interview with CNA, Chang Wen-ching 張文靜, spokesman for the Taiwan Pharmacist Association, said Prozac is a commonly used drug in treating depression. Chang said that it is a widely used first-line drug because of its long history of use and relatively fewer side effects.

For these reasons, its usage rate is very high, and in recent years, the cost of this drug under NHI coverage per tablet has dropped from NT$2.08 (US$0.067) to NT$1.96 (US$0.063).

Substitutes for Prozac:

Chang said there are substitute generic drugs available and there are also some other famous brand names with the same chemical composition in Taiwan. Chang recommends that patients return to their hospital and have their prescriptions adjusted with the help of professional physicians.

The active ingredient in Prozac is Fluoxetine, which is also sold under other brand names, such as Sarafem and Selfemra.

https://www.taiwannews.com…

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Drugs.com, Accessed March 19, 2019

U.S. price of 20mg Prozac:
from $US503.98 for 30 capsules = $US16.80 per capsule

U.S. price of 20 mg fluoxetine (generic Prozac):
from $US15.52 for 30 capsules = $US0.52 per capsule

https://www.drugs.com…

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Comment:

By Don McCanne, M.D.

Virtually everyone is in agreement that something must be done about the outrageous drug prices in the United States, though there is disagreement on how we do that. Some suggest that we should allow the free market to work to drive prices down (as if we were not already attempting to do that, unsuccessfully), while others suggest that the government should play a major role in establishing fair prices for pharmaceuticals. Since there is considerable interest in establishing fair prices through enactment of a single payer Medicare for All program, it can be instructive to look at how Taiwan establishes fair prices through their single payer health care financing system.

Because of our complex, dysfunctional health care financing system, it is difficult to determine drug prices here. Is it a brand name or a generic drug? Has the patent expired? Is it under a drug insurance plan? Is it under Medicare Part D? Is a discount coupon involved? Is it under a patient assistance program? And, perhaps most confusing of all, does it travel through the catacombs of a pharmacy benefit manager? Just for a rough idea of prices in the U.S., we’ll use those for Prozac and its generic version, fluoxetine, that are listed on the Drugs.com website.

In the United States, a 20mg capsule of Prozac sells for about $16.80. The generic version sells for about $0.52 per capsule. The discussion continues as to how much of a markup brand name drugs should have compared to the generic versions, but we likely won’t seriously address that until we are ready to switch to a publicly-administered and publicly-financed program (single payer).

Compare the price in Taiwan. The brand version of 20mg Prozac is only about six cents a capsule, and competing brand and generic versions are available. How tightly prices are controlled there is demonstrated by the fact that the government reduced the price by only four-tenths of a cent, but that proved too much for Eli Lily Taiwan, so they are pulling the product from the market. Two other brand versions and other generics are still available.

Having that kind of control over drug prices is only in our fantasies, but it doesn’t have to be. The public stewards of our single payer system, were we to establish a bona fide Medicare for All program, could work with the pharmaceutical firms (negotiating, bidding, or setting administered prices if necessary, etc.) to be sure that their legitimate costs are covered along with a fair profit margin. Is there risk of driving pharmaceutical firms out of the market? Although we don’t know the full background story in Taiwan, it is not likely that we would shut them out over four-tenths of one cent.

It is unlikely that HHS Secretary Alex Azar – former president of the U.S. division of Eli Lilly – is going to help us get there. But if the people understand that we can fix this problem, it wouldn’t matter much what he thinks since elections can have favorable consequences. But we do have to step up our education efforts directed to the public. After all, it is for their benefit. Besides, under Single Payer Medicare for All, Prozac would be freely available for Alex Azar and his colleagues in case they and their health care professionals think they need it.

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

The U.S. government claimed that turning American medical charts into electronic records would make health care better, safer, and cheaper. Ten years and $36 billion later, the system is an unholy mess. Inside a digital revolution that took a bad turn.

By Fred Schulte and Erika Fry
Kaiser Health News, March 18, 2019

In early 2017, Seema Verma, then the country’s newly appointed CMS administrator, went on a listening tour. She visited doctors around the country, at big urban practices and tiny rural clinics, and from those front-line physicians she consistently heard one thing: They hated their electronic health records. “Physician burnout is real,” she told KHN and Fortune. The doctors spoke of the difficulty in getting information from other systems and providers, and they complained about the government’s reporting requirements, which they perceived as burdensome and not meaningful.

What she heard then became suddenly personal one summer day in 2017, when her husband, himself a physician, collapsed in the airport on his way home to Indianapolis after a family vacation. For a frantic few hours, the CMS administrator fielded phone calls from first responders and physicians — Did she know his medical history? Did she have information that could save his life? — and made calls to his doctors in Indiana, scrambling to piece together his record, which should have been there in one piece. Her husband survived the episode, but it laid bare the dysfunction and danger inherent in the existing health information ecosystem.

The notion that one EHR should talk to another was a key part of the original vision for the HITECH Act, with the government calling for systems to be eventually interoperable.

What the framers of that vision didn’t count on were the business incentives working against it. A free exchange of information means that patients can be treated anywhere. And though they may not admit it, many health providers are loath to lose their patients to a competing doctor’s office or hospital. There’s a term for that lost revenue: “leakage.” And keeping a tight hold on patients’ medical records is one way to prevent it.

In the absence of true incentives for systems to communicate, the industry limped along; some providers wired up directly to other select providers or through regional exchanges, but the efforts were spotty. A Cerner-backed interoperability network called CommonWell formed in 2013, but some companies, including dominant Epic, didn’t join. (“Initially, Epic was neither invited nor allowed to join,” said Sumit Rana, senior vice president of R&D at Epic. Jitin Asnaani, executive director of CommonWell countered, “We made repeated invitations to every major EHR … and numerous public and private invitations to Epic.”)

Epic then supported a separate effort to do much the same.

Last spring, Verma attempted to kick-start the sharing effort and later pledged a war on “information blocking,” threatening penalties for bad actors. She has promised to reduce the documentation burden on physicians and end the gag clauses that protect the EHR industry. Regarding the first effort at least, “there was consensus that this needed to happen and that it would take the government to push this forward,” she said. In one sign of progress last summer, the dueling sharing initiatives of Epic and Cerner, the two largest players in the industry, began to share with each other — though the effort is fledgling.

When it comes to patients, though, the real sharing too often stops. Despite federal requirements that providers give patients their medical records in a timely fashion, in their chosen format and at low cost (the government recommends a flat fee of $6.50 or less), patients struggle mightily to get them. A 2017 study by researchers at Yale found that of America’s 83 top-rated hospitals, only 53 percent offer forms that provide patients with the option to receive their entire medical record. Fewer than half would share records via email. One hospital charged more than $500 to release them.

Nor, it seems, can high-ranking federal officials. When Seema Verma’s husband was discharged from the hospital after his summer health scare, he was handed a few papers and a CD-ROM containing some medical images — but missing key tests and monitoring data. Said Verma, “We left that hospital and we still don’t have his information today.” That was nearly two years ago.

https://khn.org…

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The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care

By David J. Brailer, MD, PhD, National Coordinator for Health Information Technology
PNHP Quote of the Day (excerpts), July 21, 2004

While the federal government plays an important role in HIT adoption, the effective use of, and value creation from, this technology lies predominantly with the private sector. The federal government will provide a vision and a strategic direction for a national interoperable health care system, but will rely on a competitive technology industry, privately operated support services, and shared investments in HIT adoption. The private sector must develop the market institutions to deliver the products and services that can transform the paper-based health care system into an electronic, consumer-centered, and quality-based system. The private sector can best ensure that HIT products are successfully implemented in ways that meet the varying needs of American health care across settings, cultures, and geographies. The private sector can also continue constant innovation in HIT and ensure that products are delivered on an affordable basis.

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Comment:

By Don McCanne, M.D.
Posted July 21, 2004

What has the magic of the competitive marketplace produced in the way of an integrated IT system to this date? High costs, very poor penetration, and system failures! Competitive market theory dictates that we should be leading the world with a high quality health care IT system at a low cost. What went wrong?

First of all, a fragmented system of multiple private plans, public programs and uninsurance does not provide an infrastructure that is very conducive to an integrated IT system. A single payer system, or, at minimum, a highly regulated system of universal coverage through multiple plans, would provide a framework that would ensure adaptability of an integrated IT system. Of course, a single, publicly administered system would be much preferred for an integrated IT system.

But the greatest difficulty with private IT solutions lies in the very nature of these marketplace models. Their goals are, above all, to maximize profits and to maximize the market price of their shares.

What might the private sector do that doesn’t serve our interests well? They will produce products that command the highest prices that the market will bear. They will design the products to provide a continuing revenue stream. Once gaining a significant share of the market, they will design incompatibility with other systems in an attempt to garner the entire market. They will design obsolescence into their systems to ensure future markets for their new innovative products. They will partner with and perhaps acquire other related entities that can expand profit potentials through greater control of components of the health care system which their products can influence. Although these are good business practices, they are terrible policies for our health care system.

The health information technology report released today (July 21, 2004) should alarm us all. Although we all agree on the importance of an integrated IT system, the Bush administration is limiting the role of the government to being an enabler that encourages the private sector to develop a successful business model. Rather than higher quality at a lower cost, we’ll end up with mediocrity at a much higher cost, wasting even more of our health care dollars.

https://www.pnhp.org…

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Comment:

By Don McCanne, M.D.
Posted March 18, 2019

Fifteen years ago, and several times since, we’ve had quite a bit to say about the direction the nation was taking with electronic health records. The narrative in the comprehensive article today by Fred Schulte and Erika Fry comes as no surprise to us. The results of insisting that the project remain in the hands of competitors in the private marketplace, with a hands-off approach by our government stewards, has been a disaster.

It is ironic that CMS Administrator Seema Verma – an outspoken proponent of privatizing all things medical – two years after her husband’s emergency hospitalization, has been unable to obtain his electronic medical records. So much for the efficiency of the private sector.

Yet, Judith Faulkner, CEO and Founder of Epic Systems – the nation’s leading medical-record software provider – as of 3/18/19, ranks #597 on the Forbes list with a net worth of $3.8 billion.

Our health information technology system represents just a microcosm of our $3.8 trillion national health expenditures in a system that leads all nations in high costs while shamefully underperforming on universality, equity, efficiency, and affordable access. We know how to correct the deficiencies – simply enact and implement a well designed, publicly-administered and publicly-financed, single payer Medicare for All program. Yet the majority of our politicians, but by no means all, are rejecting Medicare for All as they insist on protecting and perpetuating our highly dysfunctional, multi-payer health care financing system.

The results of the refusal of our public stewards to be more involved in guiding our health information technology system surely must provide us with a lesson. Public systems in health care are designed as patient service models, whereas private systems are designed as business models. One directs the flow of money to enhance the care of patients, and the other directs that flow to enhance the financial success of the business entity. One has the objective of good health, and the other the objective of wealth enhancement. If that is difficult for Seema Verma to understand, maybe Judith Faulkner can explain it to her.

On a positive note, it should be mentioned that Judith Faulkner has signed The Giving Pledge, committing 99% of her assets to philanthropy. Business success in trying to deliver a public good does not necessarily equate with greed.

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

By Merrill Goozner
Modern Healthcare, March 16, 2018

Healthcare providers and insurers are gearing up to oppose Medicare for All. No surprise there. Insurers can’t look kindly on legislation that would put them out of business. And providers are deathly afraid of losing the high rates from private insurers that cross-subsidize government-funded patients.

But at the same time as they mobilize to defeat M4A, shouldn’t they be outlining what they support?

Here’s what M4A advocates want to achieve. The first is universal coverage. Sadly, we’re again moving away from this basic human right due to actions by the Trump administration to undermine the Affordable Care Act. They want lower prices. Insurance premiums for employers and out-of-pocket expenses for individuals and families continue to rise faster than wages or economic growth.

Finally, they want an end to the frustration engendered by a system that erects roadblocks between physicians and patients. These range from insurer rules requiring prior authorization to seemingly arbitrary limits on what doctors can perform or prescribe.

Is M4A the only way to solve these problems? Of course not. When it comes to covering the uninsured, the ACA worked just fine. Massachusetts, the first state to implement an ACA-like program, had an uninsured rate of 2.5% in 2017. That’s not the 0% of most Organisation for Economic Co-operation and Development countries, but pretty close.

Politics are at the root of the ACA’s failures—not its Rube Goldberg design. The Supreme Court allowed states to opt out of the Medicaid expansion. And when the GOP-controlled Congress eliminated the individual mandate, key to making rates on the exchanges affordable, it reduced sign-ups, raised premiums and stopped the expansion dead in its tracks.

How about service prices? M4A would set prices at Medicare rates, which are well below private insurance rates but higher than Medicaid rates (both Medicaid and the Children’s Health Insurance Program are eliminated in Sen. Bernie Sanders’ M4A bill). But that’s not where most of its savings come from.

According to a sympathetic analysis from the University of Massachusetts at Amherst, half of M4A’s savings come from reducing provider and insurer administrative overhead. Another quarter comes from lower drug prices.

But these are one-time savings that will do little to stop the upward spiral of hospital and physician costs, which account for two-thirds of all spending. That’s where we get to the third issue supposedly addressed by M4A: the administrative hassles and limits imposed on obtaining care.

These aren’t eliminated by an expanded public system. They simply transfer the policing of waste, fraud and abuse from private hands to public hands and change the motivation from padding profits to protecting taxpayers. In the past, Medicare has done a better job than private payers for one simple reason: it can impose price controls. Providers have responded by shifting much of the shortfall to their private-paying patients.

There are alternatives for achieving M4A’s goals. They include private companies offering exchange policies with well-defined coverage rules and strict limits on out-of-pocket costs; all-payer rate-setting or global budgets to slow the rate of price increases; merging Medicaid with Medicare (leaving long-term services and supports to the states), which would give private employers and families rate and tax relief; and establishing all-stakeholder oversight councils to develop medically appropriate utilization rules.

There’s more. The point is that in the post-Trump era, the U.S. will once again begin moving toward a healthcare system that is universal and affordable with high-quality care for everyone.

A multipayer approach could be like Germany and Switzerland, which rely on private insurers that are regulated to a much greater extent than currently exists in the U.S. Or it will be a single-payer system like Canada, Great Britain or France. Each delivers better results at a lower cost than the U.S.

I’m agnostic on which way to go. I’m still waiting for providers and insurers to articulate their vision.

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Comment posted at Modern Healthcare:

By Don McCanne, M.D.

Put all the facts on the table and there should be no room left for agnosticism. A well designed, single payer, improved Medicare for all system does the following:

• It is truly universal in that everyone is included automatically, for life.
• It dramatically reduces profound administrative waste, recovering enough funds to pay for care for the currently uninsured and underinsured.
• It addresses the problem of excessive prices by using publicly administered global budgeting and price negotiation, covering legitimate costs while eliminating gouging.
• It improves equitable allocation of our health care resources through central planning and separate budgeting of capital improvements. Everyone would have reasonable access to care.
• It makes the financing of health care equitable by replacing premiums and cost sharing with progressive taxes based on ability to pay. The financing of the universal health care risk pool is totally separated from the delivery of health care such that nobody is ever denied care because of the inability to pay for it.
• Publicly administered programs are much more effective in reducing the trajectory of health care costs to sustainable levels (compare Canada’s spending curve to ours), ensuring that, well into the future, health care will be affordable for each of us and for society as a whole.
• Our current system has twice the average per capita costs of other wealthy nations while we fall short on universality, effectiveness, equity, resource allocation, access, and quality. The Affordable Care Act left this extremely inefficient system in place, so building on it or compounding its complexity with the addition of a public option (expanding Medicare to the few who can afford it) cannot begin to correct the profound, expensive dysfunctions in our system.

Do we want a public service model designed to take care of patients, or shall we continue with a private business model designed to enrich the vested interests? There should be no question that it is time to end equivocation and get on with enacting and implementing a model that actually would work: Single Payer Medicare for All.

https://www.modernhealthcare.com…

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Comment:

By Don McCanne, M.D.

With the surge in popularity of the single payer Medicare for All model of reform, there understandably has been a groundswell of opposition by stakeholders who stand to lose and by ideologues on the right. The media is busy providing what they profess to be balanced reporting on this activity. Unfortunately, they seem to have bought the concept that Medicare for All is only an “aspiration” that can be dismissed because it doesn’t mesh with the machinations of the political system in this country. Thus they concentrate on the status of the Affordable Care Act and the supposedly politically feasible public option in the form of Medicare for the few who can afford to purchase it, as if this represents the only realistic pathway to reform.

I have followed Merrill Goozner’s journalistic efforts for quite a few years and know him to be a person of integrity. I understand why he mentions systems in other nations that work better than ours that are not single payer systems, thus concluding that Medicare for all is not the only way to go. I have to admit that I do get a little edgy when he says that he remains agnostic as to whether we should use a multi-payer system or a single payer system because he is “still waiting for providers and insurers to articulate their vision.”

Well, the realistic vision of health care nirvana has already been articulated in the single payer, improved Medicare for all model advanced by Physicians for a National Health Program and other organizations. Just a few features that make this model an imperative are listed in the response to Goozner’s editorial above. There should be no room left for agnosticism. The vision of single payer Medicare for All is based on solid health policy science.

It’s time to move forward with fine tuning the Jayapal Medicare for All bill in the House and the Sanders Medicare for All bill in the Senate. As the politics realign, we should be able to complete the legislative process by early 2021, and finally have heath care for all, effective January 1, 2022. Or maybe we should aim for July 1, 2021.

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