PNHP

Ed Weisbart gets real on the ‘public option’

Ed Weisbart gets real on the ‘public option’

Think twice when you hear the words 'public option' health insurance

By Ed Weisbart, M.D.
St. Louis Post-Dispatch, July 4, 2019

Shhh! Don’t tell the insurance companies (it’s a secret).

That’s the logic of the presidential candidates who are pushing a “public option,” also known as Medicare for Those Who Want It. They claim that adding a Medicare-like option onto the health insurance marketplace is an easier political lift than real Medicare for All, and that such an option would thrive in the free market and open the door for Medicare for All. Then the insurance industry would admit defeat and quietly ride off into the sunset, finally achieving what should have been done in the first place.

The fact that the insurance industry is lobbying hard for this circuitous incremental approach should tell you all you need to know.

Sadly, many of us don’t understand the choice we’re being offered. That helps them sell the idea that having more options is always better. It’s true that we need free choice of doctors and hospitals, but insurance should disappear into the background. That’s what would happen with Medicare for All; that’s not what would happen with a public option, and the difference is all-important.

We could spend the next few years passing a public option and then wait several more years to see how it works. Ten years later, we would still be playing catch-up with the rest of the industrialized world, where health care costs half of what it does here in America and yet produces dramatically better results.

Why isn’t a public option good enough?

First, it’s missing nearly all the savings of a single-payer system. Health care insurance companies operate at 15% to 20% overhead; Medicare’s overhead is 2%. We will never reach Medicare’s efficiency by keeping today’s complex insurance industry in the mix. Never. Plus, the insurance companies’ inefficiency — as high as it is — is dwarfed by the untold time and money patients, doctors and hospitals waste in dealing with those companies.

American hospitals employ one insurance-related clerk for every bed they operate. We physicians often spend half of our workday fighting insurance company barriers. We’re heartsick over seeing patients skip dosages or decline essential testing because they can’t afford them.

None of this waste disappears by adding one more insurance “option.” A public option would do nearly nothing to bring down the cost of health care.

Second, a public option would be funded by premiums and co-pays. It would essentially be another regressive tax, least affordable to those in the greatest need. Only the sickest of today’s uninsured would join, driving public-option prices up higher and becoming a “high-risk pool.” Insurance depends on a mostly healthy pool of patients to balance the sickest. Whenever you turn that on its head, it goes down in flames.

Last, a “public option” does nothing to help those who now have insurance. Millions would still have sky-high deductibles. They would still be constrained by networks that tell them which doctors and hospitals to use. They would still be forced to be on constant guard for surprise medical bills and charges, even when they go to in-network hospitals. Millions still would not have access to dentistry, eyeglasses and hearing aids.

Each of these problems would be resolved by simply passing the real Medicare for All bills, H.R. 1384 and Senate Bill 1129, featuring tax-funded comprehensive benefits with no premiums, no copays, no surprise bills and your choice of doctors and hospitals.

Both bills empower Medicare to negotiate drug prices for us. Most of the public-option bills do not.

Both Medicare for All bills would stabilize hospital finances by making sure every patient had insurance and reducing administrative burdens.

Both bills allow every American their choice of physician and hospital, without fearing that a change of jobs would mean changing insurance and searching for a new doctor.

Some worry that the adversaries of Medicare for All are too powerful. In other words, they want us to believe we can sneak our way there through a public option, as if the insurance industry will never see it coming.

The next time you hear a politician say they support Medicare for All, and that the best way to get there is through a public option, raise some of these challenges. Don’t let them derail the best solution; too many lives are at stake.

Dr. Ed Weisbart is a family physician and chair of the Missouri chapter of Physicians for a National Health Program.

https://www.stltoday.com…

Comment:

By Don McCanne, M.D.

Do those supporting the diversion of plans to enact a single payer model of Medicare for All to enacting instead a “public option” – a Medicare for some – understand the terrible consequences of perpetuating our current inequitable, dysfunctional system that Ed Weisbart explains so well in this op-ed? Or do they just not care? Ask them. We need to know whether or not they really do believe in health care justice for all.

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

We’re All in This Together: Learning about Health Care Reform

Interview with 2019 Summer Interns

July 8, 2019

Dr. Betty Keller interviews 2019 PNHP-VT summer interns Gregor Dierks, Saswat Das, Shavonne Temple, and Benjamin McMahon on ORCA Media (public access TV). The group discusses the details of improved Medicare for All, and all four students have expressed enthusiasm about working towards single-payer reform in their schools and in their communities.

https://www.orcamedia.net…

‘Public charge’ immigration rules: Sorting values

Implications of Changing Public Charge Immigration Rules for Children Who Need Medical Care

By Leah Zallman, M.D., M.P.H.; Karen E. Finnegan, Ph.D.; David U. Himmelstein, M.D.; Sharon Touw, M.P.H.; Steffie Woolhandler, M.D., M.P.H.
JAMA Pediatrics, July 1, 2019

Abstract

Importance: In October 2018, the Trump administration published a proposed rule change that would increase the chance of an immigrant being deemed a “public charge” and thereby denied legal permanent residency or entry to the United States. The proposed changes are expected to cause many immigrant parents to disenroll their families from safety-net programs, in large part because of fear and confusion about the rule, even among families to whom the rule does not technically apply.

Objective: To simulate the potential harms of the rule change by estimating the number, medical conditions, and care needs of children who are at risk of losing their current benefits, including Medicaid and Children’s Health Insurance Program (CHIP) and Supplemental Nutrition Assistance Program (SNAP).

Design, Setting, and Participants: A cross-sectional study used nationally representative data from 4007 children 17 years of age or younger who participated in the 2015 Medical Expenditure Panel Survey to assess their potential risk of losing benefits because they live with a noncitizen adult. Statistical analysis was conducted from January 3 to April 8, 2019.

Main Outcomes and Measures: The number of children at risk of losing benefits; the number of children with medical need, defined as having a potentially serious medical diagnosis; being disabled (or functionally limited); or having received any specific treatment in the past year. The numbers of children who would be disenrolled under likely disenrollment scenarios drawn from research on immigrants before and after the 1996 welfare reform were estimated.

Results: A total of 8.3 million children who are currently enrolled in Medicaid and CHIP or receiving SNAP benefits are potentially at risk of disenrollment, of whom 5.5 million have specific medical needs, including 615 842 children with asthma, 53 728 children with epilepsy, 3658 children with cancer, and 583 700 children with disabilities or functional limitations. Nonetheless, among the population potentially at risk of disenrollment, medical need was less common than among other children receiving Medicaid and CHIP or SNAP (64.5%; 95% CI, 61.5%-67.4%; vs 76.0%; 95% CI, 73.9%-78.4%; P < .001). The proposed rule is likely to cause parents to disenroll between 0.8 million and 1.9 million children with specific medical needs from health and nutrition benefits.

Conclusions and Relevance: The proposed public charge rule would likely cause millions of children to lose health and nutrition benefits, including many with specific medical needs that, if left untreated, may contribute to child deaths and future disability.

Conclusions

Most children who lose Medicaid and CHIP become uninsured. Without coverage, they are likely to forego or delay needed care, and some, such as children with epilepsy or asthma, as well as newborns who require immunizations, are likely to incur higher long-term health care costs. In addition, undertreatment of illness increases school absenteeism and parental work absence, which, in the case of asthma, led to a loss of parental productivity of $719.1 million in 1996 alone.

However, our main concerns are not economic but ethical. We believe that denial of needed health care and nutrition to anyone, but particularly to children, violates human rights. We call on the medical community to speak out against this unjust and unethical proposal to change the public charge rule.

https://jamanetwork.com…

Comment:

By Don McCanne, M.D.

As we struggle to teach the policymakers, the politicians, and our nation at large about the unequivocal practical and fiscal advantages of the single payer model of Medicare for All, we seem to assume that everyone would understand and support the ethics and moral imperative of this model. Sadly, the politicians currently in control apparently do not share this view of health care ethics as they intend to modify the “public charge” rule in a manner that would result in the disenrollment of millions of resident children from the Medicaid and CHIP programs, which will surely expose many of them to adverse health consequences.

Some would frame this as an immigration issue rather than a health care issue. There is no question but that we should have rational and humane immigration policies in place, but when our immigration policies create health problems, then we need to modify the policies. Health should never be a bargaining chip as we address other socioeconomic and political problems.

How often have you heard “zero tolerance” during discussions of immigration? Yet why do we not hear “zero tolerance” during discussions of reform models of health care financing? Except for the single payer model of Medicare for All, all other models would leave tens of millions without adequate coverage, access or affordability.

We need to sort out our values. Instead of using “public charge” as a hammer to deprive people of health care, we need to first make sure that everyone does have essential health care without having to suffer financial hardship. After we declare that as an inviolate right, we can work on our other issues, but we should never, ever consider trading away health care.

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

Think twice when you hear the words ‘public option’ health insurance

By Ed Weisbart, M.D.
St. Louis Post Dispatch, July 5, 2019

Shhh! Don’t tell the insurance companies (it’s a secret).

That’s the logic of the presidential candidates who are pushing a “public option,” also known as Medicare for Those Who Want It. They claim that adding a Medicare-like option onto the health insurance marketplace is an easier political lift than real Medicare for All, and that such an option would thrive in the free market and open the door for Medicare for All. Then the insurance industry would admit defeat and quietly ride off into the sunset, finally achieving what should have been done in the first place.

The fact that the insurance industry is lobbying hard for this circuitous incremental approach should tell you all you need to know.

Sadly, many of us don’t understand the choice we’re being offered. That helps them sell the idea that having more options is always better. It’s true that we need free choice of doctors and hospitals, but insurance should disappear into the background. That’s what would happen with Medicare for All; that’s not what would happen with a public option, and the difference is all-important.

We could spend the next few years passing a public option and then wait several more years to see how it works. Ten years later, we would still be playing catch-up with the rest of the industrialized world, where health care costs half of what it does here in America and yet produces dramatically better results.

Why isn’t a public option good enough?

First, it’s missing nearly all the savings of a single-payer system. Health care insurance companies operate at 15% to 20% overhead; Medicare’s overhead is 2%. We will never reach Medicare’s efficiency by keeping today’s complex insurance industry in the mix. Never. Plus, the insurance companies’ inefficiency — as high as it is — is dwarfed by the untold time and money patients, doctors and hospitals waste in dealing with those companies.

American hospitals employ one insurance-related clerk for every bed they operate. We physicians often spend half of our workday fighting insurance company barriers. We’re heartsick over seeing patients skip dosages or decline essential testing because they can’t afford them.

None of this waste disappears by adding one more insurance “option.” A public option would do nearly nothing to bring down the cost of health care.

Second, a public option would be funded by premiums and co-pays. It would essentially be another regressive tax, least affordable to those in the greatest need. Only the sickest of today’s uninsured would join, driving public-option prices up higher and becoming a “high-risk pool.” Insurance depends on a mostly healthy pool of patients to balance the sickest. Whenever you turn that on its head, it goes down in flames.

Last, a “public option” does nothing to help those who now have insurance. Millions would still have sky-high deductibles. They would still be constrained by networks that tell them which doctors and hospitals to use. They would still be forced to be on constant guard for surprise medical bills and charges, even when they go to in-network hospitals. Millions still would not have access to dentistry, eyeglasses and hearing aids.

Each of these problems would be resolved by simply passing the real Medicare for All bills, H.R. 1384 and Senate Bill 1129, featuring tax-funded comprehensive benefits with no premiums, no copays, no surprise bills and your choice of doctors and hospitals.

Both bills empower Medicare to negotiate drug prices for us. Most of the public-option bills do not.

Both Medicare for All bills would stabilize hospital finances by making sure every patient had insurance and reducing administrative burdens.

Both bills allow every American their choice of physician and hospital, without fearing that a change of jobs would mean changing insurance and searching for a new doctor.

Some worry that the adversaries of Medicare for All are too powerful. In other words, they want us to believe we can sneak our way there through a public option, as if the insurance industry will never see it coming.

The next time you hear a politician say they support Medicare for All, and that the best way to get there is through a public option, raise some of these challenges. Don’t let them derail the best solution; too many lives are at stake.

Dr. Ed Weisbart is a family physician and chair of the Missouri chapter of Physicians for a National Health Program.

https://www.stltoday.com…

Health insurance is failing ICU patients in last year of life

Health Insurance and Out-of-Pocket Costs in the Last Year of Life Among Decedents Utilizing the ICU

By Khandelwal, Nita MD, MS; White, Lindsay PhD, MPH; Curtis, J. Randall MD, MPH; Coe, Norma B. PhD
Critical Care Medicine, June 2019

Abstract

Objectives: Use of intensive care is increasing in the United States and may be associated with high financial burden on patients and their families near the end of life. Our objective was to estimate out-of-pocket costs in the last year of life for individuals who required intensive care in the months prior to death and examine how these costs vary by insurance coverage.

Design: Observational cohort study using seven waves of post-death interview data (2002–2014).

Participants: Decedents (n = 2,909) who spent time in the ICU at some point between their last interview and death.

Interventions: None.

Measurements and Main Results: Two-part models were used to estimate out-of-pocket costs for direct medical care and health-related services by type of care and insurance coverage. Decedents with only traditional Medicare fee-for-service coverage have the highest out-of-pocket spending in the last year of life, estimated at $12,668 (95% CI, $9,744–15,592), second to only the uninsured. Medicare Advantage and private insurance provide slightly more comprehensive coverage. Individuals who spend-down to Medicaid coverage have 4× the out-of-pocket spending as those continuously on Medicaid.

Conclusions: Across all categories of insurance coverage, out-of-pocket spending in the last 12 months of life is high and represents a significant portion of assets for many patients requiring intensive care and their families. Medicare fee-for-service alone does not insulate individuals from the financial burden of high-intensity care, due to lack of an out-of-pocket maximum and a relatively high co-payment for hospitalizations. Medicaid plays an important role in the social safety net, providing the most complete hospital coverage of all the insurance groups, as well as significantly financing long-term care.

https://journals.lww.com…

Comment:

By Don McCanne, M.D.

About this great health care financing system we have that several politicians want to protect, as this study shows, “Across all categories of insurance coverage, out-of-pocket spending in the last 12 months of life is high and represents a significant portion of assets for many patients requiring intensive care and their families.” In fact, many end up depleting their assets and go on Medicaid.

We must think that there is something good about having an estate at the end of life since we have public policies that prevent modest estates from being depleted through estate taxes. So why do we tolerate a health care financing system that wipes out assets of those unfortunate enough to require intensive care services in the last year of life?

We’ve long known that Medicare alone was inadequate, but this study shows that all categories of insurance coverage may be inadequate, though adding Medicaid to Medicare provides a safety net but only after the patient’s assets are depleted.

The single payer model of Medicare for All, by covering all essential services and by eliminating out-of-pocket spending, prevents compounding the end of life with financial hardship, not to mention protecting residual assets for the benefit of a surviving partner or progeny.

This may not represent the most pressing need for health care financing reform, but it does represent the fact that we seem to be more concerned about taking care of the insurance industry by continuing to tolerate the hundreds of billions of dollars in administrative waste while continuing to tolerate the patients’ financial hardships that the insurance industry is supposed to prevent.

A Medicare public option would not prevent this since the study shows, “Among insured decedents greater than or equal to 65, those with only Medicare FFS had the highest estimated OOP costs in the last year of life in every cost category except for prescription drugs.” Allowing people to buy into Medicare will not provide adequate protection.

And allowing people to keep their employer-sponsored insurance when 60 million people leave their jobs each year? Come on!

We want real reform that takes care of everyone in a system we can afford – single payer improved Medicare for all.

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

Abolition of private insurance is a strength of Medicare for All, not a weakness

Some Democrats Talk About Cosmetic Surgery Insurance. It Doesn’t Exist.

By Margot Sanger-Katz
The New York Times, July 3, 2019

The “Medicare for all” bill written by Senator Bernie Sanders would cover not just standard medical services, but also vision, dental and long-term care. It would offer more health benefits than the world’s leading universal health care systems.

But as some politicians who support the plan are quick to clarify when asked, that does not mean it would “abolish all private health insurance.”

The next thing they may say includes something about “a role” for private insurance or “supplemental coverage.”

The example of supplemental insurance Mr. Sanders typically mentions is coverage for cosmetic surgery.

To clarify: There is no private market for cosmetic surgery insurance.

“We are not aware of any,” said Adam Ross, a spokesman for the American Society of Plastic Surgeons, the leading professional group for plastic surgeons. “Not for cosmetic procedures.”

“No one would sell a cosmetic surgery plan, since the only ones buying it would be people expecting to need cosmetic surgery,” said Linda Blumberg, a fellow at the Urban Institute.

Mr. Sanders’s bill is so expansive that it’s actually quite hard to imagine many health care services that private insurance companies would be able to cover. While the bill doesn’t explicitly ban private insurance, it makes it unlawful to “sell health insurance coverage that duplicates the benefits under this act.”

“You have to really rack your brains to think of anything that would not be covered,” said Cynthia Cox, a vice president at the Kaiser Family Foundation, a health research group.

You might think that Democratic politicians who endorse the Sanders plan would embrace the bill’s comprehensiveness as a virtue. And, in some ways, they do. But some also appear nervous about saying that they will do away with an entire industry. Public opinion surveys suggest that voters are skeptical about plans that will take away their private coverage. Some co-sponsors of Mr. Sanders’s bill now say they are more comfortable with optional plans that would not bar duplicate coverage. Some others have embraced the “supplemental coverage” line.

“In order to create a role for private insurance in any of those ways, you need to weaken the main system,” said Adam Gaffney, the president of Physicians for a National Health Program, which supports a very broad single-payer plan along the lines of Mr. Sanders’s bill. He said the effective abolition of private insurance was a strength of the proposal, which doesn’t require insurance for financial or benefit gaps.

https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

Why are so many politicians and others obsessed with protecting the private insurance industry when our goal is, or should be, to protect patients from financial hardship while ensuring access to appropriate health care? With high premiums, ever higher deductibles and other cost sharing, exposure to out-of-network medical bills, and exposure to costs of care not included as plan benefits, the private insurers fail to provide the financial protection that the single payer Medicare for All model is specifically designed to do.

Our current health care financing system is highly fragmented and extremely complex. That has not only caused it to be very expensive while falling short on efficiency and effectiveness, its complexity has also made it impossible to repair its inherent defects by merely adding to the system more complexity such as a public option which can only make modest adjustments in the numbers insured but not in the other flaws in the system.

Contrast that to a system that is specifically designed to include everyone, to provide all essential health care benefits, to eliminate financial barriers to care, and to make the system affordable to society as a whole by eliminating hundreds of billions of dollars in administrative waste. Protecting and perpetuating the private insurance industry by merely adding one more insurance option, even if public, to the current quagmire will only leave on place the current personal financial hardships and impaired access to care.

As PNHP president Adam Gaffney says, “In order to create a role for private insurance… you need to weaken the main system.” Flipping that statement to a positive, in order to strengthen the health care financing system, you need remove the role of private insurance. Abolition of private insurance is a strength of Medicare for All, not a weakness.

It is nonsense to suggest that we should open up other ways for the insurers to tap our health care dollars to benefit their own industry. They have been a very expensive monkey wrench thrust into our health care system. We need to pull the wrench out, repair the damage as we rebuild the machine, and then get on with providing comprehensive, high quality, affordable health care for everyone.

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

Pro-Life? Try Medicare for All

By Paul Song, M.D.
The Hill, July 3, 2019

As a physician and a person of faith, I believe it’s time to rethink how we value life in America.  If we are truly interested in being a “pro-life” society, we should have as much concern, if not more, for life after birth and especially for the lives of the most vulnerable among us.

Recently several states have passed legislation designed to greatly restrict the ability of women to terminate their unwanted pregnancies, even in cases of rape or incest.

Many legislators and their supporters point to their personal faith as the basis of their “pro-life” beliefs in their effort to end access to safe, medically supervised abortions.

But legally requiring a woman to carry an unintended pregnancy is not really “pro-life” if nothing is done to address our country’s alarming infant and maternal mortality rates.

The leading causes of U.S. infant deaths include preterm birth complications, childbirth-related events and sepsis, an extreme response to infection. Meanwhile, the leading causes of death of young children (age 1 to 59 months) are pneumonia, diarrhea and injury.

Medicare for all would ensure every U.S. resident had comprehensive health coverage for life, which would go a long way in combating these largely treatable or preventable conditions.

The U.S. infant and maternal mortality rates are substantially higher than those of many other developed nations, making the United States among the most dangerous wealthy nations in which to give birth; and the situation is worsening. Though the overall global maternal death rate decreased by 44 percent from 1990 to 2015, it increased by about 27 percent from 2000 to 2014 in 48 U.S. states and Washington D.C.

The greatest harm is to women of color. They tend to have far less access to high-quality reproductive services while facing greater discrimination in our health-care system. African American women are three to four times as likely to die from pregnancy-related causes than white women.

Independent of race, women living in poverty and women living in states that have failed to expand Medicaid also experience significantly higher maternal mortality rates than the U.S. average. And uninsured women are three to four times more likely to die of pregnancy-related complications than those who are insured.

Louisiana, which recently passed new “heartbeat” legislation, had the worst maternal mortality rate of 46 states, which is more than double our national average, according to a recent USA Today investigation.

If we are genuinely interested in “pro-life” issues, we should focus on fixing our current broken and immoral health-care system in which:

  1. Nearly 29 million people remain uninsured and tens of thousands of people die each year as a result.
  2. Some 530,000 families go bankrupt each year because of medical issues and two-thirds of all U.S. bankruptcies are medically related.
  3. Forty-percent of Americans recently surveyed said they skipped a recommended medical test or treatment in the past 12 months due to cost.

Meanwhile, people of faith need to revisit how we view and treat our society’s most marginalized as reflected in the New Testament’s Matthew 25:39-40. “Lord, when did we see you hungry or thirsty or a stranger or needing clothes or sick or in prison and did not help you?…. Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.”

If we are truly committed to “pro-life” legislation, we should support Medicare for all. It is the only solution to our current dysfunctional and dangerous system.

While the question of when life actually begins has been debated for centuries, most people can agree that we all want as few unintended pregnancies and abortions as possible.

Two Medicare for all bills in the House and Senate would help protect a woman’s right to choose by overriding the Hyde Amendment, which bans federal dollars from funding most abortions. Contraceptive and reproductive care would also be covered.

We should also be able to agree that if a woman decides to carry her pregnancy to term, that we as a society need to do all we can to provide her and her future child with the very best health care possible.

In reality, our failing health-care system is not pro-life. As Americans of faith, we are called upon to care for one another as a moral imperative.

As Matthew 10:8 states: “Heal the sick, raise the dead, cleanse those who have leprosy…Freely you have received; freely give.”

And truly caring for one another means redefining what “pro-life” is.

Dr. Paul Song is the president of Physicians for a National Health Program-California. He is also a board-certified radiation oncologist.

Having health insurance doesn’t mean mental health care access. Insurance companies make certain of that.

Insurers often maintain minimal lists of in-network providers, loaded with meaningless names and numbers.

By J. Wesley Boyd, M.D., Ph.D.
NBC News, July 3, 2019

Most well-insured individuals assume that, if they ever need psychiatric care, they will be able to get it.

They are wrong.

The reason that they are wrong is that insurance companies are in the business of making money, and they make money when the folks they “insure” don’t actually receive care. Although this is the basic business model of insurers, they can’t be too obvious about that fact. And so, insurers seemingly employ subtle ways to make it more difficult than is necessary for folks to receive care when it is needed.

I am a psychiatrist at a public hospital that treats a multiethnic, diverse patient population, and for years I have seen firsthand the way these tactics are utilized by insurers.

One way that insurance companies make it difficult to obtain mental health care is to require clinicians to obtain prior authorizations before patients can be admitted to inpatient psychiatric facilities. Several years ago, my colleagues and I conducted a small study and found that clinicians spent an average of 38 minutes on the phone with insurers obtaining authorization to admit someone to the hospital, even after the clinicians had deemed these individuals dangerous enough to either themselves or someone else that a psychiatric hospitalization was needed. A follow-up study with a larger sample found clinicians spending an hour on the phone for each authorization.

Given that these requests are essentially all approved if the clinician spends the time, insurance companies obviously hope that the sheer time-consuming hassle of having to make the call will dissuade clinicians from seeking to admit folks to psychiatric facilities.

It is important to note that psychiatric care is singled out for this kind of profiteering and scrutiny. By comparison, if a woman is in labor, her obstetrician does not have to spend time on the phone getting permission to admit her. If a child needs an emergency appendectomy, the pediatrician or surgeon is not required to call the parent’s insurance company.

Accessing outpatient psychiatric care isn’t much easier, even if it doesn’t require preauthorization. Insurers often maintain minimal lists of in-network providers, effectively punishing patients who choose to see a provider who is not in their network by making them pay more out-of-pocket (if the insurance company covers any of the cost at all). And the lists of in-network providers that insurers do maintain are often loaded with meaningless names and numbers.

I have to date conducted three different studies looking at availability of three different kinds of outpatient psychiatric services: clinics; adult psychiatrists; and pediatric mental health care. In each of these studies my co-authors and I used the Blue Cross Blue Shield database and posed as patients — or as the parent of a child — and called either clinics or individual providers seeking appointments. Although we were using a list of supposedly in-network providers, we were scarcely able to obtain appointments.

When we called Boston-area clinics, we were able to secure appointments only 12 percent of the time, even when we told them we had BCBS insurance. When we called adult psychiatrists, we could only obtain appointments only 26 percent of the time. For pediatric appointments, our success rate was even lower. Over and over in these studies we would simply not receive calls back, even though we left two separate messages approximately a week apart asking for calls back. Additionally, many phone numbers in the databases provided by BCBS were simply wrong (and included a McDonald’s restaurant and a jewelry store) and many of the practices we called were full and not accepting new patients.

I used to think the inadequacy of the BCBS database of providers was unintentional. But given how chronic the problem is — even in the face of scrutiny by state attorneys general and others — I now feel otherwise. After all, if a person who seeks mental health care is unable to access it, the insurance company pockets money that would otherwise go pay for its customers’ treatment.

Since I first started researching these issues, publishing our results and getting the attention of regulators, insurance companies have begun to send out letters to providers on their in-network lists asking them to update their contact and practice information; I have received a number of these requests myself. One insurer asks providers to go to a website and check all of their practice locations for accuracy and says that if all of the information is accurate, no further action is required. Another insurer sends a letter with the provider’s information printed on it and says that if one doesn’t respond within 45 days the insurer “will assume that your contact and practice information listed below is correct.”

The obvious problem with either such method of supposed due diligence is that the insurance companies have no way of knowing if their letters are delivered to the intended providers and, even if they are, whether they are ever opened. Additionally, there are no penalties for providers who fail to update their information — and I do not know of any physician who has been kicked off an insurance panel because he or she did not verify the accuracy of their information.

In conclusion, given their profit motive, accessing mental health care when it is needed — whether inpatient or outpatient — will remain difficult at best as long as insurers are in the mix. Implementing a not-for-profit single payer health care system would, I wager, improve access to mental health care and allow those who need mental health care to actually receive it.

Dr. J. Wesley Boyd is an associate professor of psychiatry at Harvard Medical School, a faculty member in the school’s Center for Bioethics and a staff psychiatrist at Cambridge Health Alliance.

https://www.nbcnews.com…

New declaration: Health care is an unalienable right

By Ean Bett, M.D.
The Columbus (Ohio) Dispatch, July 3, 2019

Our country’s most indelible document introduces its citizens to their “certain unalienable Rights,” which most Americans would quickly identify when pressed as being “life, liberty, and the pursuit of happiness.” But what many of us likely do not remember, or perhaps never learned, is that our Declaration of Independence identifies those three rights as being “among” our unalienable rights, not encompassing them.

In their wisdom, our country’s founding generation understood that not only were there other unalienable rights, but that as the United States of America matured, others would be defined.

Thankfully, our country is beginning to awaken to the realization that health care is one of those unalienable rights. Perhaps even more importantly, as is pointed out by the American scholar and Harvard professor Danielle Allen, there is more to the introductory sentence of our nation’s founding document that not only supports the groundswell for health care as a right in this country, but also provides a road map by which to achieve it:

“That to secure these rights, governments are instituted among men, deriving their just powers from the consent of the governed, — that whenever any form of government becomes destructive of these ends, it is the right of the people to alter or to abolish it, and to institute new government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their safety and happiness.”

The safety and happiness of most Americans is intimately entwined with their health or the health of their loved ones. The growing discussion around health care reform, with recent bills introduced in both the House and Senate, has brought health care once again to the main stage of American politics. And for good reason.

When the safety and happiness of our people are jeopardized, as they are by surprise out-of-pocket costs, ridiculously high private insurance deductibles, unaffordable pharmaceutical pricing and unexpected illness, all of which lead to crushing medical debt, the people of this country should turn back to our founding generation’s greatest gift — the understanding that “we the people” are able to form and effect our own safety and happiness.

Making health care fair is the essence of a Medicare-for-all universal health care platform; it is in principle an acknowledgement of the unalienable right to health in this country, and by proxy, health care. Each and every American at some point in his or her life will need the assistance provided by a robust, technologically advanced and universal health care system.

Therefore, if we are to truly recognize our rights as American citizens, we must insist that our governance provide a health care infrastructure that is universal, affordable and equitable. These characteristics will help provide a just and fair health care system.

We remain as the lone developed and technologically advanced society in the world without a guaranteed right to health care for all of its inhabitants, exposing a vast majority of Americans to insurmountable debt when illness strikes. Or even while they try to maintain their state of health with chronic diseases. Nearly 70% of Americans now believe that Medicare for all is the solution to our nation’s health care crisis, and is in effect a plan to bring all Americans one step closer to the safety and happiness our forefathers constructed for us.

Life, liberty and the pursuit of happiness have been the roots from which our modern American rights have grown; the passage of time and maturation of our great nation have brought us women’s rights, civil rights and gay rights in the past 100 years.

As Independence Day approaches, we should continue to harken back to our founding generation’s greatest gift and push for the establishment of our health care rights and a universal health care system by supporting local and national leaders who understand our government derives its power from the consent, and wishes, of the governed.

Dr. Ean Bett is a family medicine physician in Columbus.

https://www.dispatch.com…

The Business Case for Universal Health Care

A Portland physician details six goals that Oregon businesses consider critical in health care reform.

By Samuel Metz, M.D.
Oregon Business, July 3, 2019

Before business owners do battle against a dysfunctional health care system, they need common goals. And health care is indeed a big battle — Oregonians spend more on health care ($70 billion) each biennium than the U.S. military did in the Persian Gulf War ($61 billion).

One part of the battle was the Oregon Legislature’s 2013 authorization of a study of health care financing options (published by the RAND Corporation as “Oregon’s Options for Financing Health Care”).

Charged with gaining business input, I spoke to business owners to determine what they sought most from health care reform. Here are six goals they considered critical:

1. “Get me out of health care benefit management.” One owner said, “I know a lot about sheet rock. I don’t know anything about the health care needs of my employees’ children.” Owners want to focus on their business, not on congressional policy or the latest in evidence-based medical practice.

2. “Keep my employees healthy.” Whether an employee is part time or full time, productivity is lost when they call out sick. Healthy employees mean better business.

3. “Remove health care benefits from my labor negotiations.” Health care benefits are the leading cause of labor disputes. U.S. employers tolerate this as normal, but employers in other industrialized nations do not. Only the U.S. holds business owners accountable for choosing an employee’s insurance company, benefits and providers.

4. “Whatever I pay for employee health care, it can’t be more than my competitors.” Employer health care costs should be equitable. The advantage should not fall on business owners who can afford expensive attorneys to best game a wilderness of business laws.

5. “Whatever benefits my employees receive, they can’t be worse than my competitors.” If two competing businesses spend the same amount on employees’ health care, their employees should receive comparable benefits.

6. “Keep my health care costs stable and predictable.” If every year brings changes to employer health care costs, long-term planning becomes impossible.

These six goals should guide health care reform.

Our health care system misses all of them. And however well-intended, the Affordable Care Act (ACA) produced little change. This massive legislation (at 380,000 words, the ACA is shorter than War and Peace but longer than Moby Dick) was not a giant step forward — it was a great leap in place.

Health care still baffles most business owners.

Employers in competing nations are free of these burdens. They pay less for health care (on average, half — some only 40%) yet enjoy broader coverage with better outcomes. Notably, international employers don’t choose insurance companies, benefits or providers on behalf of their employees. Employees choose their own.

Our toxic bond between employers and health care cripples U.S. competitiveness in international markets. Businesses in other nations enjoy lower health care costs and healthier employees. This is not a level playing field.

How do other nations provide better care to more employees at lower cost without the bond between business and health care benefits?

They use universal health care. Each format is different, but (contrary to talk-show hosts) “socialized medicine” is rare and private insurance is common.

How does this approach lower cost? Despite differences, universal-care systems have these characteristics in common:

  • Everyone participates in a health care plan. No exclusions. No opting out.
  • Every policy is comprehensive. This does not mean unlimited; it means treatable conditions receive a treatment.
  • Employees can see any provider. And provider payment reflects value of service, not value of employee insurance policy.

Most importantly, these systems separate benefits from employment.

This combination (in insurance talk, “single-risk pool, single-benefit schedule, single network”) generates enormous administrative efficiency.

How much? Americans pay more than $1 trillion annually in administration ($7 billion in Oregon), about 30% of all health care spending. International competitors pay one quarter of that. Where does this administrative spending go?

In the U.S., insurance administrators evaluate every health care bill to determine if the patient, treatment and physician were all included in benefits. U.S. health insurance administrators process 4 billion claims each year.

These insurance costs do not include the additional costs to physicians attempting to collect from insurance companies (U.S. physicians spend $82,000 annually on insurance billing) or costs to employers paying for additional HR personnel to manage health care benefits.

These costs add up quickly. The simplified billing of universal care with one risk pool, one benefit schedule and one network cuts administrative costs by half. These recovered payments fund expanded benefits for all employees without compromising outcomes.

Universal care suffers a bad rap in the U.S. Advocates promote it to families as a way to protect access, reduce costs and prevent medical bankruptcies. While these claims are correct, advocates neglect to emphasize business benefits.

A universal-care plan addresses the six health care goals that businesses seek: Employers are free from health care benefit management; all employees, full and part time, enjoy health care access; labor negotiations are free from benefit conflicts; all businesses pay equally for health care; all employees share equal benefits; and business health care costs become stable and predictable.

For employers seeking a more functional and competitive health care system, universal health care is the gold standard.

Dr. Samuel Metz is a Portland physician.

https://www.oregonbusiness.com…

People will give up private insurance if they can keep their doctors and hospitals

Majority Backs ‘Medicare for All’ Replacing Private Plans, if Preferred Providers Stay

Reduced support for single-payer overcome by assurance that Americans would not lose their doctor and hospital

By Yusra Murad
Morning Consult, July 2, 2019

Though the dividing line between Democratic presidential candidates on “Medicare for All” concerns the elimination of the private insurance market, new Morning Consult data suggests that anxiety among voters may be misplaced fear about losing their providers rather than their private plans.

According to a Morning Consult/Politico survey conducted after the first Democratic presidential primary debates, support among voters for Medicare for All falls to 46 percent from 53 percent when respondents are told the government-run health system would diminish the role of private insurers — but rises back to 55 percent when voters learn that losing their private plans would still allow them to keep their preferred doctors and hospitals.

“These numbers only affirm what the senator has said many times: people don’t like insurance companies, they like their doctors and their hospitals,” Sanders’ campaign said of the data in an email to Morning Consult. “Despite what the pharmaceutical and insurance industries will tell you, Medicare for All is the only proposal that gives Americans the freedom to control their own futures — change jobs, start a family, start a business — and keep their doctor.”

Several polls have demonstrated that support for Medicare for All plummets when Americans learn the system would replace employer-sponsored coverage with one sweeping plan, forcing single-payer supporters to go on the defensive to alleviate concerns from voters. But as candidates attempt to persuade voters that Medicare for All would not require diminishing the role of private insurers — further adding to confusion among the electorate about what exactly the system would entail — the new data suggests that the consequences of that argument can be mitigated by clarifying that losing private insurers would not affect access to preferred providers.

The June 29-July 1 survey of 1,472 voters found that explanation to be especially effective in quelling skepticism among Democrats and independents. Among independents, 56 percent back a Medicare for All system that nixes the private market but allows people to keep their doctors — a 14-point increase over the share that only hears about the diminished role of private insurers. The poll had a margin of error of 3 percentage points.

Previous Morning Consult polling has also indicated Americans who are against Medicare for All on the grounds that it would reduce the role of insurance companies may be inadvertently conflating their payers and providers. Among adults who said they opposed the system, 62 percent said they are more likely to support the plan if they could keep their doctors and hospitals.

https://morningconsult.com…

National Tracking Poll #190675

Morning Consult + Politico, June 29 – July 1, 2019

Do you support or oppose a ’Medicare for All’ health care system, where all Americans would get their health insurance from the government?

53% – Support
30% – Strongly support
23% – Somewhat support
36% – Oppose
13% – Somewhat oppose
23% – Strongly oppose
11% – Don’t know/No opinion

Do you support or oppose the public health insurance option, a system in which Americans can choose to purchase medical coverage either entirely from a federally-run health program, entirely from private insurers, or a combination of both?

68% – Support
33% – Strongly support
35% – Somewhat support
17% – Oppose
9% – Somewhat oppose
8% – Strongly oppose
16% – Don’t know/No opinion

Do you support or oppose the 2010 Affordable Care Act, sometimes referred to as Obamacare?

48% – Support
24% – Strongly support
24% – Somewhat support
41% – Oppose
11% – Somewhat oppose
30% – Strongly oppose
10% – Don’t know/No opinion

As you may know, during the Democratic presidential primary debates some candidates advocated for installing a ’Medicare for All’ system that would diminish the role of private insurers. Would you support or oppose ’Medicare for All’ if it diminished the role of private insurers?

46% – Support
24% – Strongly support
22% – Somewhat support
35% – Oppose
9% – Somewhat oppose
26% – Strongly oppose
18% – Don’t know/No opinion

As you may know, during the Democratic presidential primary debates some candidates advocated for installing a ’Medicare for All’ that would diminish the role of private insurers but allow people to keep their preferred doctor and hospital. Would you support or oppose ’Medicare for All’ if it diminished the role of private insurers but allowed you to keep your preferred doctor and hospital?

55% – Support
31% – Strongly support
24% – Somewhat support
31% – Oppose
9% – Somewhat oppose
22% – Strongly oppose
14% – Don’t know/No opinion

https://morningconsult.com…

Comment:

By Don McCanne, M.D.

It appears that when individuals polled are told that they would lose their private insurance if a Medicare for All were enacted, they may have conflated that with losing their doctors and hospitals. This poll removed that confusion: “… support among voters for Medicare for All falls to 46 percent from 53 percent when respondents are told the government-run health system would diminish the role of private insurers — but rises back to 55 percent when voters learn that losing their private plans would still allow them to keep their preferred doctors and hospitals.”

So the message that we have to pound home until it becomes a meme: Under Medicare for All you can always keep the same doctors and hospitals, but you would lose that freedom of choice under private insurers and their restricted provider networks.

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