PNHP

Doctors to tell American Medical Association: Support Medicare for All or “get out of the way”

Doctors to tell American Medical Association: Support Medicare for All or “get out of the way”

Hundreds of doctors, nurses, medical students, and health care activists to rally at AMA annual meeting in Chicago

FOR IMMEDIATE RELEASE, June 7, 2019
Contact: Clare Fauke, Physicians for a National Health Program, clare@pnhp.org

  • WHAT: Demonstration for Medicare for All: “Tell the AMA to Get Out of the Way!”
  • WHO: Hundreds of doctors, nurses, seniors and other supporters of improved Medicare for All
  • WHEN: Saturday, June 8, 1:30-3:00 p.m.
  • WHERE: 1:30-2:00 p.m. – Rally at Blue Cross Blue Shield headquarters, 300 E. Randolph; 2:00-2:30 p.m. – March to the AMA Meeting at the Hyatt Regency, 151 E. Wacker; 2:30-3:00 p.m. – Final Rally outside AMA meeting

CHICAGO — Wearing their scrubs and white coats, hundreds of doctors, nurses, medical students, and health care activists will march on the annual meeting of the American Medical Association (AMA), demanding they drop their opposition to improved Medicare for All and withdraw from the anti-single payer lobbying group Partnership for America’s Health Care Future.

The demonstration will begin at 1:30 p.m. at the headquarters of private insurer Blue Cross Blue Shield (300 E Randolph), where health professionals will speak out against the greed and administrative waste of the insurance industry. Protesters will then march to the AMA annual meeting at the Hyatt Regency (151 E Wacker) to shine a light on the group’s anti-single payer agenda.

Even though a majority of American doctors now support improved Medicare for All, the AMA has for decades opposed any type of single-payer reform. In 2018, the AMA further angered doctors by joining the Partnership for America’s Health Care Future, a lobbying group that includes pharmaceutical and health insurance companies, and that actively campaigns against both Medicare for All and members of Congress that support single-payer legislation.

“The AMA claims to represent the values of physicians, but their policies put profits ahead of patient care,” said Dr. Adam Gaffney, president of Physicians for a National Health Program (PNHP), a group of 23,000 doctors who support single-payer Medicare for All. “It’s time for the AMA to leave the Partnership for America’s Health Care Future and join the majority of physicians who support improved Medicare for All.”

While single-payer supporters rally in the streets outside the conference, the Medical Student Section of the AMA plans to file a resolution demanding the organization rescind all policies that prohibit it from supporting or even considering single-payer reform.

Besides physicians and medical students, the demonstration includes a broad coalition of single-payer supporters, such as National Nurses United, People’s Action, Jane Addams Senior Caucus, Democratic Socialists of America, The Center for Popular Democracy, Public Citizen, Social Security Works, United Electrical Workers, National Economic and Social Rights Initiative, Healthcare-NOW!, and Progressive Doctors.

“For too long, the AMA has been a roadblock to change in our deadly health care system, where patients have to make impossible choices, like paying for medical bills or paying for food,” said Jean Ross, RN, president of National Nurses United, the largest union of registered nurses in the country. “Enough is enough! Nurses will stand in strong solidarity with doctors, students, patients, and the 70 percent of people in America who support Medicare for All.”

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization whose more than 23,000 members support single-payer national health insurance.

John Geyman’s ‘Struggling and Dying Under Trumpcare’

Struggling and Dying Under Trumpcare: How We can Fix This Fiasco

By John Geyman, M.D.
Copernicus Healthcare

From the Preface

There are four key issues involved in the future of U.S. health care:

  1. Who is the health care system for – profiteering corporate stakeholders, their shareholders and Wall Street investors – or patients, families, and taxpayers?
  2. Is health care just another commodity for sale in our largely for-profit market-based system – or essential services based on medical necessity?
  3. Is health care a human right or a privilege based on ability to pay?
  4. What ethic should prevail in health care – a business “ethic” maximizing revenue to providers or a service ethic based on needs of patients and their families?

This book has four goals:

  1. To identify and define issues concerning health care reform across the political spectrum in the upcoming 2020 election cycle;
  2. To expose disinformation and demagoguery for what it is;
  3. To focus on the real stakes for the American people regardless of political ideology; and
  4. To help educate policy makers, legislators, and the electorate concerning the real issues and likely outcomes of alternative approaches to health care reform.

Common Sense: The Case For and Against Medicare For All

By John Geyman, M.D.

This Common Sense pamphlet, written in the style of Thomas Paine, “offer(s) simple facts, plain arguments, and common sense about the current crisis in health care in this country and urgent need for reform.”

“This pamphlet is targeted to legislators in Congress who will be involved in this new debate over health care, grassroots activists, and the general public seeking to better understand the issues.”

https://www.amazon.com…

Comment:

By Don McCanne, M.D.

A bizarre twist of American exceptionalism is that we have by far the most expensive health care system in the world, and yet it is one of the poorest performing of well financed systems. Particularly egregious are the poor health outcomes of not only many of those who remain uninsured but also the tens of millions who are insured but their coverage fails them in time of medical need. John Geyman explains what is wrong, what the political failures are that led to this fiasco, and most importantly, what we can do to finally bring us a high performance system that is affordable and accessible for each and everyone of us.

(The mission of PNHP is to educate physicians, other health workers, and the general public on the need for a comprehensive, high-quality, publicly-funded health care program, equitably accessible to all residents of the United States. PNHP does not endorse any political party or candidate, but we recommend that all politicians, regardless of political affiliation, support the goal of our mission.)

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

Why we’re fighting the American Medical Association

The AMA protects corporate interests, not doctors and patients – and now it’s trying to stop Medicare for All

By Jonathan Michels, Will Cox, Alankrita Siddula, and Rex Tai
The Guardian, June 6, 2019

This Saturday, nurses, physicians, and medical students plan to walk out of their clinics and on to the streets of Chicago to confront the American Medical Association at the organization’s annual meeting. Health providers know that the outrageous costs and shameful inequality of American medicine are no accident – and that their patients’ lives are at stake.

The AMA claims to represent the interests and values of our nation’s doctors. But it has long been the public relations face of America’s private health insurance system, which treats healthcare as a commodity. This approach has resulted in some of the worst health outcomes in the industrialized world: the highest rate of infant mortality, the highest number of avoidable deaths, and health spending that eats up nearly 18% of America’s GDP.

The AMA is a major reason why 28 million Americans still don’t have health insurance. Despite recent polls showing that a majority of doctors support the single-payer system Medicare for All, which would fully insure all Americans, the AMA is leading the fight against universal coverage.

By money spent, the AMA is the nation’s third largest lobbying organization of the last 20 years, behind only the US Chamber of Commerce and the National Association of Realtors. By deploying powerful lobbying and misleading media campaigns, the AMA has opposed or hijacked nearly every health reform proposal of the last century, from Social Security to Medicare to the Affordable Care Act.

The AMA has also been a relentless opponent of universal healthcare. In 1949, the group waged an unscrupulous war against President Truman’s proposed national health insurance program, spending millions of dollars to have a political-consulting firm mislabel single-payer healthcare as “socialized medicine.” In 1961, the group doubled down on fearmongering when they hired Ronald Reagan to record an advertisement warning Americans that the passage of Medicare, an imperfect but popular health program for seniors, was a “short step to all the rest of socialism.”

The AMA, however, is finding it increasingly difficult to keep healthcare providers and patients scared of single payer.

Despite industry claims that Americans are “satisfied” with their private health plans, insured patients are saddled with exorbitant co-pays, premiums, and deductibles that keep them from actually getting the care they need. A single illness or injury pushes many Americans into bankruptcy. According to a recent Gallup poll, Americans borrowed a whopping $88bn last year simply to pay for medical expenses. So much for private insurance.

Most Americans – 70% – now favor the creation of a publicly financed but privately delivered single-payer health insurance program, better known as Improved and Expanded Medicare for All. Americans are desperate for affordable healthcare, a system that prioritizes patients over commerce, centers clinical decisions in the hands of physicians, and results in lower costs and better outcomes.

In February, Representative Pramila Jayapal, along with 106 co-sponsors, unveiled the Medicare for All Act of 2019 (HR 1384), while Senator Bernie Sanders’ revamped Medicare for All Act enjoys support from most of the leading Democratic presidential candidates. Even former President Barack Obama recently admitted that his signature health initiative – the Affordable Care Act – is no substitute for single payer.

Faced with soaring public support for Medicare for All, this past summer the AMA joined the “Partnership for America’s Health Care Future”, a benign-sounding corporate group which represents the pharmaceutical and private insurance industries and aims to “change the conversation around Medicare for All”. In order to protect their own economic interests, the “Partnership” is waging a well-funded campaign to turn elected officials away from single-payer by rallying Democrats around the ACA and preventing the Democratic party from including Medicare for All in its 2020 platform.

The campaign is merely the latest example of how the AMA uses the prestige of its white-coated members to push for market-based health reforms that maintain the status quo of our fractured health system: one in which some Americans have a lot, others have a little, and some are left with absolutely nothing.

Medical students and professionals have had enough. This Saturday’s protest is only one example. Last year, the Medical Student Section of the AMA put pressure on their leadership with a resolution demanding the organization suspend its decades-long opposition to single-payer. Single-payer activism is growing on medical school campuses across the nation, perhaps a preview of what the next generation of doctors will expect.

The public agrees with the evidence that Medicare for All is the answer to our broken health system. Until the AMA’s priorities change, it will remain an obstacle to the good of our patients.

Jonathan Michels is a premedical student at the University of North Carolina at Greensboro and a student board member of Physicians for a National Health Program (PNHP), an organization that advocates for an improved and expanded Medicare for All health system.

Will Cox is a longtime healthcare worker and social justice organizer and serves on the board of the North Carolina chapter of PNHP.

Alankrita Siddula is a medical student at Rush University in Chicago and a member of Students for a National Health Program (SNaHP).

Rex Tai is a medical student at the University of Illinois at Chicago. He is a midwest regional delegate for SNaHP and has a background organizing for criminal justice reform and harm reduction in opioid treatment.

https://www.theguardian.com…

Doctors call on AMA to drop ‘Medicare for All’ fight

A grassroots coalition that supports a single-payer system will rally against the American Medical Association and private health insurers in Chicago this weekend.

By Stephanie Goldberg
Crain’s Chicago Business, June 6, 2019

A coalition of doctors, nurses and medical students are calling on the American Medical Association to drop its fight against “Medicare for All.”

The physicians group is among associations that oppose a single-payer system, which would discontinue Medicaid and private health insurance—squeezing hospital profits and threatening the existence of many health insurers.

However, groups like Physicians for a National Health Program and National Nurses United say many health care providers actually support proposals to expand Medicare. They—along with other associations, health care workers and advocacy groups—will protest the AMA’s opposition of “Medicare for All” in Chicago on Saturday.

At least 100 people are expected to gather for the demonstration, which starts at 1:30 p.m. outside Blue Cross & Blue Shield of Illinois’ headquarters at 300 E. Randolph Street, and ends outside the Hyatt Regency Chicago at 151 E. Wacker Dr., where the AMA is holding its annual meeting.

The rally seems to have more momentum than any other single-payer protest in the last 10 years, said Dr. Philip Verhoef, a national board member of Physicians for a National Health Program, which has about 1,000 members in Illinois. He said several different groups had the idea to stage a rally during the AMA’s annual meeting, and they decided to come together to support the cause.

Starting the demonstration at Blue Cross is a “gesture to say, ‘this is the problem,’ ” added Verhoef, who is also an assistant professor of medicine and pediatrics at University of Chicago and an ICU doctor at UChicago Medicine. “Private health insurance is what has driven health care prices, inequity and waste in this country.”

The grassroots coalition is calling on the AMA to drop its fight against “Medicare for All” and withdraw from the Partnership for America’s Health Care Future, an industry coalition fighting proposals to expand Medicare. The Blue Cross Blue Shield Association is also a member.

In addition to opposing “Medicare for All,” the AMA fought the formation of the program in the 1960s. However, it supported the Affordable Care Act in 2009.

“The status quo for our patients is unacceptable, and policymakers should continue taking steps to improve coverage, affordability, and expand the safety net,” AMA President Dr. Barbara L. McAneny said in a statement. “AMA policy says patients and physicians should have a range of public and private coverage options and benefit from freedom of choice and competition, which can be achieved by building on our current system, with the goal of providing coverage to all Americans.”

Blue Cross & Blue Shield of Illinois echoes the sentiment, saying in a statement the company “believes that everyone should have access to quality, affordable health care in a system built on choice, competition and innovation. We will continue to advocate for policies that support that goal in a sustainable way.”

Verhoef said some single-payer critics believe physician autonomy would be lost under “Medicare for All,” while highly paid doctors and specialists may be concerned their income would decrease under such a system.

It comes down to equity, said Verhoef.

“We have an incredibly inequitable system right now because we have (nearly) 30 million people who are uninsured” and even more who are underinsured, Verhoef said. “They don’t get the care they deserve. (“Medicare for All”) is a way to level the playing the field and give everyone comprehensive health care.”

Talisa Hardin, a representative of National Nurses United and a registered nurse in the burn unit of University of Chicago Medical Center, said she supports a single-payer system because the current system is “not designed to support and promote health.”

To the AMA, Verhoef says: “You’re not representing the majority of Americans and, quite frankly, the majority of physicians who all argue that single payer is the best solution.”

https://www.chicagobusiness.com…

Care for America’s elderly and disabled people relies on immigrant labor

By Leah Zallman, Karen E. Finnegan, David U. Himmelstein, Sharon Touw, and Steffie Woolhandler
Health Affairs, June 2019

Abstract

As the US wrestles with immigration policy and caring for an aging population, data on immigrants’ role as health care and long-term care workers can inform both debates. Previous studies have examined immigrants’ role as health care and direct care workers (nursing, home health, and personal care aides) but not that of immigrants hired by private households or nonmedical facilities such as senior housing to assist elderly and disabled people or unauthorized immigrants’ role in providing these services. Using nationally representative data, we found that in 2017 immigrants accounted for 18.2 percent of health care workers and 23.5 percent of formal and nonformal long-term care sector workers. More than one-quarter (27.5 percent) of direct care workers and 30.3 percent of nursing home housekeeping and maintenance workers were immigrants. Although legal noncitizen immigrants accounted for 5.2 percent of the US population, they made up 9.0 percent of direct care workers. Naturalized citizens, 6.8 percent of the US population, accounted for 13.9 percent of direct care workers. In light of the current and projected shortage of health care and direct care workers, our finding that immigrants fill a disproportionate share of such jobs suggests that policies curtailing immigration will likely compromise the availability of care for elderly and disabled Americans.

From the Introduction

As the US elderly population grows, health care workforce shortages (which already limit care) are expected to increase in the coming decades. The Institute of Medicine projects that 3.5 million additional health care workers will be needed by 2030. Currently, immigrants fill health care workforce shortages, providing disproportionate amounts of care overall and particularly for key shortage roles such as rural physicians. Immigrant health care workers are, on average, more educated than US-born workers, and they often work at lower professional levels in the US because of lack of certification or licensure. They work nontraditional shifts that are hard to fill (such as nights and weekends), and they bring linguistic and cultural diversity to address the needs of patients of varied ethnic backgrounds.

The size of the elderly population is expected to double by 2050, raising concern that long-term care workers will be in particularly short supply. Direct care workers—nursing, psychiatric, home health, and personal care aides—are the primary providers of paid hands-on care for more than thirteen million elderly and disabled Americans. These workers help elderly and disabled people live at home (the preferred setting for most people) by providing assistance with daily tasks such as bathing, dressing, and eating. They also help elderly and disabled people in nursing or psychiatric facilities when living at home is not possible and during transitions home after hospitalization.

Workers prepared to fill these roles are already in short supply, and the Health Resources and Services Administration projects a 34 percent rise in the demand for direct care workers over the next decade, equivalent to a need for 650,000 additional workers. Projected shortages are compounded by high turnover and retention challenges, which create ongoing obstacles to maintaining a sufficient labor supply for long-term care.

Recent years have seen a steep decline in the number of unauthorized immigrants entering the country. The administration of President Donald Trump has taken steps to further reduce the flow of immigrants and has proposed legislation to reduce the number of legal immigrants with a focus on “skilled immigrants,” which could sharply reduce the number of low-wage immigrant workers.

Discussion

The US health care system as a whole is dependent on the work of over three million immigrants, who account for 18.2 percent of all health care workers. More than one in four direct care workers are immigrants, including nearly one in three direct care workers in home health agencies. Immigrants also account for a disproportionate share of housekeeping and maintenance personnel in nursing homes.

Our study adds to the literature on immigrants’ role in the nonformal direct care sector by including workers who are privately hired to support elderly and disabled people. We found that workers in the nonformal sector provide care to hundreds of thousands of people living at home or in other nonmedical settings such as senior housing. Such care likely reduces the need for (and expense of) institutional care.

Our findings have important implications for the care of elderly and disabled people. In light of current shortages, high turnover rates, low retention rates, growing demand for direct care workers, and immigrants’ already disproportionate role in filling such jobs, policies that curtail immigration are likely to compromise the availability of care. Moreover, the anti-immigrant rhetoric and policies that restrict immigration threaten the health and well-being of immigrants who are entrusted with the care of the nation’s elderly and disabled people.

Our study also adds to a growing literature that highlights immigrants’ support for the health care of the US born. We have previously documented that immigrants pay tens of billions of dollars more annually in taxes to Medicare and in premiums to private insurers than Medicare or private insurers pay out on their behalf, effectively subsidizing the care of US-born people. Immigrants also make major contributions to the health professions: One in four US physicians has been trained in a foreign medical school, including 38.6 percent of all US internists, 43.6 percent of cardiologists, and 50.7 percent of geriatricians. Our study highlights immigrants’ contribution to the everyday care of elderly and disabled people.

Addressing the direct care worker shortage will require a multifaceted approach, including better wages, benefits, and education and training programs to draw people into the labor force while reducing turnover. However, curtailing immigration will almost certainly move us in the wrong direction, worsening the shortage and the availability of high-quality care for elderly and disabled Americans.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

Health policy frequently interacts with other public policies, in this case with immigration policy. This study shows the very important role that immigrants have played in providing health care and long-term care, especially for elderly and disabled people.

Further, there has been a shortage in direct care workers and that is likely to worsen with the anticipated increase in the numbers of disabled elderly, and with the immigration policies that our current administration is putting into place. For our health, we need to support these workers through better wages and benefits, which we can do through a Single Payer Medicare for All program. but it will also be imperative that we get immigration policies right.

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

Mitchell Katz endorses single payer

New York Health Act Testimony

By Mitchell Katz, M.D., President and Chief Executive Officer, New York City Health + Hospitals
New York State Hearing, Joint Senate and Assembly Committees on Health, May 28, 2019

Good morning Chairpersons Gottfried and Rivera and members of the Assembly and Senate Committees on Health. I am Mitch Katz, M.D., President and Chief Executive Officer of the New York City Health + Hospitals (“Health + Hospitals”). On behalf of Health + Hospitals and the de Blasio Administration, thank you for the opportunity to provide testimony in support of the New York Health Act.

It is well established that health insurance coverage plays a critical role in enhancing one’s access to needed care and maintaining or improving health status. There is strong evidence that insurance coverage is associated with having a consistent source of care and being able to afford needed care, both of which are critical for achieving better health outcomes. Not having insurance also increases health disparities across race, ethnicity and socioeconomic status. Health insurance plays a major role in access to primary care and evidence-based preventive health services, which can help people avoid or delay the onset of disease, slow or prevent the progression of diseases, lead productive lives and reduce costs. In fact, studies have shown that lack of health insurance may increase the likelihood of mortality.

Health insurance coverage is also important for the city’s economy and job markets, as it directly supports health care providers, including hospitals, community health centers, nursing facilities, and health insurance plans. Expanding access to health insurance coverage and implementing a single payer system would support NYC Health + Hospitals mission to provide high quality health care services to all New Yorkers regardless of their ability to pay. Health + Hospitals is the largest public health care system in the nation and serves over a million patients each year, of which nearly 400,000 are uninsured.

Since the Affordable Care Act (ACA) was enacted in 2010, the uninsured rate in New York City across all ages has dropped significantly. During the most recent open enrollment period, a record 1 million New Yorkers, 57% of whom were New York City residents, enrolled in health insurance through the state’s ACA exchange; almost three quarters of those individuals signed up for Essential Plan. Overall, New York’s ACA exchange saw a 70,000 (7%) increase in Essential Plan and qualified health plan enrollment from the previous year , despite the fact that enrollment through the federally facilitated exchange declined by approximately 4% during the same period. Unfortunately, coverage gaps remain; over 1.1 million New Yorkers, including the estimated 600,000 New York City residents that remain uninsured.

A single payer health system would provide coverage to these uninsured and underinsured New Yorkers. The New York Health Act would create a comprehensive system of access to health insurance to provide a health plan available to every New York State resident. The program does not require participants to pay any premium or out-of-pocket costs, and provides all benefits currently included in Medicaid, Medicare, Child Health Plus and other state programs. This new system will ensure access to critical care for those who need it most, and will increase positive health care outcomes for all New Yorkers. We have read about concerns expressed by labor about the New York Health Act, and we are confident that the bill sponsors can address the concerns raised.

A single payer system would also make major strides to decrease segregation of care based on insurance type. Research has shown that many private practices do not accept Medicaid ; other studies suggest that Medicaid is generally accepted at hospital clinics, but not necessarily in the faculty practices of the same hospitals. The difference in rates paid by Medicaid when compared to private insurance is a contributor to this inequity, which would be eliminated with a single payer system.

As a primary care doctor, what is most important is care. A single payer system would allow me to spend more time on patient care than checking formularies. The current system makes me check formularies of each insurance company rather than providing prescriptions that I know work for my patients. It would also alleviate administrative burdens that safety net hospitals face. Health + Hospitals is currently fighting to make sure insurance companies pay us back when they have underpaid us in the past for care provided to patients.

The continued effort to undermine or eliminate the ACA is a threat to all New Yorkers and especially to Health + Hospitals patients. The threat of Federal Disproportionate Share Hospital payments cuts which will be devastating to Health + Hospitals, the proposed public charge rule and immigration policy changes harm our efforts to reach new patients and provide them the care they need. Despite these risks, Health + Hospitals will not be deterred from serving our patients across our health system.

As the Trump Administration continues its assault on the ACA and Medicaid, it is our job to ensure that everyone, regardless of their age, employment status, household income, immigration status or health status, has access to health care. The New York Health Act would guarantee this access for every New York State resident.

The City of New York strongly supports the New York Health Act. Thank you for the opportunity to join the growing chorus of voices in support of a single payer health care system.

Thank you to the Chairs of the Assembly and Senate Health Committees for your tremendous support of Health + Hospitals and I look forward to taking your questions.

(Thanks to New York Assembly Health Chair Richard Gottfried – author of the New York Health Act – for sending this draft of Mitch Katz’s testimony.)

Comment:

By Don McCanne, M.D.

Although today’s selection is standard testimony on behalf of the single payer model of health reform, it is highly authoritative because of the status of Mitchell Katz. He implemented the Healthy San Francisco program which established “universal” coverage in that city (under then mayor Gavin Newsom). He then led the Los Angles County Department of Health Services during implementation of the Affordable Care Act, transforming it into the Los Angeles County Health Agency – the nation’s second largest public health system. Now he is CEO of NYC Health + Hospitals – the largest public health care system in the United States.

Dr. Katz has received accolades for his efforts to improve health delivery under these public health systems, using all resources at his disposal in the most effective manner possible. This has been particularly important considering the safety-net role of these institutions. Yet 600,000 New Yorkers served by the system remain uninsured. It does not require a visionary like Dr. Katz to imagine what he could do if everyone were enrolled in a single payer system.

Although Dr. Katz’s comments are specifically in support of the New York Health Act, they can be extrapolated to apply to a national Single Payer Medicare for All. Without even asking, I know Dr. Katz would certainly concur.

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

Voters do not have a sophisticated understanding of health policy

Voters are tuning out the health care debates

By Drew Altman
Axios, June 3, 2019

There’s a big disconnect between the health care debates that dominate Washington, the campaigns and the politically active — where all of the talk is about sweeping changes like Medicare for All or health care block grants — and what the voters are actually thinking about.

The big picture: In our focus groups with independent, Republican, and Democratic voters in several swing states and districts, the voters were only dimly aware of candidates’ and elected officials’ health proposals. They did not see them as relevant to their own struggles paying their medical bills or navigating the health system.

Details: We conducted six focus groups in three states (Texas, Florida, and Pennsylvania), facilitated by Liz Hamel, the Kaiser Family Foundation’s Director of Polling and Survey Research. Each one had eight to 10 people who vote regularly and said health care will be important in their presidential vote in 2020.

The highlights:

  • These voters are not tuned into the details — or even the broad outlines — of the health policy debates going on in Washington and the campaign, even though they say health care will be at least somewhat important to their vote.
  • Many had never heard the term “Medicare for all,” and very few had heard about Medicare or Medicaid buy-in proposals, or Medicaid and Affordable Care Act state block grant plans like the one included in President Trump’s proposed budget.
  • When asked what they knew about Medicare for all, few offered any description beyond “everyone gets Medicare,” and almost no one associated the term with a single-payer system or national health plan.
  • When asked about ACA repeal, participants almost universally felt that Republicans did not have a plan to replace the law.
  • When voters in the groups were read even basic descriptions of some proposals to expand government coverage, many thought they sounded complicated and like a lot of red tape.
  • They also worried about how such plans might strain the current system and threaten their own ability to keep seeing providers they like and trust.

Between the lines: Most voters in these groups don’t seem to see the current health reform proposals on either side of the aisle as solutions to their top problems: paying for care or navigating the health insurance system and red tape.

  • That, combined with a general distrust of politicians, can make these voters wary of any plan that sounds just a little too good to be true to them.

The bottom line: For most voters, the debate will be more meaningful when they see stark differences on health between the Democratic nominee and President Trump in the general election. Then they may be able to focus more on what differences on health reform mean for the country and their daily lives.

https://www.axios.com…

Comment:

By Don McCanne, M.D.

Although we should be cautious about trying to draw Great Truths from half a dozen focus groups, we should be concerned about what these groups revealed about their understanding of the basis of the problems that they experience with our health care system.

They see problems with navigating the health care system and with paying their medical bills. But when offered solutions for these problems they show little understanding of even basic health policy, and they seem to be influenced more by political memes expressing a distrust of government, complexity of public solutions, and government interference with their interactions with the health care system.

A particularly important example of this is, “When asked what they knew about Medicare for all…almost no one associated the term with a single-payer system or national health plan.”

This lack of sophistication leaves them unaware that the government Medicare program is far more deserving of our trust than the private insurers (“surprise medical bills” anyone?), that a government program that includes everyone though a publicly funded universal risk pool is far less complex than a multitude of private insurers with various complex rules for accessing and paying for care, and that a single payer system interferes less since the patient has free choices in health care whereas the private plans are more restrictive of benefits while limiting coverage to their contracted provider lists (a minute fraction of the physicians and hospitals available throughout the nation).

Health policy is complicated, but the message for single payer Medicare for All need not be: enrollment for life, free choice of physicians and hospitals and other health care professionals and institutions, and automatic payment by our own public program. The focus groups already understand that the Republicans do not have a replacement plan, but what they do not understand is that only the single payer model of Medicare for All meets these goals whereas the ACA/public option Medicare for Some often leaves them exposed to the access and affordability issues they already face.

Again, single payer Medicare for All means:

  • Never have to change insurers.
  • Free choice always of doctors and hospitals.
  • No medical bills since care has been prepaid through our taxes.

None of these are features of either the Republican proposals or the Democratic ACA/public option proposals. It’s a simple message. Let’s do our best to see that the American voter understands it.

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

Single-Payer Reform—“Medicare for All”

By Steffie Woolhandler, M.D., M.P.H. and David U. Himmelstein, M.D.
JAMA, Viewpoint, May 31, 2019

The prospect of single-payer “Medicare-for-all” reform evokes enthusiasm and concern. Proponents maintain that a single-payer system would be the simplest route to universal coverage; every US resident would qualify for comprehensive insurance under a public, tax-financed plan that would replace private insurers, Medicaid, and Medicare. Others are concerned that costs would escalate or that the government would limit and underfund care, particularly hospital care, which commands the largest share of health spending; innovation might lag; and government may infringe on medical decisions.

Physicians are understandably cautious about prescribing a radical cure for minor ills. However, current health policies have substantial shortcomings for many individuals, minor changes appear certain to fail, and the single-payer remedy may be less disruptive than often portrayed.

Few argue with the need for reform. The United States has fallen behind other nations in measures of life expectancy and access to care. Drug prices in the United States, already twice those in Europe, continue to increase, compromising patient adherence to vital medications, such as insulin. Twenty-nine million US residents remain uninsured, and co-payments and deductibles force many individuals with insurance to choose between skipping care and incurring overwhelming debts.

Many physicians feel frustrated by mandates and restrictions of insurers and by electronic health records (EHRs) with designs driven by the logic of billing. New payment modalities, euphemistically labeled “value-based,” favor large systems at the expense of small practices and community-controlled hospitals and impose new layers of quality reporting and fiscal managers. However, these payment modalities appear to have done little to improve care or moderate costs, and physicians continue to bear responsibility for patients even as their authority in many health care settings erodes.

Single-payer reform could mitigate the stresses on patients and clinicians. A well-designed reform could potentially generate large savings on billing-related costs and lower drug prices, which would make expanded coverage more affordable.

The current, fragmented payment system entails complexity that adds no value. Physicians and hospitals must navigate contracting and credentialing with multiple plans and contend with numerous payment rates and restrictions, preauthorization requirements, quality metrics, and formularies. Narrow clinician and hospital networks and the constant flux of enrollment/disenrollment as patients change jobs or their employers switch plans disrupt long-standing patient-physician relationships. Many insurers devote resources to recruiting profitable enrollees and encouraging unprofitable enrollees to disenroll.

This complexity drains resources from patient care. According to official estimates, insurance overhead is projected to cost an estimated $301.4 billion in 2019, including an estimated $252 billion for private insurers, approximately 12% of their premiums.1 In contrast, overhead is 1.6% in Canada’s single-payer system and 2.2% in Medicare’s fee-for-service plan. Reducing US systemwide insurance overhead to 2.2% could save an estimated $238.7 billion.1

The complex payment system also increases hospital costs and prices. Single-payer nations, such as Canada and Scotland, pay hospitals global budgets, analogous to the way US cities fund fire departments. That payment strategy obviates the need to attribute costs to individual patients and insurers and minimizes incentives for upcoding, gaming quality metrics, bolstering profitable “service lines,” and other financially driven exertions; a 1272-bed multihospital system in Toronto employs only 5.5 full-time equivalent employees to handle all billing and collections.2 A 2014 report suggested that administration consumes 12.4% of hospital budgets in Canada (and 11.6% in Scotland) vs 25.3% in the United States,3 a difference of an estimated $162 billion annually.

Interacting with multiple insurers also raises physicians’ overhead and, in turn, the prices they must charge. In 2016, an efficient group practice at a North Carolina academic medical center spent $99,581 (and 243 hours of physician time) per primary care physician on billing.4

As in Canada, a US single-payer system could pay physicians based on a simple fee schedule negotiated with medical associations. All patients would have the same coverage and office staff would not need to process prior authorizations, collect co-payments, or field pharmacists’ calls driven by the confusion that arises from multiple formularies. Anecdotal reports suggest that Canadian physicians have been spared much of the burden imposed by poorly conceived privacy regulations, “meaningful use” requirements, and quality and efficiency metrics.2 A 2011 study found that US physicians spent 4 times more money interacting with payers than their Canadian counterparts,5 who report spending only 24.7% of gross revenues on practice overhead (including rent and staff) and 4% of their workweek on insurance-related matters.6 US insurers try to detect billing abuses by demanding substantial amounts of documentation. In single-payer nations, the sole insurer can use comprehensive claims data to monitor for outlandish billing patterns.

A 2019 Congressional Budget Office (CBO) report7 concluded that single-payer reform could lower administrative costs, increase incentives to improve health, and substantially reduce the number of uninsured individuals. However, if undocumented immigrants were excluded, 11 million US residents could remain uninsured.

Realizing the benefits of single-payer reform entails many challenges and potential pitfalls. As the CBO report noted, the effects on the economy and individuals would depend on key features of the design of the program, such as how it paid clinicians and what services were covered. While single-payer reform could simplify bureaucracy and free up hospital resources and physicians’ time to meet the increased demand for care, poorly designed legislation might perpetuate Medicare’s burdensome payment and monitoring strategies. Even in a well-designed system, waiting time for care might increase; however, the Affordable Care Act, which covered 20 million uninsured individuals, did not significantly increase waiting time or compromise access for previously insured individuals. Nonetheless, enhanced funding for training programs might be needed to ensure an adequate supply of clinicians, particularly in primary and behavioral health care and in regions with physician shortages. In addition, as with Medicare, politics could affect decisions regarding coverage in a single-payer system.

Most individuals would have an insurance transition, but they could keep their physicians and would be spared future transitions. Although patients would not be able to choose among insurers, they would no longer face network restrictions and, in many cases, could have improved benefits. To protect innovation, some drug price savings could be used to augment federal research funding.

Single-payer reform would be best done at the federal level. Without federal waivers, state-based reforms cannot redirect federal and employer spending through the single-payer system, compromising the administrative savings needed to make expanded care affordable—a problem that bedeviled Vermont’s reform effort.

Consolidation of purchasing power in a public agency may raise concerns that funding reductions would endanger quality or cause rationing, and that physicians would essentially become tradesperson paid by a single entity. Schulman et al calculated that hospitals’ average margins would decline to −9% if all inpatient stays were reimbursed at Medicare’s current rates.8 While hospitals’ savings on their own administrative costs (as much as $162 billion) could allow them to transition to a leaner cost structure, a sensible phase-in plan would be needed. Although neither of the congressional Medicare-for-all bills calls for the adoption of Medicare’s rates, their budgeting is predicated on the assumption that hospitals could redirect resources from billing to clinical sites, allowing them to provide more care within current budgets.

Previous experience with coverage expansions is also reassuring. In Canada, mean physician income (in 2010 inflation-adjusted Canadian dollars) increased from about $100,000 in 1962 to $248,113 in 2010 (from 2.5 times the average worker’s income to 4.3 times),9 which was comparable to US physician income at the time. Similarly, hospital revenue per patient-day increased 8.9% annually in the 3 years after the 1959 startup of Canada’s universal hospital insurance program.10 The implementation of Medicare in 1966, the closest US analogue of a single-payer startup, also was associated with increased physician and hospital revenues.

State and federal legislators have introduced dozens of single-payer bills. Sixteen US senators and 110 representatives are cosponsoring companion Medicare-for-all bills that would implement universal, first-dollar coverage without network restrictions. Both federal bills would raise taxes, but those increases are projected to be fully offset by savings on premiums and out-of-pocket expenses. Both bills would augment funding for clinical services by redirecting funds now wasted on bureaucracy and excessive drug prices and the payer would pay physicians on a fee-for-service basis or salaries from hospitals or clinics that receive global budgets. The bill in the US House of Representatives adopts Canadian-style global budgeting for hospitals. However, the current US Senate bill retains Medicare’s payment strategies (although not Medicare’s payment rates), a provision that would modestly attenuate savings on hospital administration and maintain some unnecessary regulations that frustrate physicians. This shortcoming underscores the importance of physician input in crafting single-payer legislation.

Several legislators have introduced public-option (Medicare buy-in) proposals, portraying these proposals as more practical variants of Medicare for all. However, such reform would do little to simplify billing and paying, generating minimal administrative savings for clinicians or hospitals. Savings on insurance overhead would also be modest unless Medicare Advantage (in which overhead averages 13.7%) was excluded. Moreover, private insurers might selectively enroll healthy patients, turning the public option into a de facto high-risk pool requiring large subsidies. Hence, as the CBO report noted, expanded coverage would be costlier than under single-payer reform.

Halfway measures are politically attractive but economically unworkable. The $11,559 per capita that the United States spends on health care could provide high-quality care for all or it can continue to fund a vast health-managerial apparatus—it cannot do both.

https://jamanetwork.com…

References

  1. NHE historical and projections 1960-2027. Centers for Medicare & Medicaid Services website. Updated February 26, 2019. Accessed April 14, 2019.
  2. Meyer H. Why does the U.S. spend so much more on healthcare? Modern Healthcare. Published April 7, 2018. Accessed April 28, 2019. Google Scholar.
  3. Himmelstein DU, Jun M, Busse R, et al. A comparison of hospital administrative costs in eight nations. Health Aff (Millwood). 2014;33(9):1586-1594. PubMed | Google Scholar | Crossref.
  4. Tseng P, Kaplan RS, Richman BD, Shah MA, Schulman KA. Administrative costs associated with physician billing and insurance-related activities at an academic health care system. JAMA. 2018;319(7):691-697. doi: 10.1001/jama.2017.19148. Article | PubMed | Google Scholar | Crossref.
  5. Morra  D, Nicholson  S, Levinson  W, Gans  DN, Hammons  T, Casalino  LP. US physician practices versus Canadians.  Health Aff (Millwood). 2011;30(8):1443-1450.PubMed | Google Scholar | Crossref.
  6. Canadian Medical Association. Hours on administrative forms. 2017. Accessed April 28, 2019.
  7. Congressional Budget Office. Key design components and considerations for establishing a single-payer health care system. Published May 2019. Accessed May 29, 2019.
  8. Schulman KA, Milstein A. The Implications of “Medicare for All” for US hospitals [published online April 4, 2019]. JAMA. doi: 10.1001/jama.2019.3134. Article | Google Scholar.
  9. Grant HM, Hurley J. Unhealthy pressure: how physician pay demands put the squeeze on provincial health-care budgets. University Calgary Sch Public Policy Res Pap. 2013;6(22):1-35. Google Scholar.
  10. Reed LS, Carr W. Utilization and cost of general hospital care. Soc Secur Bull. 1968;31:12. Google Scholar.

JAMA – Woolhandler and Himmelstein explain single payer Medicare for All

Single-Payer Reform — “Medicare for All”

By Steffie Woolhandler, M.D., M.P.H.; David U. Himmelstein, M.D.
JAMA, Viewpoint, Health Policy, Published Online May 31, 2019

The prospect of single-payer “Medicare-for-all” reform evokes enthusiasm and concern. Proponents maintain that a single-payer system would be the simplest route to universal coverage; every US resident would qualify for comprehensive insurance under a public, tax-financed plan that would replace private insurers, Medicaid, and Medicare. Others are concerned that costs would escalate or that the government would limit and underfund care, particularly hospital care, which commands the largest share of health spending; innovation might lag; and government may infringe on medical decisions.

Physicians are understandably cautious about prescribing a radical cure for minor ills. However, current health policies have substantial shortcomings for many individuals, minor changes appear certain to fail, and the single-payer remedy may be less disruptive than often portrayed.

Few argue with the need for reform. The United States has fallen behind other nations in measures of life expectancy and access to care. Drug prices in the United States, already twice those in Europe, continue to increase, compromising patient adherence to vital medications, such as insulin. Twenty-nine million US residents remain uninsured, and co-payments and deductibles force many individuals with insurance to choose between skipping care and incurring overwhelming debts.

Many physicians feel frustrated by mandates and restrictions of insurers and by electronic health records (EHRs) with designs driven by the logic of billing. New payment modalities, euphemistically labeled “value-based,” favor large systems at the expense of small practices and community-controlled hospitals and impose new layers of quality reporting and fiscal managers. However, these payment modalities appear to have done little to improve care or moderate costs, and physicians continue to bear responsibility for patients even as their authority in many health care settings erodes.

Single-payer reform could mitigate the stresses on patients and clinicians. A well-designed reform could potentially generate large savings on billing-related costs and lower drug prices, which would make expanded coverage more affordable.

The current, fragmented payment system entails complexity that adds no value. Physicians and hospitals must navigate contracting and credentialing with multiple plans and contend with numerous payment rates and restrictions, preauthorization requirements, quality metrics, and formularies. Narrow clinician and hospital networks and the constant flux of enrollment/disenrollment as patients change jobs or their employers switch plans disrupt long-standing patient-physician relationships. Many insurers devote resources to recruiting profitable enrollees and encouraging unprofitable enrollees to disenroll.

This complexity drains resources from patient care. According to official estimates, insurance overhead is projected to cost an estimated $301.4 billion in 2019, including an estimated $252 billion for private insurers, approximately 12% of their premiums. In contrast, overhead is 1.6% in Canada’s single-payer system and 2.2% in Medicare’s fee-for-service plan. Reducing US systemwide insurance overhead to 2.2% could save an estimated $238.7 billion.

The complex payment system also increases hospital costs and prices. Single-payer nations, such as Canada and Scotland, pay hospitals global budgets, analogous to the way US cities fund fire departments. That payment strategy obviates the need to attribute costs to individual patients and insurers and minimizes incentives for upcoding, gaming quality metrics, bolstering profitable “service lines,” and other financially driven exertions; a 1272-bed multihospital system in Toronto employs only 5.5 full-time equivalent employees to handle all billing and collections. A 2014 report suggested that administration consumes 12.4% of hospital budgets in Canada (and 11.6% in Scotland) vs 25.3% in the United States, a difference of an estimated $162 billion annually.

Interacting with multiple insurers also raises physicians’ overhead and, in turn, the prices they must charge. In 2016, an efficient group practice at a North Carolina academic medical center spent $99 581 (and 243 hours of physician time) per primary care physician on billing.

As in Canada, a US single-payer system could pay physicians based on a simple fee schedule negotiated with medical associations. All patients would have the same coverage and office staff would not need to process prior authorizations, collect co-payments, or field pharmacists’ calls driven by the confusion that arises from multiple formularies. Anecdotal reports suggest that Canadian physicians have been spared much of the burden imposed by poorly conceived privacy regulations, “meaningful use” requirements, and quality and efficiency metrics. A 2011 study found that US physicians spent 4 times more money interacting with payers than their Canadian counterparts, who report spending only 24.7% of gross revenues on practice overhead (including rent and staff) and 4% of their workweek on insurance-related matters. US insurers try to detect billing abuses by demanding substantial amounts of documentation. In single-payer nations, the sole insurer can use comprehensive claims data to monitor for outlandish billing patterns.

A 2019 Congressional Budget Office (CBO) report concluded that single-payer reform could lower administrative costs, increase incentives to improve health, and substantially reduce the number of uninsured individuals. However, if undocumented immigrants were excluded, 11 million US residents could remain uninsured.

Realizing the benefits of single-payer reform entails many challenges and potential pitfalls. As the CBO report noted, the effects on the economy and individuals would depend on key features of the design of the program, such as how it paid clinicians and what services were covered. While single-payer reform could simplify bureaucracy and free up hospital resources and physicians’ time to meet the increased demand for care, poorly designed legislation might perpetuate Medicare’s burdensome payment and monitoring strategies. Even in a well-designed system, waiting time for care might increase; however, the Affordable Care Act, which covered 20 million uninsured individuals, did not significantly increase waiting time or compromise access for previously insured individuals. Nonetheless, enhanced funding for training programs might be needed to ensure an adequate supply of clinicians, particularly in primary and behavioral health care and in regions with physician shortages. In addition, as with Medicare, politics could affect decisions regarding coverage in a single-payer system.

Most individuals would have an insurance transition, but they could keep their physicians and would be spared future transitions. Although patients would not be able to choose among insurers, they would no longer face network restrictions and, in many cases, could have improved benefits. To protect innovation, some drug price savings could be used to augment federal research funding.

Single-payer reform would be best done at the federal level. Without federal waivers, state-based reforms cannot redirect federal and employer spending through the single-payer system, compromising the administrative savings needed to make expanded care affordable—a problem that bedeviled Vermont’s reform effort.

Consolidation of purchasing power in a public agency may raise concerns that funding reductions would endanger quality or cause rationing, and that physicians would essentially become tradesperson paid by a single entity. Schulman et al calculated that hospitals’ average margins would decline to −9% if all inpatient stays were reimbursed at Medicare’s current rates. While hospitals’ savings on their own administrative costs (as much as $162 billion) could allow them to transition to a leaner cost structure, a sensible phase-in plan would be needed. Although neither of the congressional Medicare-for-all bills calls for the adoption of Medicare’s rates, their budgeting is predicated on the assumption that hospitals could redirect resources from billing to clinical sites, allowing them to provide more care within current budgets.

Previous experience with coverage expansions is also reassuring. In Canada, mean physician income (in 2010 inflation-adjusted Canadian dollars) increased from about $100 000 in 1962 to $248 113 in 2010 (from 2.5 times the average worker’s income to 4.3 times), which was comparable to US physician income at the time. Similarly, hospital revenue per patient-day increased 8.9% annually in the 3 years after the 1959 startup of Canada’s universal hospital insurance program. The implementation of Medicare in 1966, the closest US analogue of a single-payer startup, also was associated with increased physician and hospital revenues.

State and federal legislators have introduced dozens of single-payer bills. Sixteen US senators and 110 representatives are cosponsoring companion Medicare-for-all bills that would implement universal, first-dollar coverage without network restrictions. Both federal bills would raise taxes, but those increases are projected to be fully offset by savings on premiums and out-of-pocket expenses. Both bills would augment funding for clinical services by redirecting funds now wasted on bureaucracy and excessive drug prices and the payer would pay physicians on a fee-for-service basis or salaries from hospitals or clinics that receive global budgets. The bill in the US House of Representatives adopts Canadian-style global budgeting for hospitals. However, the current US Senate bill retains Medicare’s payment strategies (although not Medicare’s payment rates), a provision that would modestly attenuate savings on hospital administration and maintain some unnecessary regulations that frustrate physicians. This shortcoming underscores the importance of physician input in crafting single-payer legislation.

Several legislators have introduced public-option (Medicare buy-in) proposals, portraying these proposals as more practical variants of Medicare for all. However, such reform would do little to simplify billing and paying, generating minimal administrative savings for clinicians or hospitals. Savings on insurance overhead would also be modest unless Medicare Advantage (in which overhead averages 13.7%) was excluded. Moreover, private insurers might selectively enroll healthy patients, turning the public option into a de facto high-risk pool requiring large subsidies. Hence, as the CBO report noted, expanded coverage would be costlier than under single-payer reform.

Halfway measures are politically attractive but economically unworkable. The $11 559 per capita that the United States spends on health care could provide high-quality care for all or it can continue to fund a vast health-managerial apparatus—it cannot do both.

https://jamanetwork.com…

Comment:

By Don McCanne, M.D.

This article, published by JAMA – the Journal of the American Medical Association – and written by Steffie Woolhandler and David Himmelstein – cofounders of Physicians for a National Health Program – is a highly credible, objective explanation of the single payer model of Medicare for All.

The article has been published online in advance of its publication in the June 25 edition of JAMA, and the paywall has been removed by the publisher. It is a very important article. The link above should be distributed widely to help enable others to understand just what this single payer Medicare for All proposal is all about.

There is nothing like facts to provide enlightenment.

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

The Surprising Origins of ‘Medicare for All’

By Abigail Abrams
Time, May 30, 2019

When Medicare was created in 1965, few Americans were talking about universal health care. Even fewer realized that the bureaucrats behind the program hoped that it would eventually become that.

With America at the height of Cold War anti-communist sentiment, the Social Security Administration staffers who set up Medicare did not articulate their goal, instead hoping that lawmakers would incrementally expand Medicare to include everyone — not just the elderly.

“The original idea behind Medicare was Medicare for all,” says Jonathan Oberlander, professor and chair of social medicine at University of North Carolina Chapel Hill

Now, more than a half-century later, “Medicare for All” has become a slogan for a number of different proposals by Democratic presidential candidates, members of Congress and liberal think tanks to expand government-sponsored health insurance to more Americans.

In some ways, the phrase “Medicare for All” is better known among voters than more precise terms such as universal health care, single-payer health care, socialized medicine or government-run health care, but that same flexibility also means that it is not always clear what a candidate means when using it.

Here’s a closer look at how “Medicare for All” became a catchphrase in U.S. politics and what it means.

Advocating for universal health care

The idea of the government ensuring that people have access to health care began long before Medicare. While local governments experimented with health care for centuries, the first national health insurance program came from Germany’s Otto von Bismarck in the 1880s. Other European countries followed with their own versions of government health care for workers, and by the early 1900s, reformers in the U.S. were advocating for a similar system.

The push was closely tied to the labor movement, according to Northern Illinois University history professor Beatrix Hoffman, who studies the politics of health reform. But businesses and doctors attacked the idea of government health care, and it soon died. This opposition also killed President Franklin Roosevelt’s desire to add health coverage to the Social Security Act in 1935. And when President Harry Truman took up the cause after World War II, the American Medical Association and other opponents used Cold War scare tactics to paint “health security,” as it was known then, as socialized medicine and kill the plan again.

“The defeat of the Truman plan was so massive, it was such a big failure, that supporters decided they were going to stop trying for universal coverage,” Hoffman says. “That’s when they invented the idea of Medicare for the elderly only.”

From Medicare’s start, it was a popular program. But it also quickly became expensive, and the 1970s turned to discussions about how to control health care costs — not exactly a helpful political environment for those looking to expand coverage.

The first major change to Medicare came in 1972 when Richard Nixon added individuals with disabilities and those with end-stage renal disease. But this took the program in a fundamentally new direction: serving as a fallback for people who couldn’t get insurance through their employers, rather than building toward universal coverage as Medicare’s designers had hoped.

Amid these discussions about how to rein in health care costs, Sen. Ted Kennedy introduced his first national health insurance plan in 1971, proposing financing it through payroll taxes. But this failed, along with the rest of the plans discussed at this time.

Still, someone else did see hope in Medicare. One of these failed plans came from Republican Sen. Jacob Javits, who proposed expanding Medicare to cover the entire country’s population. Javits still used the language of “national health insurance,” but he became one of the first people publicly associated with the phrase “Medicare-for-all” when the New York Times used it to describe his plan, declaring on April 15, 1970: “Medicare For All Is Asked By Javits.”

Finding the right political message

This phrasing did not take off right away. The Vietnam War and Watergate pushed health care reform from most lawmakers’ minds, and then the 1980s ushered in the conservative Reagan era.

As Congress turned away from the issue, activists took up the charge. The 1980s saw the birth of groups such as Physicians for a National Health Program, which brought doctors together to advocate for universal health care, and the growth of the Gray Panthers, which had been founded to fight ageism and other social issues and made health care a major part of its agenda.

The advocacy groups of the ’80s started by using “national health insurance” to describe their goal, but soon moved toward the phrase “single-payer” health care. The latter meant that their ideal national health program would have just one payer — the government — as opposed to the many payers of the private insurance industry.

“As doctors we like to be very clear about what we’re advocating for. So ‘single payer’ was an accurate description,” Dr. David Himmelstein, co-founder of Physicians for a National Health Program, told TIME.

Though some doctors’ groups were part of the early opposition to single-payer health care, Himmelstein says he and his colleagues found that when they talked to individual physicians, many supported the idea of universal health care. In these years, other groups such as the American College of Surgeons also joined the fight.

As Himmelstein and his co-founder Dr. Steffie Woolhandler built their group, they were inspired by Canada’s national health program, also called Medicare. But in the 1980s, Physicians for a National Health Program did not initially use the Medicare framing because they still saw plenty of flaws in the American version of the system. While Medicare was helpful to many patients who used it, critics said that it didn’t cover all medical expenses, its payment policies were overly complex and it still relied too much on private industry.

In contrast, the language of “single-payer” health care symbolized a kind of political purity, according to Yale political scientist and health care policy expert Jacob Hacker. “There was some thought that the word ‘payer’ made clear that you were still purchasing the good kind of health care that people knew and loved,” Hacker says. “Before people saw Medicare as the platform, they wanted to say ‘payer’ because they didn’t want to say it’s about socialized medicine.”

However accurate single-payer might have been, it did not really catch on outside health policy and activist circles. “It’s like trying to sell a house by describing its plumbing,” Hacker says.

By the 1990s, Democrats geared up to tackle health reform again under President Bill Clinton. But the Clinton Administration intentionally distanced itself from the single-payer model, instead taking a more moderate approach and sought to expand coverage to everyone while preserving private and employer insurance.

“That represented a shift in Democratic thinking to the right, that the only feasible way to pass health care reform was one that built on the status quo and built on private insurance,” says UNC’s Oberlander.

Again, alternative plans popped up, and this time Rep. Pete Stark proposed enrolling uninsured people in what he called “Medicare Part C.” But like the Javits plan in the 1970s, this did not gain traction. Instead Democrats pushed the Clintons’ plan, which proved too complicated for voters and ultimately imploded, setting back the cause of major health care reform.

Returning to Medicare

The new millennium brought a Republican administration and a resistance to pursuing big health care changes. When President George W. Bush created Medicare Part D, the legislation did not allow the federal government to negotiate drug prices, leaving progressives feeling frustrated and powerless against the growing power of the pharmaceutical industry.

Despite this, the rest of Medicare had substantially improved since its early days. Reforms to the program had brought down spending, and it now had low administrative costs plus a demonstrated ability to control prices, often giving it an advantage over private coverage. That made it popular not only with recipients but also among lawmakers.

In this climate, “Medicare-for-all” finally arrived in Congress. In 2003, Rep. John Conyers introduced the Expanded and Improved Medicare For All Act, a bill that would create a universal single-payer health care system. His fellow lawmakers largely ignored it at the time, but Conyers introduced the bill in each session of Congress until he resigned in December 2017 in the wake of sexual harassment allegations. In 2006, Kennedy also tried again, introducing the Medicare for All Act, which proposed gradually expanding coverage to include all citizens and legal residents.

Though these bills were not successful, they signaled a coming change in strategy from the technical language of single-payer to the aspirational message of expanding on Medicare to create an even better system.

“There were concerns that it was hard to communicate what single-payer really means,” says Randy Block, chair of the National Council of Gray Panther Networks, who has been involved in health care advocacy since the 1970s. “A big portion of Americans do know about Medicare, and it’s a vehicle for building on existing systems and for helping the public understand that it’s possible to do a good job.”

If the first steps in moving toward the use of Medicare-for-all were about people recognizing the program’s efficiency and familiarity, the final one has come from a growing sense of frustration with the country’s current health care system. In the years leading up to the Affordable Care Act, the public ramped up its anger at the insurance industry. People were tired of high premiums, losing insurance over pre-existing conditions or going bankrupt to afford life-saving care.

Barack Obama entered the White House promising to do something about that. He initially supported the idea of a “public option,” which would let consumers who didn’t have coverage through work or other existing programs buy in to a Medicare-like government plan. But the public option idea died during the ACA debates, and the final law, while the largest health care reform since 1965, was criticized by those on the left for not going far enough and continuously attacked by those on the right.

“The lack of any bipartisan buy in for the ACA — which was designed in ways that the advocates hoped would encourage that kind of bipartisan buy-in — has meant that the advocates have said, if you can’t get significant Republican support or any Republican support, why don’t we do something we really want to, like expand Medicaid and Medicare?” explains Hacker, the health policy expert whose public option plan helped inspire the ACA.

Medicare-for-all advocates like Vermont Sen. Bernie Sanders have certainly felt this way. The Senator has now put forth five versions of his Medicare for All Act, with the latest bill recently introduced in in April.

And his idea is increasingly popular. While his 2013 bill had zero co-sponsors, the current version has 14, including four of his fellow 2020 Democratic hopefuls. A recent poll from the nonpartisan Kaiser Family Foundation found that support for a national single-payer health plan has increased 16% since 2000. And when it comes to the actual “Medicare-for-all” terminology, 63% of voters had a positive reaction to the phrase.

One thing experts note, however, is that voters are not always clear on what “Medicare-for-all” really means. The same Kaiser poll also found that when voters were told the details of health plans, 56% supported a true Medicare-for-all plan and 74% said they favored a proposal that would give them the option to buy a Medicare-like plan or keep their current coverage if they like it. This would actually be closer to Hacker’s new work, which led to the “Medicare for America” proposal that was introduced by Connecticut Rep. Rosa DeLauro and Illinois Rep. Jan Schakowsky in the House.

“I think the enthusiasm for Medicare-for-all has outpaced the changes in the political reality that would make Medicare-for-all possible. It’s still a really big lift,” Hacker says.

While several Democratic presidential candidates have supported Sanders’ plan, it seems that many are still navigating the nuances of what that means politically. New Jersey Sen. Cory Booker and California Sen. Kamala Harris, for example, have said they support “Medicare-for-all” but don’t want to get rid of private insurance, while Pete Buttigieg said he believes the best way is to provide “Medicare for all who want it” and Joe Biden similarly told voters they should have the option of a Medicare-like plan. Even Massachusetts Sen. Elizabeth Warren has said she is looking at “different pathways” to reach universal coverage.

“Because the enthusiasm of Medicare-for-all is growing among Democratic voters, other Democrats like many of those running for president are trying to tap into that enthusiasm,” says Oberlander. “They’re trying to use the rhetoric and rhetorical advantages of Medicare expansions while avoiding the political liabilities of Medicare-for-all.”

As politicians have seen over the past century, the political liabilities can be dangerous. But warnings of socialism are unlikely to have the same effect in the era of Sanders and Rep. Alexandria Ocasio-Cortez that they did during the 1950s.

“Young people are not afraid of the word socialism,” Hoffman says. “I’ve noticed that is not the major line of attack anymore. The main thing that we hear now is how are you going to pay for it?”

These attacks may yet be successful. Just because a policy is popular among Democratic primary voters is no guarantee it can survive the general election, particularly against President Donald Trump. But even if no plan succeeds this cycle, experts and activists say the current wave of support for Medicare-for-all feels vastly different from previous reform efforts that died under Truman or Clinton.

“It’s not like people can come in and say let’s just do incremental reform. We did try that,” Hoffman says. “It’s not just that it didn’t completely work, but it was so vulnerable to attack. The only way to prevent that is to have full scale comprehensive reform.”

http://time.com…

The public’s views on health care costs

The Upcoming U.S. Health Care Cost Debate — The Public’s Views

By Robert J. Blendon, Sc.D., John M. Benson, M.A., and Caitlin L. McMurtry, S.M.
The New England Journal of Medicine, May 29, 2019

U.S. health care costs — and not merely prescription-drug prices — have risen to the top of the national agenda. More than two thirds (69%) of the U.S. public has said that reducing these costs should be a top priority for President Donald Trump and Congress in 2019, ranking it behind only strengthening the economy (70%) on a list of 18 possible priorities (Pew, 2019) (see table). Given a list of 13 possible health-specific priorities, about 9 in 10 Americans said both prescription-drug prices (92%) and lowering the overall cost of health care (88%) were extremely important (Politico–HSPH, December 2018). In addition, when asked how much of a problem each of 18 domestic issues was, respondents ranked affordability of health care first, with 70% saying it was “a very big problem” (Pew, September–October 2018). We reviewed 14 national public opinion polls from 2018 and 2019 to elucidate the public’s perspective on health care costs and possible solutions.

Although the United States spends 18% of its gross domestic product on health — more than any other industrialized country — that is not the focus of the public’s concerns. In fact, 69% of the public believes that the United States is spending too little on health (only 10% believes we’re spending too much) (NORC–GSS, 2018); 56%, too little on Medicare (10%, too much); and 42%, too little on Medicaid (17%, too much) (West Health–NORC, February 2018).

Instead, the driving force for concern is the belief that health care services are unreasonably priced and that what people pay for care harms their household’s financial situation. More than half (53%) of Americans say the cost of health care affects their own household’s financial situation “a lot” (Pew, March 2018). Forty percent say they’re dissatisfied with the total amount they pay for care (Gallup, 2018).

So why, according to the public, are health care costs so high? When given lists of 12 or more possible reasons identified by policy experts and the media, respondents focus on charges by pharmaceutical companies (78% in one survey, 79% in another), insurance companies (70%, 75%), and hospitals (71%, 74%) as the main causes (KFF, 2018; Politico–HSPH, 2019).

Unlike many experts, the public does not see overuse of services as a significant contributor to the cost problem that concerns them. Some 60% of Americans attribute high costs to unreasonably high prices for services and drugs; 23% believe that Americans are getting more health care and prescription drugs than they need; and 11% consider these two factors equally responsible (Politico–HSPH, 2019).

About three fourths (76%) of the public believes that Americans are paying too much for most care they receive, relative to its quality. A majority also believes that health insurance premiums are increasing primarily either to boost profits for insurance companies (47%) or to accommodate high prices for care (16%), not because care is better (21%) or coverage is broader (13%) (West Health–Gallup, 2019).

Numerous broad-based proposals for reducing U.S. health care costs have been put forth by experts and covered by the media. More than half the public supported five of the seven such proposals they were asked to consider: making greater efforts to prevent disease and ensure that people live healthier lives (84%), having the government facilitate competition among health care professionals and hospitals based on price and quality (67%), having the government establish limits on what health care professionals and hospitals can charge (65%), allowing people 50 to 64 years of age to buy into Medicare (61%), and changing our health care system so that most people have Medicare and there is little or no private health insurance (52%) (Politico–HSPH, 2019). Although experts see competition and government regulation as fundamentally different ways of controlling health care costs, Americans are nearly equally supportive of both.

The two proposals the public does not favor would restrict patient access to treatments and prescription drugs: allowing payers not to cover some services deemed by experts not to be beneficial enough to justify their high cost, and giving individuals tax incentives to buy high-deductible plans. Each proposal was favored by only 37% of the public (Politico–HSPH, 2019). The public’s opposition to allowing experts to make decisions based on cost-effectiveness was similar in 2019 (56%) to what it was in 2012, when 43% were in favor and 54% opposed.

When asked whether they thought the five proposals favored by the majority would greatly reduce health care costs, however, a preponderance of respondents said they didn’t think any of the five, including Medicare for All, would do so (Politico–HSPH, 2019).

A similar pattern can be seen in attitudes toward high prescription-drug costs. Shortly after May 11, 2018, when Trump released the outline of a plan to lower prescription-drug prices, the public was asked whether they favored or opposed four components of the plan. Although a majority supported three of the four proposals, they saw only one as likely to be effective: having the Food and Drug Administration approve more generic, over-the-counter, and biosimilar drugs to encourage greater competition. Sixty-six percent favored this proposal, and 56% believed it would lower drug prices (Politico–HSPH, June-July 2018).

A large majority (82 to 89%) favors allowing the federal government to negotiate with drug companies for lower medication prices for people on Medicare (West Health–NORC, August 2018; KFF, February 2019; HSPH–SSRS, 2019). A smaller majority (58%) believes that such negotiations would reduce prices (HSPH–SSRS, 2019).

When asked whether government or private health insurance companies would be better at controlling health care costs, nearly half (47%) of respondents said government, while 38% said private companies. Notably, 61% of Republicans were in the latter camp, and 65% of Democrats were in the former (Politico–HSPH, 2019). And when respondents who thought that government-set limits on what health care professionals and hospitals can charge would reduce U.S. health care costs were asked which level of government would do a better job of establishing these limits, there was a similar lack of consensus: 51% said the federal government, and 45% said state governments. Once again, a partisan split was evident: 69% of Democrats chose the federal government, whereas 63% of Republicans chose state governments (Politico–HSPH, 2019).

What can we conclude from these findings as we approach the 2020 election? First, health care costs are likely to be an important election issue. But unlike many experts and political leaders, most Americans are not particularly concerned about aggregate health spending, either overall or on the part of government. In fact, when asked about the possibility of the Medicare Part A trust fund running out of money in the next 10 years, only 25% of the public was very concerned that it would (Politico–HSPH, 2019).

The public sees the issue of health care costs primarily as a price problem, rather than one of overutilization. Thus, proposals focused principally on reducing overuse of care are likely to be less popular than those that address high prices directly. People are likely to support candidates who talk about increasing overall health spending, not reducing it. In addition, it’s important to recognize that the public has not reached a judgment about whether increased competition or government regulation is more effective in controlling health care costs.

This debate tracks with the partisan divide: Republicans generally believe that private health insurance and state governments would be more effective at reducing costs, whereas Democrats tend to support efforts by government, especially the federal government, to address the problem. Finally, given the public’s skepticism that any approach will greatly reduce health care prices, if they are to actively support particular cost-saving proposals, they will have to be shown that those approaches would actually reduce what they pay for care. And if the public’s view is going to converge with that of many experts, they will have to be convinced that overuse of services plays a greater role in high health care costs than they currently believe.

https://www.nejm.org…

Comment:

By Don McCanne, M.D.

This review of recent national public opinion polls on health care costs shows that the public is very concerned about high costs, and that they believe those high costs are due to high prices rather than overutilization of health care services.

They are less consistent in their views of what can be done about it, and that confusion is compounded by political polarization.

What they do want are approaches that would actually reduce what they pay for health care. If you could remove ideology and political bias from their thinking, and if they would look more carefully at the policy options, then support for the single payer Medicare for All model would certainly prevail.

If we could only figure out why so many cling tenaciously to the simplistic antigovernment rhetoric that expresses concepts that are not in the interests of the great majority of us – if we could understand that, then maybe we could improve our message beyond that of affordable health care for all (not that there is anything wrong with our message).

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