March 1, 2019

Dr. Bohmfalk details the history of fire departments and suggests that, if we can move from exploitative private entities to public entities that serve the common good, then we can do the same in health care. Hosted by Joseph Sparks. Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

By Jeffrey Sachs
CNN, March 1, 2019

By Shefali Luthra
Kaiser Health News, February 27, 2019

Members of the House on Wednesday offered their version of a “Medicare-for-all” bill that is broader than what’s been put forth by Sen. Bernie Sanders (I-Vt.), whose 2016 presidential run pushed the issue into the political mainstream.

Rep. Pramila Jayapal (D-Wash.) and Rep. Debbie Dingell (D-Mich.) unveiled the “Medicare for All Act of 2019,” which redefines what the change in health care coverage might mean. The specifics included in the bill could play a role in the upcoming Democratic presidential primary campaign because candidates seeking support from the party’s progressive wing leverage the phrase. But often, they use it to mean various things.

Is this bill so different from Medicare-for-all proposals that have come before? And why would those differences matter? Here are the essential takeaways:

In terms of the policy 411, the Jayapal-Dingell bill includes provisions not in other proposals.

In many ways, the proposal sounds familiar: The government would establish a health plan that pays for basically all forms of medical care for all citizens. That’s how it gets the moniker “Medicare-for-all.”

Under this plan, patients would not be responsible for any cost sharing of medical expenses, and the government coverage would include hospitals, doctors, preventive care, prescription meds and dental and vision care. Private insurers would not be allowed to sell plans that compete with the government program.

Senior citizens would be folded into the new Medicare plan, which would be more generous than their current coverage, and the government would make sure any medical care they are getting is not disrupted. The bill leaves two other government health care payers intact: the Veterans Health Administration and the Indian Health Service. Beneficiaries enrolled in these programs would have a choice of enrolling in the new Medicare-for-all plan or sticking with their current coverage.

Just like the Sanders bill, the House legislation covers what it calls “comprehensive reproductive health.” Backers say it is meant to cover abortion — a controversial provision. Right now, government-funded health plans are legally prohibited from providing funds for abortions.

There are differences, too. For one, the transition to the new Medicare-for-all system would take place over two years, which would be a fast turnaround for a substantial task. Sanders’ bill suggested a four-year transition.

The biggest difference: This House vision of Medicare-for-all would also cover long-term care. That isn’t part of the Sanders bill, and it is not covered by Medicare. But for people with disabilities and the elderly, it’s a significant benefit — and one that can get very expensive to pay for out-of-pocket. (The Affordable Care Act included a long-term care provision that was eventually scrapped because of its high cost.)

The House bill also would take a swipe at high prices for prescription drugs by empowering the government to negotiate prices directly with manufacturers and to take away and reissue drug patents if such efforts faltered. This idea, known as “compulsory licensing,” has appeared in drug-pricing bills, but not in other Medicare-for-all legislation.

And the bill wades into one of the hottest Medicare-for-all controversies: the role of private health care. Notably, it permits it. Private plans can cover services not included in the single government health plan. Doctors can also refuse to participate in the program and charge patients cash for medical treatment instead.

“Whether there’s someone out in Beverly Hills who sees the stars and doesn’t partake — that would be possible,” said Dr. Adam Gaffney, a doctor and president of Physicians for a National Health Program, a single-payer advocacy group that supports the legislation. “The way the whole program is structured is to really make it such that that’s a very insignificant overall phenomenon.”

And the legislation takes on wonkier questions, like health care costs — proposing so-called global budgets that set a firm amount the federal government would pay for hospitals, for instance, as a strategy to bring down spending.

Still, the legislation leaves a lot of meaningful details open to interpretation.

Three big ones: what precisely would be covered, what doctors would be paid and how the program would be financed.

Generally, Medicare-for-all would provide “comprehensive benefits,” accounting for health care needs as “medically necessary or appropriate.” That means covering hospital and doctor visits, but also, for instance, mental health, maternity services, addiction treatment, pediatrics and medications.

Where it gets tricky is determining which specific services qualify as “necessary.” Sometimes that’s obvious — insulin for diabetics or a cast for a broken leg.

In other cases, it’s not as clear. Examples include politically controversial treatments, like gender confirmation surgery. Many experts do say the procedure is an important option for people with gender dysphoria. But specific components of it are sometimes deemed cosmetic or unneeded — often by those skeptical of the treatment to begin with.

There are also reconstructive surgeries that provide medical value, but may be deemed cosmetic.

The Department of Health and Human Services would have significant discretion in interpreting what specific services are “medically necessary.” That means political leanings or scientific debates could sway what’s covered, even from administration to administration.

“Reasonable people could disagree on certain things,” Gaffney acknowledged.

The legislation also spells out steps for determining how to pay doctors — a tricky issue, since doctors often complain that traditional Medicare pays them less than does private insurance. But the bill doesn’t set up a reimbursement system.

Of course, there’s the question of how the U.S. pays for the new program. Studies suggest Medicare-for-all would bring down national health care costs. Currently, though, much of that health spending is borne by the private sector. Under the Jayapal-Dingell bill, the money would have to come out of taxpayer dollars.

That would mean new taxes, and that’s a subject that does not appear anywhere in the Jayapal-Dingell bill. (Jayapal has said she will put out a separate list of potential taxes that could finance her single-payer proposal. Sanders also used this strategy — a separate list of “pay-fors” — to make a case for his bill.)

The bill could resonate throughout the 2020 campaign.

The House bill keeps a spotlight on the Medicare-for-all issue — requiring Democratic presidential primary candidates to answer more questions and spell out stances on this particular policy.

That could create some land mines. Medicare-for-all is controversial, and already major health industry groups have ramped up opposition to the broad idea. This bill’s specific provisions, such as its coverage of abortion, would add more adversaries. Its long-term care coverage would further drive up its multitrillion-dollar price tag

But Robert Blendon, a health care pollster at the Harvard T.H. Chan School of Public Health, pointed out that addressing concerns such as the long-term care benefit could add to the measure’s political muscle. It could make the idea more attractive to older voters, who otherwise might be hesitant to change their coverage but who do turn out disproportionately to vote in primaries.

That dynamic, he said, could skew primary results to favor candidates who endorse Medicare-for-all, as opposed to more moderate Democrats who have distanced themselves from the issue. (In a general election, he noted, costs could certainly diminish that support.)

“The long-term care piece is unbelievably significant,” he said. “It surely will help [progressives] with older voters.”

https://khn.org…

Remarks by Adam Gaffney, M.D., M.P.H.
Introductory Press Conference, H.R. 1384, February 27, 2019

I am so happy to be here today, speaking as a representative of Physicians for a National Health Program, an educational and advocacy organization of physicians across the country who know first-hand that a single-payer Medicare for All system is what this country needs.

I’d like to thank Congresswoman Pramila Jayapal for her leadership on this, and everyone here who’s joining together for this critical cause at this crucial moment.

As physicians, we see daily the harm that a for-profit, fragmented, privatized health care system imposes on our patients. We see the uninsured — the 29 million people without any health coverage — who go untreated, who develop unnecessary complications, who even die as a consequence.

We see the under-insured — the 44 million people who have coverage, but with holes and gaps so big it’s as if they’re not covered at all. These are people who go without needed care. People with asthma who don’t take their inhalers because they can’t afford the prescription. People with heart disease who don’t fill their prescription at all because they can’t afford it. People with multiple sclerosis, mental illness, or cancer who can’t get the care they need because the copays and the deductibles are too high.

Meanwhile, as physicians, we are encumbered with never-ending billing tasks and administrative tasks that take us from the bedside, that take us from the patient, from the practice of medicine itself. We see a corporate calculus replacing the fundamental calling of the medical profession and the profit motive superseding medical science and justice.

No longer. A Medicare for All system would guarantee health care for everyone in America, replacing the current welter of fragmented, inadequate plans that deny claims with universal coverage that is not only comprehensive, but first-dollar; not only portable, but seamless over life; that allows you to see the doctors and go to the hospitals that you want, not the ones that your insurance company tells you you have to go to.

At the same time, such a system would allow us as physicians to again focus on the care of patients, away from billing and back to the beside, which is why we became doctors to begin with.

Thank you so much, everyone, for joining together. The time for half-measures is over. Medicare for All, a single-payer universal health care system, is the name of the game and we’re going to win it!

more information on H.R. 1384:
pnhp.org/housebill

By Robert King
Modern Healthcare, February 27, 2019

House Democrats on Wednesday rolled out an ambitious proposal to extend Medicare to all Americans, eliminate private insurance and drastically overhaul reimbursement for doctors and hospitals.

Rep. Pramila Jayapal (D- Wash.) told reporters that the goal of the Medicare for All Act of 2019, which has more than 100 co-sponsors, is to completely overhaul the U.S. healthcare system and convert it to a government-run entity.

The legislation provides an outline of the thinking of some congressional Democrats on “Medicare for All,” an issue that has been highly debated among Democrats running for president in 2020.

“We believe that the market is broken and that is the core idea that we would like to fix,” She said on a call with reporters Tuesday. “We love to buy our coffee from Starbucks…but there are some things that should not be provided through the for-profit marketplace and we believe healthcare is one of them.”

The legislation would expand Medicare to provide insurance coverage to every American and would ban private insurers from offering any benefits that duplicate the benefits covered by Medicare, likely eliminating most of the private insurance market.

It would also drastically revamp how hospitals and doctors get reimbursed by Medicare.

Each hospital would get an annual prepaid budget to cover all healthcare costs for the facility for the given year. HHS would appoint regional directors that would oversee all hospitals and doctor offices in a specific region.

The director and the hospital would negotiate the budget. Nursing homes, health centers, home health agencies and independent dialysis facilities would also get an annual budget.

The budget would be determined by a host of factors that include the historical volume of services the hospital provided in the area, Jayapal told reporters.

“It is a common practice of most of the developed countries around the world and it has been very successful,” she said of global budgets. “It increases accountability over hospital spending.”

The annual budget could also be changed if there are certain circumstances, Jayapal said.

Doctor offices would still be paid under a fee-for-service model, however some physicians included in certain group practices can opt to get a salary from a hospital or another provider that gets a global budget.

Jayapal expects that around one to two million people would be out of work if the legislation becomes law because of the elimination of most private insurance. She said that 1% of the global budget for hospitals will go to a fund to provide services to displaced workers in the insurance industry.

“This could include pension benefits, include any number of things that would take care of these workers as we transition,” Jayapal said. “I do think there will be a boon to the economy once we get healthcare under control.”

Jayapal added that a private insurance industry could still exist, but they couldn’t cover the same benefits as Medicare, which include coverage of prescription drugs, hospital and physician services and long-term care services. However, an insurers could cover services such as cosmetic surgery or other types of elective benefits.

Healthcare sector lobbyists are expected to put up a vigorous fight against any “Medicare for All” proposal.

America’s Health Insurance Plans, the top lobbying group for the insurance industry, issued a pre-emptive strike on Tuesday in anticipation of the bill’s introduction.

“The vast majority of Americans are satisfied with the coverage they have today,” the group said in a statement. “They have choice and control over their coverage, options, and treatment.”

Jayapal said that money from industry groups would be the biggest obstacle to getting the bill through Congress.

But it’s unclear whether the bill will come up for a vote in the Democratic controlled House. Jayapal said that the legislation will first get a hearing in the House Rules Committee and in the House Budget Committee.

The bill has been referred to the House Energy & Commerce Committee and Ways & Means Committee, which both have healthcare jurisdiction. So far no hearing has been scheduled.

https://www.modernhealthcare.com…

By Jeff Stein
The Washington Post, February 26, 2019

More than 100 House Democrats plan to unveil a new “Medicare-for-all” plan Wednesday to provide government health insurance to every American, according to a copy of the bill provided to The Washington Post, as a number of Democratic-leading presidential candidates for 2020 feud over the party’s health-care platform.

Rep. Pramila Jayapal (D-Wash.), co-chair of the Congressional Progressive Caucus, is expected to release legislation Wednesday that incorporates key policy demands of single-payer activists, aiming to overhaul the U.S. health-care system even faster and more dramatically than legislation proposed in 2017 by Sen. Bernie Sanders (I-Vt.).

Jayapal’s Medicare-for-all would move every American onto one government insurer in two years, while providing everyone with medical, vision, dental and long-term care at no cost. Similar proposals have been projected to increase federal expenditures by at least $30 trillion but virtually eradicate individuals’ health spending by eliminating payments such as premiums and deductibles. About 30 million Americans do not have insurance, while tens of millions more are “underinsured,” meaning they cannot afford or do not seek care, according to the nonpartisan Kaiser Family Foundation.

The bill has 106 co-sponsors but essentially no chance of passing the House or Republican-controlled Senate this term. It comes amid a wider debate about the meaning of Medicare-for-all in Democratic policy circles, as some presidential candidates and center-left think tanks have said they support both Medicare-for-all while also aiming to preserve private insurance that currently enrolls about 150 million Americans. Jayapal’s plan would leave only a minimal role for private insurance in the United States, similar to Sanders’s bill in the Senate.

“We have a plan. We have a real plan,” Jayapal told reporters, calling the state of U.S. health care “atrocious” and dominated by a handful of wealthy corporate interests. “Americans are literally dying because they cannot afford insulin and can’t get the cancer treatments they need . . . I think this Medicare-for-all bill makes it clear what we mean by health care for all. We mean a complete transformation of our health-care system.”

The plan is, in a number of ways, more aggressive than the Sanders plan co-sponsored by more than a dozen Democratic senators, including presidential candidates Sens. Cory Booker (D-N.J.), Kamala D. Harris (D-Calif.) and Elizabeth Warren (D-Mass.). It is also significantly more detailed than the previous single-payer bill in the House introduced by then-Rep. John Conyers Jr. (D-Mich.), which at about 30 pages outlined only a set of goals with few legislative specifics.

Tim Faust, a single-payer advocate, said it was the first “comprehensive, battle-ready” single-payer plan to be introduced in Congress.

“The idea of Medicare-for-all has become extremely popular, but it’s at risk of being co-opted by those who want modest, incremental proposals that fall well short of true universal health care,” said Adam Gaffney, president of Physicians for a National Health Program, a group of doctors supporting single-payer that provided input to the Jayapal plan. “What we’re doing here is a big step forward to clarify exactly what Medicare-for-all means.”

Critics say the plan would require impossibly large new taxes, given its estimated $30 trillion price tag, and question the political wisdom of forcing nearly half the country to switch from the current private plan to a public insurer. Conservatives have also argued that a single-payer system could impede quality of care for those who have it, pointing to the potential for longer wait times.

Supporters point out that U.S. health-care spending per capita is more than two times as large as the average for developed nations, even as Americans have below-average life expectancy at birth and lag on a number of other key health outcomes. Single-payer advocates say one government insurer would have the bargaining power to drive down costs, while giving free health care to those who lack coverage.

Jayapal’s plan, about 120 pages, would transition every American to Medicare-for-all over two years, cutting the four-year transition in Sanders’s Senate bill in half. Sanders is currently working on an updated version of his legislation, according to Josh Miller-Lewis, a spokesman for the senator.

Some health policy experts fear that dramatically disrupting the health markets over four years could lead prices to explode in the private market, increasing the urgency of a quicker transition.

Jayapal’s bill also includes two big new provisions left out of the Senate legislation: a crackdown on the pharmaceutical industry aimed at lowering drug prices, and new government-run long-term care to help people with disabilities. It does not specify how it would finance the new legislation.

The number of Americans who require long-term care is expected to explode over the next few decades as the baby-boom generation ages, with the number of Americans with a disability projected to more than double from 2015 to 2065. Jayapal’s new Medicare-for-all bill, unlike the one Sanders introduced in the Senate in 2017, would guarantee free long-term care, including home health care, for Americans with disabilities as part of the single-payer system.

“This one part of it is, in some ways, as complicated and expansive as the Affordable Care Act itself,” said Harold Pollack, a University of Chicago health expert. “It’s an unbelievably complicated and fraught issue.”

Jayapal’s bill will include a proposal from Rep. Lloyd Doggett (D-Tex.) aimed at bringing down prescription drug prices by allowing Medicare to negotiate the price of drugs. The bill would give the government the ability to issue a generic license to produce the medication if negotiations fail, a provision known as “compulsory licensing.”

The previous version of the Medicare-for-all bill called for the elimination of all for-profit hospitals, and it called on the government to give financial compensation to providers that would be forced to become nonprofits. That provision was removed from the new Jayapal bill, in part because House aides feared it would lead the government to compensate hospital shareholders. In December 2018, Politico reported that hospitals, insurance companies and other health-care lobbies had launched a unified front to beat back the push for Medicare-for-all, raising the political stakes for Democrats who embrace the plan.

The new bill specifies that funds from the government’s Medicare-for-all could not be used “for profit,” union-busting, marketing or federal campaign contributions. Many hospitals with the biggest budget surpluses are also nonprofit, which seems to diminish the case for converting all hospitals to that model.

Jayapal also said between 1 million and 2 million people currently work in the private health insurance system, and that 1 percent of the new Medicare-for-all fund would go to a five-year transition program to pay for pension benefits, job training programs and other assistance for affected workers.

Congressional Democrats have proposed a number of incremental health reform provisions recently, including a plan by Sen. Debbie Stabenow (D-Mich.) and Tammy Baldwin (D-Wis.) that would create a public option for Americans from ages 50 to 64 to buy into Medicare. Sen. Brian Schatz (D-Hawaii) has proposed a Medicaid expansion via a state-based buy-in program. The recent push leftward on single-payer has made those plans, which would still use the federal government to expand health insurance to millions of people, seem more modest by comparison.

“Even though it’s still extremely unlikely to pass, Medicare-for-all has moved the political landscape so suddenly, it’s created a window for these other proposals to seem quite feasible,” said Pollack, a single-payer skeptic.

Hearings on the legislation are expected to begin later this year.

https://www.washingtonpost.com…