PNHP

Trump Administration’s proposed public charge immigration rules likely to harm millions of children: JAMA Pediatrics study

Trump Administration’s proposed public charge immigration rules likely to harm millions of children: JAMA Pediatrics study

The study is the first to examine the impact of the proposed change on children with significant medical needs

Contact:
Leah Zallman, M.D., M.P.H.: (917) 520-8918, lzallman@icommunityhealth.org
Steffie Woolhandler, M.D., M.P.H.: (617) 312-2766, swoolhan@hunter.cuny.edu

A proposal by the Trump administration to deny legal permanent residency status to immigrants who legally use public benefits like food assistance and Medicaid may prevent health care and nutrition aid from reaching millions of children, according to a new study by researchers from Harvard Medical School and the City University of New York at Hunter College that was published online today in JAMA Pediatrics. Currently, enrollment in public food, housing, and health insurance programs are not counted against immigrants applying for permanent residency, also known as “green cards.”

The study is the first to examine the impact of a proposed change in the U.S. Department of Homeland Security’s ‘public charge’ rule on children with significant medical needs. Researchers found that between 0.8 million and 1.9 million such children currently enrolled in public health insurance and the Supplemental Nutrition Assistance Program (food stamps), may lose these benefits, endangering their health. Most of these children are citizens living in households with a non-citizen immigrant parent or other family member. 

Using data from the Medical Expenditure Panel Survey, the authors estimated the number of children who need medical care and who live in families that may disenroll from public benefits. They also estimated the number of children in need of medical care, e.g., kids with asthma, who may lose benefits due to the proposed rule change.

In 2015, 8.3 million children enrolled in Medicaid and the Children’s Health Insurance Program or who received Supplemental Nutrition Assistance Program benefits lived with adults who may disenroll their families from benefits due to fear or confusion caused by the proposed rule, even if the rule does not technically apply to them. Of these children, 5.5 million had medical needs, including 615,842 with asthma; 53,728 with epilepsy; 3,658 with cancer; and 583,700 with disabilities or functional limitations. The article concludes that this policy would threaten the health and wellbeing of millions of children, most of whom are U.S. citizens.

“Most children who lose Medicaid or CHIP due to this proposed rule will become uninsured, and are likely to skip needed care,” said lead author Dr. Leah Zallman, Director of Research at the Institute for Community Health at Cambridge Health Alliance/Harvard Medical School, where she is also an Assistant Professor of Medicine. “For many children, skipping care will lead to long-term medical problems, increased health care costs and school absenteeism. It also means that their parents — many of whom play vital roles as caregivers in nursing homes and home care — will be forced to skip work. The proposed public charge policy will threaten the health of millions of children and have negative repercussions for generations to come.”

The DHS proposal would affect both green card applications and applications for admission to the U. S. It would not apply to other immigrants, including: refugees; asylees; survivors of trafficking, domestic violence, or other serious crimes (T or U visa applicants/holders); VAWA self-petitioners; special immigrant juveniles; and certain people paroled into the U.S. Immigrants who already hold green cards are also exempt from public charge requirements when applying for U.S. citizenship.

The DHS proposal is one of several regulatory policy changes experts expect to dissuade lawfully-present immigrants and their families from using health and social services programs. Other Trump Administration regulatory proposals contributing to this “chilling effect” have been proposed by the U.S. Department of Housing and Urban Development, U.S. Department of Agriculture’s Food and Nutrition Service, U.S. Department of State (which processes visa applications abroad), the Social Security Administration, and a draft proposal by the U.S. Justice Department.

“Punishing children by denying them medical care and nourishment is a gross violation of medical ethics and common decency. But that’s what President Trump’s proposed immigration policy changes will do to millions of innocent children,” said Dr. Steffie Woolhandler, Distinguished Professor of Public Health at the City University of New York at Hunter College and Lecturer in Medicine at Harvard.

“Implications of changing public charge immigration rules on children who need medical care,” Leah Zallman, M.D., M.P.H., Karen Finnegan, P.h.D, David Himmelstein, M.D., Sharon Touw, M.P.H., Steffie Woolhandler, M.D., M.P.H., JAMA Pediatrics, July 2019.

Drs. Woolhandler and Himmelstein are co-founders of Physicians for a National Health Program (PNHP) which advocated single-payer health reform.  PNHP had no role in the funding or designing the research, which was partially funded by a grant to Dr. Zallman from the California Health Care Foundation.

The truth behind the lies about Medicare for all

By James Binder, M.D.
The Cincinnati Enquirer, July 1, 2019

The private insurance industry cannot reasonably defend CEO salaries of $100,000 a day, wasting $ 500 billion dollars a year on excessive bureaucracy, denying care to sick and dying patients, restricting care to small networks, charging $5,000 deductibles, so they go on the attack. They attack single-payer Medicare for all with lies.

These are felony lies because many lives would be saved with an improved single-payer Medicare for all. Allowing the private insurance to restrict and deny care results in tens of thousands of unnecessary deaths a year due to uninsurance (and underinsurance), according to a 2009 Harvard study. I say unnecessary deaths because a single-payer, improved Medicare for all program would cover everyone automatically, provide comprehensive care (dental, mental, eye, long-term care) for life, allow free choice of doctors and hospitals and cost no more than what we are currently paying into the system.

Myths about single-payer Medicare for all are perpetuated daily by politicians and uninformed media. It is crucial to expose these myths, because they are the biggest obstacle to establishing a just, equitable and humane health care system in the U.S.

Myth: It will be expensive and lead to a large increase in taxes.

Single-payer programs in other nations, such as Canada, Taiwan, and Australia show that it is possible to provide high quality for everyone at about one-half the cost, per capita, that the U. S. is spending now. This is accomplished by eliminating the costs of a wasteful, complex private insurance bureaucracy, negotiating fair prices from Big Pharma through the power of a monopsony, and operating hospitals with a global budget, just like fire departments and public schools operate now.

Medicare has an overhead of about 2%; private insurers have a 12-14 % overhead. The only way the enemies of single-payer can argue against this type of basic economic fact is to use scare tactics and cite false information.

There would be a 2% increase in income taxes for individuals if single-payer Medicare for all was adopted. Since there would be no premiums, deductibles, and co pays, the net result for 95% of people would be to pay less for health care, yet get full, comprehensive care. Only the wealthy would pay more than they pay now.

Myth: The government will run it poorly. There will be rationing and long waits to see a doctor.

There are many parts of our government that run well, such as the CDC, NIH, and Social Security system. Many private companies run poorly. I’d rather have a committee of health professional and informed citizens with oversight responsibilities making health care decisions than CEOs responding to investors.

Remember, we are talking about the financing of health care; the delivery of health care will remain private. The clinician-patient relationship would become sacred once again, since the intrusion of private insurers would be removed.

Finally, we already have rationing of health care. We ration on the basis of ability to pay, and that is unjust. No one will be excluded in a single-payer Medicare for all program. We have a large capacity in the U.S. The flow of patients will be readily managed, just as it was when 19 million senior citizens were suddenly covered by Medicare in 1966.

Myth: It will take away patient choices of doctors and hospitals.

The truth is, patients would have free access to any doctor or hospital they wanted with single-payer Medicare for all. The narrow networks are the creation of the private insurance industry. People with employment health insurance often find that their coverage is not so great when they actually need to use it. Deductibles and copays are very high and specialists are frequently out of network. In addition, they forego other employment benefits, like salary increases, in order to have these limited health care benefits.

Myth: It will lower innovation for new treatments and worsen our health care.

Most health research is financed through the National Institutes of Health (NIH). Private companies become involved only after the public has paid for the development and clinical trials for new treatments.

Myth: It would be better to simply add a public option and retain the hundreds of private insurance companies. Examples: Medicare -X and Medicare for America.

This is a con. The private health insurers are trying to avoid elimination. They provide no value to the system or to the patient. They just add costs and complexity. The huge cost savings gained from eliminating the wasteful health insurance bureaucracy would be lost if we simply added a public option. Public option plans have been tried and tried and failed every time. It is time to move to a solution that has been shown to work in countries throughout the world.

Support single-payer improved Medicare for all.

Dr. James Binder is co-founder of the Cincinnati Chapter-Physicians for a National Health Program.

https://www.cincinnati.com…

Sources of inertia in health plan choice

Sources of Inertia in Health Plan Choice in the Individual Health Insurance Market

Presenter: Coleman Drake
Co-Authors: Conor Ryan; Bryan Dowd
8th Conference of the American Society of Health Economists, June 23-26, 2019

Inertia, the tendency to stay enrolled in a health plan from one year to the next, is a well-documented phenomenon in the health insurance literature. Handel and Kolstad (2015), among others, find that consumers are willing to pay hundreds of dollars per month to avoid switching health plans. However, it is less clear why consumers exhibit inertia. In this paper, we separately identify three separate reasons consumers may exhibit inertia: (1) tastes for continuity of care from in-network providers and insurers; (2) hassle costs; and (3) inattention resulting from choice frictions. While the literature has begun to explore these different sources of inertia, it has not incorporated them into a single model. We do so using a novel combination of Abaluck and Adams’s (2018) default-specific consideration model and a random parameters mixed logit model. This model allows us to separately examine inattention in plan choice and plan choice among attentive households. Our data are household-level 2014-2018 enrollment data from Covered California, California’s State-based Health Insurance Marketplace. Covered California is the nation’s largest Marketplace; it covers roughly 1.4 million enrollees each year. Preliminary results suggest that the mean household is willing to pay $77 per month to avoid the hassle of plan switching (conditional on being aware of plan characteristics) and $282 per month for continuity of care. Inattention increases total switching costs by an additional $150 per month. Tastes for continuity do not directly reduce consumer welfare – consumers may derive utility from staying with the same health care provider – but they could limit the benefits of competitive insurance markets. Choice frictions and hassle costs, in addition to having the same anti-competitive effects, reduce welfare through sub-optimal choices. Policymakers seeking to improve consumer welfare should therefore focus on reducing consumers’ choice frictions and hassle costs. Potential remedial policies include increasing outreach from insurance navigators and funding programs to educate consumers about the benefits of active health plan choice.

https://ashecon.confex.com…

Comment:

By Don McCanne, M.D.

Because of its technical nature, this is a report that only an economist can love, but it does have an important lesson for single payer supporters.

Enrollees in health plans tend to be reluctant to change plans at the policy anniversary. This inertia can be due to: “(1) tastes for continuity of care from in-network providers and insurers; (2) hassle costs; and (3) inattention resulting from choice frictions.” Although hassle costs are an important factor, even more important is the reluctance to risk continuity of care that stems from changes in provider networks. This inertia can result in additional insurance costs of $509 per month ($77 + $282 + $150).

Every time that you hear the opponents of single payer Medicare for All say that people want to keep the insurance they have, you can feel confident that they don’t really want to pay an extra $509 per month. It has been said many times, it is not the insurance that they want to keep, it is their choice of health care professionals and institutions that they value highly.

The spin masters keep telling us that polls show that people do not want Medicare for All if it means being deprived of their choice of private insurance. But what if the polls asked this question instead: Would you give up the insurance you now have if the new public plan was guaranteed for life, always providing you with your choice of physicians and hospitals, providing all essential benefits, including drugs, dental, eye, mental health, and long term care, had no out-of-pocket costs whenever accessing health care, and was paid for by taxes that you could afford because they are based on your ability to pay instead of being based on the high costs of care? That was a long question so let me ask that again…

The point is we need to step up our efforts to be sure that the public understands what they actually could have if we were to enact and implement the single payer model of Medicare for All.

Addendum:

By Don McCanne, M.D.

Although the comment states that inertia in changing health plans could result in additional insurance costs of $509 per month, that is unlikely since the amount was derived by adding three different thresholds for what a household would be willing to pay to avoid three specified reasons for inertia. In fact they should not be additive since exceeding any one of the three thresholds would likely overcome the inertia to change plans at the policy anniversary. But that does not change the fact that most people, if they were well informed on the single payer model of reform, would be much more satisfied with a new public plan that was “guaranteed for life, always providing you with your choice of physicians and hospitals, providing all essential benefits, including drugs, dental, eye, mental health, and long term care, had no out-of-pocket costs whenever accessing health care, and was paid for by taxes that you could afford because they are based on your ability to pay instead of being based on the high costs of care.”

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

Single-Payer Advocates Seek to Reverse Doctors’ Lobby Opposition

By Alex Ruoff
Bloomberg, June 28, 2019

About a decade ago Phillip Verhoef left the American Medical Association because it wouldn’t back efforts to replace the nation’s private health insurance system with a public one. He was frustrated the group focused more on doctors’ pay than what saw as a flawed health system.

Verhoef, assistant professor of medicine and an intensivist at the University of Chicago, has spent the years since selling the idea of “Medicare for All” to medical students, fellow doctors, elected officials and anyone who will listen. He’s met with medical student organizations to explain how it might work and their role in changing people’s minds about the subject.

Now, he’s hoping to convince the AMA it’s time to join him.

“We won’t get single payer until we get a demand for it from a large body of physicians,” Verhoef said. “I believe we can do that.”

Verhoef, who serves on the Illinois board for Physicians for a National Health Program, an organization of about 20,000 doctors who advocate for a single-payer health system, is part of a collection of groups hoping to persuade the AMA to reverse its long-standing opposition to ending private health insurance in the U.S. They see the medical group as crucial to their goal of getting lawmakers—and the nation—to support Medicare for All because the AMA is the single largest organization representing doctors and has a long-standing presence on Capitol Hill.

“They’re on the wrong side of history and we want them to get on the right side,” Lori Clark, executive director of the Jane Addams Senior Caucus, said.

These groups are organizing rallies outside the AMA’s headquarters in Chicago and held a protest inside the group’s annual meeting early in June demanding the country’s largest doctors lobby support some type of Medicare for All legislation.

Their first demand is that the AMA end its association with the Partnership for American’s Health Care Future, a collection of hospital, doctors and insurance groups that works through a D.C.-based lobbying shop to oppose single-payer legislation.

Doctor groups have fought the growth of public insurance largely because it typically pays much less for their services than private insurance. Medicare can pay half or even a third as much for some common doctors services than private insurers.

Making Progress

The organizations pushing for single payer, including the National Nurses United, People’s Action, Democratic Socialists of America, and others, say they’re seeing progress.

AMA members voted down a measure to support a single-payer health system by 53% to 47% in June, the closest the group has ever come on such a vote.

Pramila Jayapal (D-Wash.), the lead sponsor of the House’s Medicare for All bill (H.R. 1384), celebrated the vote as a sign more doctors favor her idea.

“Doctors and the AMA are influencers in this debate and we want them lining up behind us,” she said. “It’s slower than we want, but it’s happening.”

The AMA vote came from the group’s Medical Student Section. “They’re the most interested in what we have to say,” Verhoef said.

However, the groups are also looking at the AMA’s finances and leadership, searching for ways to influence them, Clark said. She said the group has deep pockets, taking in more than $360 million in 2018, according to tax reports. It makes decisions about its lobbying positions based on votes cast by individual delegates.

AMA Stance

After the failed vote on a single-payer amendment, 83% of AMA delegates at that same meeting signed on to a report from the AMA Council of Medical Service calling for policies to “build upon and fix” the Affordable Care Act.

The AMA has fought most expansions of public health insurance programs, including the creation of Medicare in 1965.

The AMA spent nearly $20 million in 2018 on lobbying efforts, partly to fight the push toward Medicare for All, according to lobbying disclosure forms.

The AMA referred questions to the Partnership. Lauren Crawford Shaver, the executive director of the Partnership, said support for Medicare for All is waning, not growing.

“If you look at the polls, people are getting educated and realizing what it means,” Shaver said.

A June 18 poll from the Kaiser Family Foundation showed that most Americans are unaware of how dramatically a single-payer system would change the U.S. health care industry. About 40% of those Kaiser polled thought private insurance would continue in a single-payer system, something the Jayapal bill would nearly eliminate.

https://news.bloomberglaw.com…

Amanda Snead Cook County Testimony

Chicago-area medical student and SNaHP member Amanda Snead testified at a Cook County Board of Commissioners hearing on June 27, 2019 (testimony begins at 32:27). She was joined by other SNaHP students and members of National Nurses United, all of whom urged the County Board to support a resolution advocating single-payer reform. The resolution passed unanimously.

Garnishing wages for medical debt

Prevalence and Characteristics of Virginia Hospitals Suing Patients and Garnishing Wages for Unpaid Medical Bills

By William E. Bruhn, BS; Lainie Rutkow, JD, PhD, MPH; Peiqi Wang, MD, MPH; Stephen E. Tinker, BS; Christine Fahim, PhD; Heidi N. Overton, MD; Martin A. Makary, MD, MPH
JAMA, June 25, 2019

An estimated 20% of US consumers had medical debt in collections in 2014. Medical debt has been increasing with direct patient billing, rising insurance deductibles, and more out-of-network care being delivered, even at in-network facilities. Bills sent directly to patients may use the undiscounted price of a hospital’s services and can result in financial hardship and avoidance of future medical care. Hospitals need to be paid for care delivered, but some bills are unpaid. Hospitals may negotiate, reduce, or write off payments. Some have begun adopting a range of aggressive strategies for collecting unpaid bills, including suing patients and garnishing their wages or bank savings. We examined garnishment legal actions among Virginia hospitals.

From the Discussion

Thirty-six percent of Virginia hospitals garnished wages in 2017, with a small number of hospitals accounting for most cases. Some characteristics suggest that hospitals with greater financial need (nonprofit, lower annual gross revenue) may be pursuing debt collection to the final stage of garnishment.

https://jamanetwork.com…

The Nonprofit Hospital That Makes Millions, Owns a Collection Agency and Relentlessly Sues the Poor

By Wendi C. Thomas
ProPublica, June 27, 2019

From 2014 through 2018, Methodist Le Bonheur Healthcare filed more than 8,300 lawsuits, according to an MLK50-ProPublica analysis of Shelby County General Sessions Court records.

Other hospitals in Memphis and around the country also sue patients. According to a study published Tuesday in the Journal of the American Medical Association, researchers found more than 20,000 debt lawsuits filed by Virginia hospitals in 2017.

Its handling of poor patients begins with a financial assistance policy that, unlike many of its peers around the country, all but ignores patients with any form of health insurance, no matter their out-of-pocket costs. If they are unable to afford their bills, patients then face what experts say is rare: A licensed collection agency owned by the hospital.

Lawsuits follow. Finally, after the hospital wins a judgment, it repeatedly tries to garnish patients’ wages, which it does in a far higher share of cases than other nonprofit hospitals in Memphis.

Its own employees are no exception. Since 2014, Methodist has sued dozens of its workers for unpaid medical bills, including a hospital housekeeper sued in 2017 for more than $23,000. That year, she told the court, she made $16,000. She’s in a court-ordered payment plan, but in the case of more than 70 other employees, Methodist has garnished the wages it pays them to recoup its medical charges.

Debt That Will Follow Her to the Grave

Judge Betty Thomas Moore called Carrie Barrett’s name again.

Barrett stood, and (hospital attorney Dewun) Settle asked the judge to set her payments at $100 a month.

The judge agreed, denying Barrett’s motion to pay $40 per month.

Months later, Barrett was still bothered by the outcome.

“If you know I can’t pay $40, why you think I can pay $100?” Barrett said.

Between February and May, Barrett managed to make her payments on time, by shorting other bills and relying on payday loans. But this month, she missed her payment due date.

If Methodist doesn’t add any interest to Barrett’s debt and she pays as ordered, she will pay it off in 330 months.

She will be 90 years old.

Not long after her day in court, Barrett filed her 2018 taxes.

She made $13,800.

“It’s in the hands of God now,” she said. “There’s only so much I can do.”

https://www.propublica.org…

When Hospitals Sue For Unpaid Bills, It Can Be ‘Ruinous’ For Patients

By Selena Simmons-Duffin
NPR, June 25, 2019

(Daisha) Smith is unflinching when she talks about Mary Washington and what happened to her after she went to the hospital in 2017.

At the time she didn’t have insurance. She was working part time at Walmart for $11 an hour. She doesn’t want to give the details about why she ended up at the hospital. “I was not myself,” she says. “So I walked myself into Mary Washington to get help — to get myself on track.” She says she was admitted for two weeks.

The hospital sued her for $12,287.68. She had a default judgement against her and did not realize she had been sued until she saw her paycheck mysteriously disappearing.

“When I looked at my pay stub, I’m like, ‘Why do I only have like $600-something in my account?’ ” She noticed “garnish” written on the bottom of her pay stub. “So I called my company and asked them, ‘Who’s garnishing my check?’ ” They told her it was Mary Washington.

With the garnishment, her take-home pay for a month of work comes to about $1,400. Her rent is $1,055. “I literally have no food in my house because they’re garnishing my check,” she says.

https://www.npr.org…

Comment:

By Don McCanne, M.D.

Even with insurance, our current health care financing system does not prevent medical debt for millions of workers and their families. For far too many, essential expenses such as housing, food, and transportation exceeds their incomes. What does adding to this the stresses of wage garnishment and taking out usurious loans from payday lenders do? Who benefits when the hole is only dug deeper?

Under a single payer Medicare for All program that eliminates premiums and cost sharing, no medical debt accrues since the health care system is prepaid through equitable taxes. Taxes should not create the same kind of financial burden since progressive taxes are based on the ability to pay.

Yet most of the Democrats in the presidential debate last evening want to protect the private, employer-sponsored insurance system that covers about half the population. They seem to feign obliviousness to the consequences of such a financing system including potential exposure to wage garnishment and usurious payday loans. Not that the Republicans are any better since they keep promising a better system but than never deliver.

Single payer Medicare for All removes financial barriers to care. It’s that simple.

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

Despite the Affordable Care Act, millions of Americans with cardiovascular diseases and cardiovascular risk factors still can’t get needed care

Harvard researchers found that nearly 10 million Americans with cardiovascular conditions gained coverage, but twice as many still lack insurance post-ACA

Contact: Danny McCormick, M.D., M.P.H., Harvard Medical School, 617-548-7213 or danny_mccormick@hms.harvard.edu
Clare Fauke, Physicians for a National Health Program, 312-782-6006 or clare@pnhp.org

Cardiovascular disease (CVD) is the leading cause of death for Americans, yet millions with CVD or cardiovascular risk factors (CVRF) still can’t access the care they need, even years after the implementation of the Affordable Care Act (ACA).

In a new study published today in the Journal of General Internal Medicine, researchers at Harvard Medical School found the ACA increased insurance coverage and improved access to medical care for Americans with CVD such as heart disease and stroke, and for those with CVD risk factors including smokers and those with diabetes and obesity. However, three years after the ACA took full effect, 20.6 million remained uninsured, and many were unable to get regular medical care due to cost. The study is the first to document the effect of the ACA on Americans with CVD and CVRF, a group with complex health care needs that face significant health consequences when they lack coverage.

Researchers analyzed nationally representative data on more than one million adults aged 18 to 64 with a range of cardiovascular conditions, comparing data from before ACA implementation (2012-13) to data after the ACA was in effect (2015-16). They estimated that nearly 7% of those with CVD or CVRF gained insurance coverage in the first three years after the ACA went into effect, and that the ACA slightly narrowed previous disparities in coverage for ethnic and racial minorities.

Insurance coverage increased most in states that expanded Medicaid, from 81% to 89%. In non-expansion states, coverage increased more modestly, from 76% to 81%. Post-ACA, the percentage of chronically ill people with insurance ranged from a high of 94% in Massachusetts to a low of 73% in Texas. In addition to increases in coverage, the study found that post-ACA, Americans with CVD were less likely to forgo a doctor visit due to cost, and were more likely to have a check-up in the last year, and to have a primary care physician.

Despite these gains, researchers discovered major gaps in coverage and access to care: Nearly one-quarter of low-income Americans with a CVD or CVRF — more than 20 million people — still lacked coverage, and approximately 13% of black and 29% of Hispanic adults in the U.S. with CVD/CVRF remain uninsured. Among Hispanic people with CVD/CVRF in non-Medicaid expansion states, 42% still lack insurance, 25% could not afford a doctor visit, 40% did not have a checkup in the last year, and 48% did not have a personal physician.

“Patients with existing cardiovascular conditions require regular medical care and daily medications to prevent another heart attack or stroke,” said lead author Ameen Barghi of Harvard Medical School. “The good news is that the medications for cardiovascular disease are very effective, and millions of Americans gained some coverage under the ACA. Unfortunately, despite these gains, millions of Americans with these conditions remain uncovered, and many of those will likely suffer serious complications and even death because they cannot get the care they need.”

“The data shows that insurance coverage increased more in states that opted to expand Medicaid, and also that coverage rates were already lowest in non-expansion states before the ACA, highlighting the importance of the Medicaid expansion for people with serious pre-existing medical conditions,” said Dr. Hugo Torres, a study author and also a physician at Massachusetts General Hospital and Instructor of Medicine at Harvard Medical School. “If more states expanded Medicaid, many more people with cardiovascular disease would be covered, particularly among people with low incomes, and in communities of color.”

Dr. Torres notes that these findings should be considered in light of the Trump administration’s intention to repeal and replace the ACA with a more “market-based” system.

“Repealing or weakening the ACA would strip coverage from millions of Americans with cardiovascular disease or cardiovascular risk factors, spelling disaster for many of them,” said the study’s senior author, Dr. Danny McCormick, a physician at Cambridge Health Alliance and Associate Professor at Harvard Medical School. “However, today’s piecemeal approaches to coverage, including the ACA, will not get all these patients covered. Only a comprehensive Medicare-for-All plan could provide both coverage and good access to care for everyone with a cardiovascular disease or risk factor. Polls show that such reform is popular with the American people, and increasingly on the agenda of many elected officials.”

###

“Coverage and Access for Americans With Cardiovascular Disease or Risk-Factors after the ACA: A Quasi-Experimental Study,” Ameen Barghi, B.A., M.P.P.; Hugo Torres, M.D., M.P.H.; Nancy Kressin, Ph.D.; and Danny McCormick, M.D., M.P.H. Journal of General Internal Medicine, published online first, June 27, 2019. DOI: 10.1007/s11606-019-05108-1

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. PNHP had no role in funding or otherwise supporting the study described above.

Out-of-pocket costs increased 14% in 2018

Report: Patients' out-of-pocket costs increased up to 14% in 2018

By Tara Bannow
Modern Healthcare, June 25, 2019

Patients’ out-of-pocket costs for inpatient services increased by 14% on average between 2017 and 2018, according to a new report from TransUnion Healthcare.

Revenue-cycle management provider TransUnion revealed its findings Tuesday during the Healthcare Financial Management Association’s annual conference in Orlando, Fla.

Last year, patients who received inpatient care saw the biggest hikes in their out-of-pocket costs. Patients’ deductibles and co-pays averaged $4,659 for an inpatient visit in 2018, compared with $4,086 in 2017.

Outpatient care saw a noteworthy uptick of its own. Patients’ out-of-pocket costs averaged $1,109 for an outpatient visit in 2018, up 12% compared with $990 in 2017.

Parallon, HCA Healthcare’s revenue-cycle subsidiary, has observed patients’ co-pays and deductibles increasing between 6% and 8% annually for at least seven years, said Eric Ward, Parallon’s CEO.

https://www.modernhealthcare.com…

Comment:

By Don McCanne, M.D.

According to this report, co-pays and deductibles have been increasing between 6% and 8% for at least seven years, and it is getting worse. Between 2017 and 2018, the increase in out-of-pocket costs was 14% on average.

Recent polls have shown that it is the costs of health care about which the public is most concerned, yet the insurance industry appears to be relatively insensitive to these issues. Also a recent poll showed that much of the public is not aware that the single payer model of Medicare for All would eliminate deductibles, coinsurance, and co-payments.

In advocating for single payer Medicare for All, it is important to deliver this point. There are no out-of-pocket expenses for accessing health care. The system is prepaid by fair taxes based ability to pay. Most individuals would be paying less than they do now, though much of what they are paying is hidden from them (forgone wage increases for employer contributions to plans, and general revenue taxes that pay for much of government-funded health care which is about 60% of all health care spending).

It is also important that they know that single payer uses tools to slow the rate of increases in health care costs, providing greater financial security for the future.

These out-of-pocket costs are highly visible to the patients. They need to understand that they would go away under single payer Medicare for All.

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

Beware of Medicare Advantage for All

AHIP19: Cigna's Cordani says it's time to press pause on 'Medicare-for-All' talk—but change is necessary

By Paige Minemyer
Fierce Healthcare, June 19, 2019

Cigna chief David Cordani said it’s time to pump the brakes on calls for a healthcare system overhaul like “Medicare for All.”

Cordani, speaking at the AHIP Institute & Expo Wednesday, said insurers should hear the underlying message from consumers that their care is often too costly. And while reform on the scale of transitioning to a single-payer system may not be necessary, consumers’ frustration with healthcare costs does speak to the need for real, substantial change, he said.

“There’s a real call from a societal standpoint for more value and more peace of mind to be delivered to individuals,” Cordani said.

Instead, Cordani said the solution is for insurers like Cigna to strengthen the public-private partnerships they operate today—Medicare Advantage and Medicaid managed care being the two prime examples—and pivot toward work that keeps people healthy in the first place.

https://www.fiercehealthcare.com…

Q&A: ‘We have had a maniacal focus on the patient’

Modern Healthcare, June 22, 2019

Dr. William Shrank had some big shoes to fill. In April he succeeded now-retired Dr. Roy Beveridge as chief medical officer at Humana. Shrank was previously CMO at UPMC. Shrank recently met with Modern Healthcare’s editorial board to discuss his goals at the large insurer.

MH: How will you apply some of what you learned at UPMC to your new role at Humana?

Shrank: We’re focused on the elderly population; we’re focused on Medicare Advantage. We have been putting a whole host of assets and tools together that we can wrap around and meet patients in the community.

MH: Recently it was reported that Humana CEO Bruce Broussard came out against proposals to adopt a Medicare for All type of proposal. What would you see as some of the drawbacks of such a plan?

Shrank: We should be really precise about some of the terms here. Everyone agrees that expanding healthcare coverage is a good thing. That’s not in question. The response was very specific about a very specific part of a proposal that said that there would be no private insurance, there would be no Medicare Advantage. We believe very firmly that Medicare Advantage is an important part of the solution set for our seniors for a variety of reasons. We know that Medicare Advantage allows us to offer a broader set of benefits that we know are not covered in traditional Medicare—vision, hearing aids, a variety of things that are not available in traditional Medicare.

We know that Medicare Advantage offers protection against financial catastrophe with maximum out-of-pocket costs. We know, most importantly, that Medicare Advantage is the most rapid way to transform healthcare to a value-based system.

https://www.modernhealthcare.com…

Former Aetna CEO Mark Bertolini on ‘Medicare for All’: No one can explain to me what it is

Medicare Supplement News, March 28, 2019

Squawk Box: How do you deal with things like Medicare for All?

Mark Bertolini: Well, let’s talk about Medicare for All. Medicare for All, single payer – great populist term to throw out to the public. What is it? Nobody can tell me… Tell me a country that has a program like that. Most people say Canada or the UK. Those are not Medicare for All or single payer systems. Those are socialized systems…

SB: Wouldn’t single payer here mean that it’s a public option and there aren’t private options any more?

MB: So that’s the second question I ask. Who runs all of our public programs today… The private insurers… The health care insurance companies are the intermediaries for Medicare and Medicaid. We run it for the government. They give us the specs. We build it out…

SB: There’s a lot of things in Medicare, a lot of waste, a lot of fraud.

MB: There sure is in Medicare fee for service, not in Medicare Advantage which is what we run more tightly…

SB: Didn’t we try to drive a stake into Medicare Advantage?

MB: It’s too big to kill; it’s over 20 million lives… Back to the ACA, if we had allowed Medicaid expansion to happen and we would have means tested people down to age 50 for Medicare – Medicare Advantage – so 50 to 65, we would have covered more people than the ACA did at far less cost…

http://medsuppnews.com…

As Democrats Talk Single Payer, Private Medicare Advantage Soars

By Bruce Japsen
Forbes, February 3, 2019

Health insurers are reporting unprecedented growth in the number of seniors flocking to private Medicare Advantage plans amid talk of a single payer government-run approach that could uproot such coverage.

https://www.forbes.com…

How About Medicare Advantage for All?

By Froma Harrop
Real Clear Politics, September 13, 2018

Let’s be blunt. The government must limit its spending by fiat. Then we can let the market step in and sort out the details. Under Medicare Advantage for all, the insurers would become, in effect, regulated utilities.

https://www.realclearpolitics.com…

One Proven Way to Improve U.S. Health Care: Expand Medicare Advantage

By John S. Toussaint
Harvard Business Review, February 14, 2018

It’s time for a better idea that addresses both cost and quality. That better idea is expanding the successful Medicare Advantage program to both Medicaid and employer-covered populations.

https://hbr.org…

Comment:

By Don McCanne, M.D.

The single payer model of Medicare for All would eliminate private health insurance plans (except for supplemental plans for nonessential services), but nobody should expect the insurance industry to sit back and accept this fate. In fact, the private Medicare Advantage plans have already been very successful in displacing about 40 percent of the traditional Medicare program. It appears that they are ready to take advantage of the popularity of the Medicare for All concept by usurping it as an even better Medicare for All by offering competing private plans supposedly with higher quality and lower costs: Medicare Advantage for All.

As the private insurers continue to integrate themselves into the health care delivery system, it will be much more difficult to displace them with a single, publicly-administered Medicare for All insurance program. Two decades of delay have allowed them to become thoroughly entrenched in the Medicare and Medicaid programs. Experimenting with a public option model of Medicare for some will just give them that much more time to implement their irreversible innovations. How do you get rid of the large private insurers when they have become the health care delivery system?

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Single Payer addresses income inequity; public option does not

Notes on Excessive Wealth Disorder

By Paul Krugman
The New York Times, June 22, 2019

No doubt many wealthy backers of tax cuts for themselves and benefit cuts for others manage to convince themselves that this is in everyone’s interest. People are in general good at that sort of self-delusion. The fact remains that the wealthy, on average, push for policies that benefit themselves even when they often hurt the economy as a whole. And the sheer wealth of the wealthy is what empowers them to get a lot of what they want.

So what does this imply going forward? First, in the near term, both during the 2020 election and after, it’s going to be really important to ride herd on both centrist politicians and the media, and not let them pull another 2011, treating the policy preferences of the 0.1 percent as the Right Thing as opposed to, well, what a certain small class of people want. There’s a fairly long list of things progressives have recently advocated that the usual suspects will try to convince everyone are crazy ideas nobody serious would support, e.g.

  • A 70 percent top tax rate
  • A wealth tax on very large fortunes
  • Universal child care
  • Deficit-financed spending on infrastructure

You don’t have to support any or all of these policy ideas to recognize that they are anything but crazy. They are, in fact, backed by research from some of the world’s leading economic experts. Any journalist or centrist politician who treats them as self-evidently irresponsible is doing a 2011, internalizing the prejudices of the wealthy and treating them as if they were facts.

But while vigilance can mitigate the extent to which the wealthy get to define the policy agenda, in the end big money will find a way — unless there’s less big money to begin with. So reducing the extreme concentration of income and wealth isn’t just a desirable thing on social and economic grounds. It’s also a necessary step toward a healthier political system.

Reader Comment:

By Don McCanne, M.D.

Although there has been considerable support for the single payer model of Medicare for All, the prevailing rhetoric has now become “letting you keep the insurance you have,” and this bears directly on the wealth inequality issue.

The single payer model addresses wealth and income inequality by switching from a system heavily dependent on individual contributions (premiums, deductibles, and especially forgone wage increases) to a system that uses progressive taxes to fund the 18 percent of our economy that we’re devoting to health care. This is one of the most important tools available to us to reduce the inequities in income and wealth distribution.

Most of the politicians who claim they support Medicare for All actually support the perpetuation of our highly regressive method of funding health care through employer-sponsored plans – health care financing that is costing middle-income Americans a significantly larger percentage of their incomes than they would be paying under single payer, whereas the wealthy are paying a percentage that is not detectable to them, unless they study their accountants’ reports.

Only the genuine single payer Medicare for All proposal of Bernie Sanders and Pramila Jayapal would take a major step towards reducing income inequality. The other Medicare for Some proposals fall miserably short of this crucial goal.

https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

Although this blog is devoted primarily to achieving health care equity through a single payer national health program, the profound income and wealth inequity in our nation is a parallel problem, but the great thing is that they can both be addressed simultaneously.

Although the politicians are once again touting employer-sponsored health insurance as the mainstay of health care financing (“you can keep the insurance you have” for half of the population), middle-income employees and their families are finding health care less affordable because they are footing the bill for their share of the 18 percent of our economy devoted to health care since they have to pay individually through premiums, deductibles, and especially through forgone wage increases.

This has been compounded during the last four decades by an economy that has left wages comparatively flat while gains of increased productivity have moved to the top of the income scale. Opponents of single payer Medicare for All claim that there is not enough money amongst the very rich to be able to make health care affordable for the rest of us. They also say that individuals could not afford the payroll taxes that would be required to pay for health care. This is nonsense, and here’s why.

The money is there, but a disproportionate amount is up at the top. This means that, if we want everyone to have health care, we have to shift from individual financing to a more progressive, equitable system of financing, and that means progressive taxes. Funding it all through payroll taxes leaves too great of a burden on workers, and it fails to correct the profound inequity of income and wealth. So the taxes need to be more progressive.

This is not the place to discuss specifics of the intricacies of tax policy, but suffice it to say that taxes are not only important as a revenue source to fund our essential government functions, tax policies also can go a long way toward correcting some of the economic injustices in our society. Thus we need to consider using potential tax sources such as higher progressive taxes on marginal income, wealth taxes including taxes on high net worth estates, appropriate taxes on pass-through income, Tobin taxes on equity transactions, and the $1.5 trillion in tax expenditures (reductions in federal income tax revenues through deductions, exclusions and other tax preferences – why should tax payers help pay for mortgages on million dollar homes when homelessness is rampant?). The money is there, and the amount that would be collected under a more progressive but equitable tax system would never impact the life styles of the wealthy.

Thus when we advocate for an affordable and equitable health care system – single payer Medicare for All – we will have the satisfaction of knowing that we would also be reducing (though not eliminating) the profound inequities in income and wealth. The rich will still be very, very rich, but all the rest of us will have health care.

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Medicare works better when Medigap benefits are added

How Does Supplemental Medicare Coverage Affect the Disabled Under-65 Population?: An Exploratory Analysis of the Health Effects of States’ Medigap Policies for SSDI Beneficiaries; NBER Working Paper No. 25564

By Philip Armour and Claire O’Hanlon
National Bureau of Economic Research, February 2019

Abstract

A substantial portion of the costs associated with, and the value to beneficiaries of, Social Security Disability Insurance is Medicare eligibility. However, the benefits of this eligibility can vary due to differences in state policies on supplemental Medicare coverage, also known as Medigap. Although Medigap policies are federally regulated to be issued to 65-and-over Medicare beneficiaries with specific restrictions over underwriting, these policies are left to states to regulate with regard to the under-65 SSDI population, generating substantial cross-state and temporal variation. This paper documents the variation in availability and generosity of under-65 Medigap eligibility for the SSDI population. Furthermore, it exploits this variation to provide initial estimates of how this eligibility affects the health status of non-Medicaid-eligible SSDI recipients. Our main finding is that requiring Medigap plans be offered for under-65 SSDI recipients substantially improves self-reported health of this population, with suggestive evidence that this improvement is stronger as underwriting restrictions increase and among SSDI beneficiaries with mental health conditions. The estimated effect is highly robust to alternative scaling or categorizations of self-reported health, choice of data set, inclusion of fixed effects, controls for local Medicare Advantage penetration, and falsification tests. This effect is nearly three times the size of the estimated increase in self-reported health in the Oregon Medicaid expansion.

From the Conclusion

Overall, the size and robustness of the estimated effect indicates that the SSDI Medicare population’s health is very sensitive to even supplemental coverage; that is, the policy variation in question is over the remaining 20% coinsurance and insurance products that limit this cost sharing. The size of the impact on changes in health indicates that state-level Medigap policy has not just a comparable, but a substantially larger effect on health for under-65 Medicare beneficiaries than Medicaid expansion on the marginal Oregon Medicaid entrant.

https://www.nber.org…

Comment:

By Don McCanne, M.D.

The conclusion of this study is quite intuitive. Individuals under 65 with long term disabilities who qualify for Medicare – people who could benefit from health care – have substantial improvement in their self-reported health (a valid indicator of health) when they receive additional coverage through a Medigap plan.

It is not unreasonable to conclude that those over 65 with disabling medical conditions would also benefit if Medigap benefits were added to the traditional Medicare program. Further, if we had a single payer Medicare for All program covering everyone, essentially everyone with significant medical needs would benefit. So why is Congress catering to the private Medicare Advantage plans by enabling them to offer more generous benefits, at taxpayer expense, while neglecting the traditional Medicare program?

Better benefits equate to not only better health outcomes but also greater financial security in the face of medical need. So why is there so much stubborn resistance to enacting and implementing single payer Medicare for All when it would greatly benefit those who need it now and those who may need it in the future?

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Arkansas’ Medicaid work requirements proved to be detrimental

Medicaid Work Requirements — Results from the First Year in Arkansas

By Benjamin D. Sommers, M.D., Ph.D., Anna L. Goldman, M.D., M.P.A., M.P.H., Robert J. Blendon, Sc.D., E. John Orav, Ph.D., and Arnold M. Epstein, M.D.
The New England Journal of Medicine, June 19, 2019

As of April 2019, nine states have received approval by means of a federal waiver to implement work requirements in Medicaid, and six have applications pending. According to the Centers for Medicare and Medicaid Services, work requirements — also known as community engagement requirements — may promote better health and help beneficiaries escape poverty. However, critics dispute these claims and warn that the policy could lead to large coverage losses.

In June 2018, Arkansas became the first state to implement work requirements in Medicaid. Medicaid beneficiaries 30 to 49 years of age were notified by the state (by mail and informational fliers) that they were required to work 80 hours per month, participate in another qualifying community engagement activity such as job training or community service, or meet criteria for an exemption such as pregnancy or disability. Three months of noncompliance or nonsubmission of monthly online reports within a year led to removal from Medicaid. By December, nearly 17,000 adults were notified by mail that they had been removed from Medicaid. In March 2019, a federal judge halted the program owing to concerns about its effect on coverage. Although several analyses have predicted various results of Medicaid work requirements, data from independent assessments since the policy took effect have been limited. Our objective was to assess early changes in insurance coverage and employment after implementation of the work requirements in Arkansas.

From the Discussion

Using a timely survey involving low-income adults in Arkansas and three comparison states, we found that implementation of the first-ever work requirements in Medicaid in 2018 was associated with significant losses in health insurance coverage in the initial 6 months of the policy but no significant change in employment. Lack of awareness and confusion about the reporting requirements were common, which may explain why thousands of persons lost coverage even though more than 95% of the target population appeared to meet the requirements or qualify for an exemption.

Our results show that this loss of Medicaid coverage was accompanied by a significant increase in the percentage of adults who were uninsured, indicating that many persons who were removed from Medicaid did not obtain other coverage.

Although Medicaid has always struggled with high turnover owing in part to legally required annual eligibility redeterminations, our findings suggest that work requirements have substantially exacerbated administrative hurdles to maintaining coverage.

In conclusion, in its first 6 months, work requirements in Arkansas were associated with a significant loss of Medicaid coverage and rise in the percentage of uninsured persons. We found no significant changes in employment associated with the policy, and more than 95% of persons who were targeted by the policy already met the requirement or should have been exempt. Many Medicaid beneficiaries were unaware of the policy or were confused about how to report their status to the state, which suggests that bureaucratic obstacles played a large role in coverage losses under the policy.

https://www.nejm.org…

Comment:

By Don McCanne, M.D.

Should there ever be a circumstance in which individuals are deliberately deprived of appropriate health care? There are certainly financial barriers to care, but shouldn’t public policies be designed to remove those barriers? Yet several states are deliberately attempting to erect financial barriers to care for low-income individuals who fail to meet work or community service requirements for Medicaid.

Arkansas led the way and has shown us that Medicaid work requirements caused thousands to lose their Medicaid coverage as the number of adults who were uninsured increased. Further, there were no significant changes in employment suggesting that this policy did not achieve its intended goal. Also the program increases the administrative burden even though health care in the U.S. is already unique for its wasteful administrative excesses. Hopefully, we will not learn what the long-term results of this policy would be since it has been halted by a federal judge, though the Trump administration is appealing the decision.

What is most perplexing is that it seems that our public policies should be designed to enable everyone to receive appropriate health care when they need it, yet they are not. When our public stewards establish or perpetuate policies that impair access to care, then it seems that we should dismiss them and bring in people who actually do care about the health of the nation.

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