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The socioeconomically deprived fare much better medically in Canada than in the USA

The socioeconomically deprived fare much better medically in Canada than in the USA

Care of acute conditions and chronic diseases in Canada and the United States: Rapid systematic review and meta-analysis

By Keren M. Escobar, Dorian Murariu, Sharon Munro, Kevin M. Gorey
Journal of Public Health Research, March 11, 2019

Abstract

This study tested the hypothesis that socioeconomically vulnerable Canadians with diverse acute conditions or chronic diseases have health care access and survival advantages over their counterparts in the USA. A rapid systematic review retrieved 25 studies (34 independent cohorts) published between 2003 and 2018. They were synthesized with a streamlined meta-analysis. Very low-income Canadian patients were consistently and highly advantaged in terms of health care access and survival compared with their counterparts in the USA who lived in poverty and/or were uninsured or underinsured. In aggregate and controlling for specific conditions or diseases and typically 4 to 9 comorbid factors or biomarkers, Canadians’ chances of receiving better healthcare were estimated to be 36% greater than their American counterparts (RR=1.36, 95% CI 1.35-1.37). This estimate was significantly larger than that based on general patient or non-vulnerable population comparisons (RR=1.09, 95% CI 1.08-1.10). Contrary to prevalent political rhetoric, three studies observed that Americans experience more than twice the risk of long waits for breast or colon cancer care or of dying while they wait for an organ transplant (RR=2.36, 95% CI 2.09-2.66). These findings were replicated across externally valid national studies and more internally valid, metropolitan or provincial/state comparisons. Socioeconomically vulnerable Canadians are consistently and highly advantaged on health care access and outcomes compared to their American counterparts. Less vulnerable comparisons found more modest Canadian advantages. The Affordable Care Act ought to be fully supported including the expansion of Medicaid across all states. Canada’s single payer system ought to be maintained and strengthened, but not through privatization.

From the Introduction

Canadians and Americans rate health care a top concern. They seem naturally to wonder if health care policies are greener on the other side of their unfenced 5,000-kilometer border. Some Americans − particularly concerned with health care inaccessibility among the uninsured − have called for a more Canada-like single payer system. In contrast, some Canadians − concerned with health care shortages − have called for a more American-like system with more private options. Aiming to contribute critical evidence to these debates, our research group has focused on the health care of people living in poverty. We assume that this magnifies human and policy significance.

From the Discussion

This study found that Canadians with any number of acute health conditions or chronic diseases are significantly more advantaged on health care access and outcomes compared to their counterparts in the USA. It estimated that the chances of Canadians receiving indicated treatments and surviving were 13% greater than Americans. That estimate was more unequivocal and larger than previous review estimates that were based on less internally valid research designs. We advanced and found much support for a meta-analytic country by socioeconomic status interaction. This clearly demonstrated that Canadian advantages were significantly larger among those living in poverty or those who were otherwise socioeconomically vulnerable such as the uninsured or inadequately insured.

Among patients who lived in high poverty neighborhoods, it was estimated that the chances of Canadians receiving indicated treatments and surviving were 36% greater than Americans. That estimate was essentially unequivocal across all the reviewed studies and was larger than a previous meta-analytic estimate based on less prevalently poor neighborhoods. Recalling that such a 36% differential is implicated across most common health conditions and diseases over the lives of millions of impoverished Canadians and Americans, its population-level significance is clear. In addition to accounting for socioeconomic factors most of these primary studies also accounted for key personal and contextual case-mix differences between Canada and the USA, notably disease severity and health care service endowments in diverse large to small urban or rural places. We consider the robustness of the observed Canadian advantage to be our review’s most provocative scholarly and policy-significant finding.

As with primary research, we think that the interpretation of significant interaction effects or important effect modifications ought to take precedence in synthetic research. Therefore, we think four more interpretive adjuncts are in order. First, larger Canadian advantages were replicated among socioeconomically vulnerable patients with acute conditions and chronic diseases, representing a multiplicative Canadian advantage among those living in poverty with chronic diseases. Such patients probably had multiple experiences with their respective health care system over several years. In other words, it seems that the longer patients were in contact with their respective Canadian or American health care systems, the larger were their respective advantages or disadvantages. Second, three studies included four assessments of wait-lists, estimating that the exemplary risks of experiencing relatively long waits for adjuvant cancer care or of dying while waiting for a liver transplant were much greater in the USA (RRs ranged from 1.89 to 2.99, precision-weighted RR=2.36, 95% CI 2.09-2.66) than in Canada. This evidence stands in stark contrast to prevalent contemporary political rhetoric. Third, all this field’s synthetic evidence strongly suggests a dose-response relationship between socioeconomic vulnerability and Canadian advantages. It seems, therefore, that Canada’s single payer healthcare system causally provides much better health care than does the USA’s multiple payer system that still leaves millions uninsured or inadequately insured. The Canadian health care system’s most pronounced evidence-based advantages are clearly among those who live in poverty who consistently experience much better health care compared to impoverished Americans. In short, the more socioeconomically vulnerable a person is the more protective a single payer health care system is likely to be.

The fourth interpretive adjunct arose serendipitously in our systematic search for eligible studies. We retrieved 8 within-Canada studies of socioeconomic factors and cancer care. Though ineligible for this review, these studies were very interesting. One observed a modest indirect low-income-care association. Five others observed similar trends, but were not statistically significant and two others were null. The pooled precision-weighted estimate was minuscule (RR=0.97, 95% CI 0.95-0.99). We identified more than 100 such within-USA studies nearly all of which observed the well-known, large American socioeconomic-care gradient. Six studies that were included in this review, but that also observed typically very low-income or poverty associations with cancer care in both Canada and the USA allowed for a controlled, precision-weighted synthetic comparison. A large disadvantage of being poor was observed in the USA (RR=0.73, 95% CI0.71-0.75) while no such association was observed in Canada (RR=0.99, 95% CI 0.96-1.02), z=14.44, P<0.05. Such within-country observations clarify the between-country comparisons. Given the intimate relationship between low socioeconomic status and health insurance inadequacy in the USA, but not in Canada, the pattern resolutely identifies inadequate health insurance coverage in the USA as the primary explanation for this study’s findings. It clearly indicts the USA for the largely inadequate health insurance coverage it provides its underclass, including those who live in poverty or near poverty as well as the periodically unemployed or underemployed middle-class. Most regrettably, this indictment holds true in post-Affordable Care Act America. For example, at the time of this writing, 14 states still had not fulfilled the Act’s legislative intent to expand Medicaid.

Conclusions

This field’s research now seems rigorous enough to support confident judgements about the relative effectiveness of Canadian versus American health care, especially among the most socioeconomically vulnerable. Socioeconomically vulnerable Canadians are consistently and highly advantaged on health care access and outcomes compared to their American counterparts. Less vulnerable comparisons found more equivocal and more modest Canadian advantages. The Affordable Care Act ought to be retained, indeed fully supported, including the envisioned expansion of Medicaid across all states. When politically achievable, however, single payer health care would better ensure truly equitable access and outcomes among America’s diverse population. Canada’s single payer system ought to be maintained and strengthened where needed, but not through the addition of private tiers.

Significance for Public Health

This study estimated that socioeconomically vulnerable Canadians’ chances of receiving better health care were 36% greater than their American counterparts and this estimate was larger than that based on general patient comparisons (9%). One may wonder about the public health significance of such relative risks/protections. Attributions of risk/protection among populations are a function of three factors of which relative risk is only one. The size of the population and the prevalence of exposure to risks are also important. In this instance, the entire USA population is at relatively greater risk of receiving lower quality care, its more prevalent low-income and inadequately insured populations more so. Applying our findings to population parameters and attributable risk formulations we estimated that without reform, over the next generation more than 50 million Americans will be treated less optimally and die earlier than had they enjoyed a single-payer health care system like Canada’s.

https://www.jphres.org…

Comment:

By Don McCanne, M.D.

Socioeconomically vulnerable residents of the United States fare much worse medically under our health care system than do socioeconomically vulnerable Canadians under their health care system. The authors of this meta-analysis estimate, “over the next generation more than 50 million Americans will be treated less optimally and die earlier than had they enjoyed a single-payer health care system like Canada’s.”

Solution? Single Payer Improved Medicare for All – Now!

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Hospital-sponsored study of Medicare-X Choice Act

The Impact of Medicare-X Choice on Coverage, Healthcare Use, and Hospitals

By Lane Koenig, PhD, Asha Saavoss, Samuel Soltoff, Berna Demiralp, PhD, Jing Xu, PhD
KNG Health Consulting, LLC, March 12, 2019

In this study, we model the effects of the Medicare-X Choice Act on coverage and healthcare spending. Although not as expansive as Medicare-for-All, Medicare-X Choice would allow any individual to voluntarily enroll in a public plan offered on each health exchange.

Key Findings

We find that national enrollment in the public plan would be 40.7 million in 2024 and would increase slightly to 42.3 million by 2033 (Table ES1). Under Medicare-X Choice, the number of uninsured and the commercially insured on the non-group market would fall by 5.5 and 12.6 million in 2024, respectively, while enrollment in employer-sponsored insurance (ESI) would fall by 22.6 million. About ninety percent of the enrollment in the public plans would comprise individuals who were either covered under ESI or on a commercial non-group plan in the baseline. While most of the enrollment in the public plan comes from those previously with ESI, the public plan take-up rate is highest (67%) among those with commercial non-group insurance.

We estimate considerable reductions in healthcare spending of 7 percent under Medicare-X Choice over the 10-year period from 2024 to 2033 (Table ES2). Spending on individuals who are uninsured in the baseline is projected to increase by 9 percent in 2024, however, increased spending on the uninsured would be more than offset by spending reductions among those who are enrolling in the public plan but previously insured through private insurance. While hospital- based services represent 47 percent of total baseline healthcare spending, these services would account for roughly 67 percent of the reduction in total spending. Overall, we estimate that hospitals would experience a 10-percent reduction in payments among the relevant population.

Conclusions

Medicare-X Choice would result in significant changes in the health insurance landscape, with 36.5 million people leaving private coverage for the new government-run public option, and 5.5 million individuals without insurance gaining coverage. While we estimate material reductions in the number of uninsured, most of those choosing coverage under a public plan would come from those currently covered under a commercial non-group plan or ESI. We estimate reductions in total healthcare spending due to reduced payments to providers, given the large differences in prices between Medicare and commercial insurers. For hospitals and other providers, the introduction of Medicare-X Choice would reduce revenue without commensurate reductions in costs. Although the increase in the number of insured individuals would increase revenue from the formerly uninsured, higher spending from this group would not be enough to offset the lost revenue from shifts between private and public insurance coverage.

For hospitals, the introduction of a public plan that reimburses providers using Medicare rates would compound financial stresses already faced by the sector, potentially impacting access to care and provider quality. CBO projects that between 40 and 50 percent of hospitals could have negative margins by 2025 under current law. Given that Medicare pays hospitals below their costs (e.g., the Medicare Payment Advisory Commission estimates that Medicare inpatient margins will be -11 percent in 2018), Medicare-X Choice would be expected to increase the number of hospitals with negative margins. While hospitals may attempt to shift some costs to commercial insurers, the ability to do this under a public plan may be limited because of the study’s projected significant take-up by those in the non-group market. Policymakers should have a clear understanding of potential effects on patient access, provider payment, the commercial insurance market, and ESI (desired as well as unintended) when considering proposals to expand Medicare coverage.

https://fah.org…

Comment:

By Don McCanne, M.D.

This study was prepared for the American Hospital Association and the Federation of American Hospitals. They wanted to see the potential impact of a Medicare-for-some model of reform, choosing as an example the Medicare-X Choice Act of Sen. Michael Bennet and Sen. Tim Kaine. They show that the shift of enrollees from employer-sponsored plans and commercial non-group plans into the public option Medicare-X plan, which would have payment rates set at Medicare levels, would reduce hospital net revenues without commensurate reductions in costs, even though the impact is partially offset by the newly insured.

Although the report is mostly about hospitals (understandably so considering the sponsors of the study), the report does show that not only would payments to hospitals decline by 10 percent, continuing over a decade, but payments to physicians also would decline by 8 percent (page 10, Table 4).

More importantly, and not mentioned in this study, is that the Medicare-X Act and all other Medicare-for-some Acts would leave in place most of the critical flaws in our health care financing system – flaws that would be corrected by enacting and implementing a well designed, Single Payer Medicare for All program. The authors suggest that instead we should strengthen existing components of the Affordable Care Act, but that won’t do it. We really desperately need to enact Single Payer Medicare for All.

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Insurance churning an instability for health care users

No one has ever kept insurance they like

By Brad Cotton, M.D.
Circleville (Ohio) Herald, March 13, 2019

It is true that President Obama misspoke during the crafting of the Affordable Care Act (ACA) promising that anyone who likes his or her health insurance can keep it. The truth is that, even before the ACA, no one (or almost no one) kept the same insurance year after year.

The fact is everyone loses insurance they like, constantly, and if you have employer purchased health insurance, there is very darn little of your so-called free market choice about it. You get the insurance your employer picks for you, or maybe you get to choose from two or three plans. You can bet that the choice of plans from year to year will have higher premiums, your employer will require a higher percentage of the premiums be deducted from your check, the deductibles will be higher, there will be narrower networks or restricted drug formularies forcing you to change your doctor, your hospital or your meds. I see patients daily who can’t see their new doctor, can’t afford their new meds they were herded into, or were forced into physicians, hospitals or meds they don’t like.

The insider term for this constant insurance instability is “churning,” and it is an inevitable and undesirable event as profit-based health insurers plot to keep more of your premium dollars and avoid paying for your care. Insurance companies look for the least expensive doctors, hospitals or meds while you get a new but worse deal each year. What a perverse system. We pay health insurers so that we may get health care when we need it; the insurer sees our hard-earned cash as theirs to keep and fights tooth and nail to avoid paying for your care.

If you have ever had to fight with an insurance company, you know they will fight you and your physician with denial after denial. Prior to the ACA, many health insurers spent as little as 50-60 percent of the monies they received from you on actual paying for health care. This is in industry terms called the “medical loss ratio” or MLR. The ACA requires health insurers to spend 90 percent of your premiums on actually caring for you, or refund the difference.

Churning leaves you feeling as if you had been thoroughly churned in your washing machine, pockets inside out, wallet gone and feeling as if you have been taken to the cleaners.

Our private health insurance system illustrates the aphorism that every system is perfectly designed to get the results it gets. The constant churning of your coverage, the constant instability, that feeling that you and your family are on thin ice is real and it is unsafe. The ACA was an immense regulatory attempt to force health insurers to behave responsibly by limiting an insurer’s ability to avoid covering anyone with pre-existing conditions, limiting their abilities to sell junk policies that cover nothing, or to actually dump you once you get sick. The monster of profit in healthcare can never be safely tamed and the ACA was an ineffectual attempt to do so.

For more detailed reading on the deviousness of the health insurance industry read former Cigna insider Wendell Potter’s book: “Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR is Killing Health Care and Deceiving Americans”. I further suggest “Trumpcare: Lies, Broken Promises, How it is Failing, and What should be Done” by physician John Geyman.

Safety lies in improved and expanded single-payer Medicare. Ask any senior how safe even currently unimproved and unexpanded traditional Medicare is. That 65th birthday is a lighthouse, guiding the way into the safe harbor of traditional Medicare. Traditional Medicare does not and has never limited physician, hospital, medications and treatment choice. Improved and expanded means we eliminate deductibles and co-pays and offer first-dollar coverage and we cover vision, dental and long-term care. We also eliminate the private Medicare Advantage plans that re-introduce all the downsides of private insurance, including churning.

Don’t be afraid of Medicare, be afraid of getting churned, your coverage constantly at risk when the health insurer’s corporate boardroom can sell your employer a cheaper or skimpier plan. When you are sick, do you go to the doctor or do you go to the banker? There are an abundance of U.S. physicians who support improved and expanded single-payer Medicare. That fact ought to tell us something.

https://www.circlevilleherald.com…

Diane Archer explains why Medicare for some is the wrong idea

Why Medicare for some is the wrong idea

By Diane Archer
The Hill, March 11, 2019

If you’re following the health care debate, you’ve already heard quite a bit about “Medicare for all,” the proposal to improve and expand Medicare, the government health insurance program for older adults and people with disabilities, to all Americans. As proposed by Sen. Bernie Sanders (I-Vt.) and others, Medicare for all provides all Americans the right to use physicians and hospitals of their choice anywhere in the country, eliminates premiums, deductibles and co-payments, and is projected to drive down national health care spending by $2 trillion to $5 trillion over the next 10 years.

For most Americans, this sounds like a pretty good idea. And it looks even better when compared against the failures of our commercial health insurance system. Commercial insurance forces Americans to spend nearly twice as much on health care as our peers in Europe and Japan for significantly worse health care outcomes. Commercial insurance creates an estimated $500 billion a year in administrative waste, enables excessive and irrational provider rates, and forces one in four Americans under 65 to forgo necessary health care because they cannot afford their out-of-pocket costs.

Nonetheless, a number of thoughtful commentators and well-intentioned politicians are telling us that Medicare for All is not a practical approach to health care reform – that it’s just not doable given the political context and the country’s long history with employer-based health insurance. These self-described “pragmatists” would offer Medicare as an additional option alongside commercial insurance, proposing a Medicare buy-in or Medicare for some.

By any measure, Medicare for some would deliver very little for the American people. At best, it would capture a fraction of the health care savings created under Medicare for all. It would not address the unaffordable premiums, deductibles and coinsurance that keep millions of Americans from getting needed health care. And it would leave tens of millions of Americans uninsured or underinsured.

So, too, Medicare for some does not address the most basic questions about our health care system: Why do we trust health insurers to determine the doctors and hospitals we can see? Why should a knee replacement cost anywhere between $16,000 and $61,000? Why should Americans pay twice as much for prescription drugs as our peers in Europe and Japan? And, why should our health coverage depend on where we work?

The “pragmatists” argue that we have to live with this crazy system because Americans want “choices” in health care, and most are not willing to give up their current insurance. As a result, they say, the best we can do today is to support Medicare for some and hope for real reform in the future. However sincere or politically fashionable, this view makes no sense.

Let’s get real: Commercial insurance is the biggest threat to health care choices and our freedom to receive the health care we need. Employers choose our insurers, and the insurers restrict the providers we can use, the treatments we can receive, and the prescription drugs we can take. Every year, we can be forced to change provider networks, benefits, out-of-pocket costs and, often, insurers. If we change jobs, every aspect of our health insurance changes. And, we are left to fend for ourselves if we leave the job market.

No one loves Aetna, Anthem or any other insurance company. What we love – and what we need – is the freedom to get care from the doctors we want to see at a price we can afford. Medicare for all guarantees all Americans access to health care, with freedom to see the doctors we want, throughout our lives, wherever we live, wherever we work and whenever we are out of work. That’s about as pragmatic as it gets.

Maybe the “pragmatists” are concerned that we lack the votes in Congress to pass Medicare for all or that the commercial interests with a stake in maintaining the status quo are too powerful to overcome. That might be right. The health care industry is flush with cash, and insurers use campaign contributions to wield substantial influence in Congress. As we learned in 2009 and 2010, the health insurance industry will fight hard to retain its place in the health care system.

But fixing our broken commercial health insurance system is too important to leave to the politicians or to the insurance industry. The American people deserve a frank conversation about how we can guarantee access to health care as a right in this country. That conversation does not begin with Medicare for some. It begins – and ends – with Medicare for all.

Diane Archer is a senior adviser at Social Security Works. She is founder and president of Just Care USA, an independent digital hub covering health and financial issues facing boomers and their families and promoting policy solutions. Archer is the past board chair of Consumer Reports and serves on the Brown University School of Public Health Advisory Board.

https://thehill.com…

Comment:

By Don McCanne, M.D.

Diane Archer says it. The conversation on affordable health care for all does not begin with Medicare for some. It begins – and ends – with Medicare for all.

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We’ve tried everything else – it’s time for universal health care

Even Maine people with insurance can't afford to access care, and hospitals are going broke.

By Les Fossel
Portland (Maine) Press-Herald, March 11, 2019

Interesting things are happening in rural Maine:

  • People with software jobs elsewhere are moving to Maine – but only where high-speed internet exists.
  • Artists, photographers, actors, musicians from away have created a sophisticated cultural economy.
  • A bumper crop of young farmers is moving in – the number of farmers, the acres under cultivation and the value of their product are all increasing. Farmers are now growing, processing and marketing specialty products – 30 Acre Farm and Singing Prairie Farm are good examples. This is part of the foodie revolution – note how craft breweries have gone statewide, as is increasingly true of high-quality restaurants.
  • Retirees are attracted to our world-class health care, cultural amenities and low living costs. Our economy benefits since they have middle-class incomes and volunteer in the community but do not strain the tax base.

These four legs can be the economic foundation for rural Maine. However, health care is facing daunting challenges:

Maine’s per capita health care costs are among the nation’s highest, but our per capita income is in the middle range. Maine’s per capita wage income is among the lowest and all the other states with the highest health care costs also have the highest incomes. That’s not us. A large portion of our population cannot afford to use our health care system. This is creating a severe financial crisis in health care.

While we like to think that quality is the same among health care providers in Maine, it is not true. The Leapfrog Group is the organization whose annual ratings are the recognized standard for comparing health care quality across America. Only seven hospitals in Maine got the award – all were small rural hospitals with higher costs. Every one of these same rural hospitals also is either in the red, or close to it.

My hospital, LincolnHealth (I’m on the board), has won the Leapfrog Award almost every year. Three years ago Consumer Reports named our hospital the safest in America. This high quality does nothing for our bottom line. Rural hospitals are merging with larger health care groups because we have no alternative. Medicare and Maine-Care reimbursements (which represent most of our revenues) don’t cover costs. We were not bought out – we joined MaineHealth in order to continue to provide world-class care.

Though most Mainers have health insurance, they don’t use it since they can’t pay the deductibles. This is why LincolnHealth’s uncompensated and charity care is so high. Further, the unaffordability crisis in Maine gets worse every year, since health care cost increases always outstrip economic growth – much like a cancer. Health care is now over 20 percent of our economy, but it should be half that. Imagine if Maine could devote those wasted health care dollars to address our real needs.

I served in the Maine Legislature on the Health and Human Services Committee. I authored some good health care legislation, but I could not address our underlying problems. I have been an employer for over 40 years. I have seen solution after solution attempted – but none has worked.

Now I am treasurer of Maine AllCare – our largest universal health care education group – because it is the only way left to control health care costs. Exporting patients to Portland or Boston just treats the symptoms of the crisis, not the underlying problems. To cut health care costs and live longer, we must root our health care in our local communities – the approach that has worked for all other First World countries.

We must pay attention to what works. Universal health care works. It is less costly and more effective. Winston Churchill once said that Americans always do the right thing – but only after they’ve tried everything else.

Well, we have tried everything else – and it doesn’t work. Isn’t it finally time we do the right thing in health care?

Les Fossel is a former member of the Maine Legislature.

https://www.pressherald.com…

BlueCross BlueShield proposal to reduce premiums and expand access

Reducing Individual Market Premiums to Expand Access to Coverage and Care

BlueCross BlueShield Association, Issue Brief, March 2019

Many individuals who have significant medical conditions and need extensive and often costly care depend on the individual market for coverage.

Unfortunately, individual market premiums are often unaffordable for people who do not qualify for financial assistance, and coverage options for these people remain limited. For many, the cost of coverage and care is out of reach, with many purchasers required to pay more than 15 percent of their income for health insurance so they can obtain the medical care they need.

The individual market is a critical source of coverage for people from all walks of life, and it should be strengthened to make coverage more affordable while protecting those with pre-existing conditions. To achieve this, BCBSA recommends that policymakers take three critical steps:

1. Revise federal assistance to help more people afford coverage

  • Congress should adjust tax credits to make coverage more affordable and boost enrollment among younger people.
  • Congress should adjust the current tax credit structure to help those who are ineligible for tax credits today.
  • Congress should improve cost-sharing protections to help lower-income people access medical care.

2. Enact policies to lower costs and remove financial barriers to accessing care

  • Congress should establish a sustained federal funding system to support the cost of caring for those with significant medical needs.
  • Congress should provide relief from the health insurance tax.
  • Congress should modernize health plans that are linked with health savings accounts (HSAs).

3. Improve outreach to encourage people to obtain and maintain insurance

  • Exchanges should provide enhanced outreach to ensure that people enroll in coverage.
  • Exchanges should provide information on coverage status to states to improve outreach efforts and simplify enrollment.
  • Policymakers should continue to allow consumers to automatically renew coverage.

https://s3.amazonaws.com…

Comment:

By Don McCanne, M.D.

The support for single payer Medicare for All stems from the recognition that too many people are not being served well by our current dysfunctional health care financing system, resulting in impaired access to health insurance and health care and exposure to financial hardship. The vested interests that would lose by changing to a single payer public financing system have had initial success in shifting the media toward bemoaning the loss of private insurance that would occur under single payer. This Issue Brief from BlueCross BlueShield Association is important because it explains how the private insurance industry would address the problems of access and affordability facing the insurance beneficiary.

The basic problem is straightforward. Health care has now become so expensive that each beneficiary’s proportionate share of risk – the premium – that would fund a common risk pool now exceeds the financial resources available to the typical working family. It has long been understood that the government must cover the deficit. Earlier, Medicare for retirees with their limited incomes, and Medicaid for individuals living in poverty, filled in the largest gaps. Once insurance premiums exceeded the abilities of average-income families to pay them, more government intervention was required, and that resulted in enactment of the Affordable Care Act with its insurance premium and cost sharing subsidies plus its expansion of Medicaid.

Now it is widely recognized that not even the Affordable Care Act is meeting the needs. People well informed on health policy understand that the single payer model has become the obvious solution that would ensure affordable health care for all, but some are ideologically opposed, willing to sacrifice the suffering of others in order to reduce the role of government, and others are opposed because of the impact on the vested interests, especially the private insurers and the profiteers such as the pharmaceutical firms.

So it is understandable that traditional insurers such as Blue Cross and Blue Shield would want policies enacted that would not only salvage their industry but would also further nurture them. A quick look at their proposals leads to an obvious conclusion: They do not propose policies that would control future health care spending; instead they support proposals that would infuse more government money – our taxes – into their industry.

By providing more public support to the insurers, we would be perpetuating their very costly administrative excesses, while not receiving anything of substance from them in return for us increasing further our already too high national health expenditures. But, you say, more people would be insured? Taking money from the federal government, carving out a portion for themselves, and then passing the rest on to the actual health care delivery system is not providing us with value for our tax dollars that they keep.

This is where the media is failing us. A single payer Medicare for All program would meet our goals of universality, effectiveness, efficiency, equity, and affordability for each of us and for the nation as a whole. Simply throwing more money at the current, fragmented, dysfunctional system will perpetuate most of our problems, not to mention that it is the most expensive model of reform. If the media is going to cover reform, it is imperative that they understand fully the policy science behind it.

Although some in the media parrot the policy principles behind reform, it is difficult to believe that they understand the issues in depth when you listen to them whine about the potential loss of our revered private plans, especially the employer-sponsored plans. Really? We need to protect that industry when the result is to spend even more money while perpetuating unnecessary financial hardship, physical suffering and even premature death? Start whacking the media (figuratively) when they deserve it. Enough of their crescendo of journalistic crap about our precious private insurance industry.

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High-deductible health plans cause women to delay breast cancer care

Vulnerable And Less Vulnerable Women In High-Deductible Health Plans Experienced Delayed Breast Cancer Care

By J. Frank Wharam, Fang Zhang, Jamie Wallace, Christine Lu, Craig Earle, Stephen B. Soumerai, Larissa Nekhlyudov, and Dennis Ross-Degnan
Health Affairs, March 2019

Abstract

The effects of high-deductible health plans (HDHPs) on breast cancer diagnosis and treatment among vulnerable populations are unknown. We examined time to first breast cancer diagnostic testing, diagnosis, and chemotherapy among a group of women whose employers switched their insurance coverage from health plans with low deductibles ($500 or less) to plans with high deductibles ($1,000 or more) between 2004 and 2014. Primary subgroups of interest comprised 54,403 low-income and 76,776 high-income women continuously enrolled in low-deductible plans for a year and then up to four years in HDHPs. Matched controls had contemporaneous low-deductible enrollment. Low-income women in HDHPs experienced relative delays of 1.6 months to first breast imaging, 2.7 months to first biopsy, 6.6 months to incident early-stage breast cancer diagnosis, and 8.7 months to first chemotherapy. High-income HDHP members had shorter delays that did not differ significantly from those of their low-income counterparts. HDHP members living in metropolitan, nonmetropolitan, predominantly white, and predominantly nonwhite areas also experienced delayed breast cancer care. Policies may be needed to reduce out-of-pocket spending obligations for breast cancer care.

From the Discussion

This study found that both vulnerable and less vulnerable women experienced delays in breast cancer diagnostic testing, early-stage diagnosis, and chemotherapy initiation following an employer-mandated switch to high-deductible health plans. Although magnitudes of delays among women in the three income categories were not statistically different at a 95 percent level of certainty, the graduated duration of the delays in the expected direction suggests true differences. For example, HDHP enrollment was associated with delays in chemotherapy initiation of 8.7 months among low-income women, 8.1 months among middle-income women, and 5.7 months among high-income women. We also detected delayed breast cancer care among HDHP members living in metropolitan, nonmetropolitan, predominantly white, and predominantly nonwhite areas.

These results suggest that HDHP-associated delays in breast cancer care are only partially related to patients’ sociodemographic characteristics and that women across the income spectrum might experience high out-of-pocket spending obligations as a barrier to breast cancer care. The delay of approximately five to seven months in early-stage breast cancer diagnosis among women across the sociodemographic spectrum could imply suboptimal breast cancer outcomes.

High-income women have greater ability to afford out-of-pocket expenses than low-income women do, so our finding that high-income women experienced substantial delays in breast cancer care was unexpected.

Our findings raise concerns that in coming years a majority of commercially insured women of all sociodemographic levels could experience delayed breast cancer care.

Conclusion

Both vulnerable and less vulnerable women who were switched to high-deductible health plans experienced delays in breast cancer diagnostic testing, early-stage diagnosis, and chemotherapy initiation, compared to women remaining in low-deductible health plans. Such delays could lead to adverse long-term breast cancer outcomes affecting a substantial proportion of commercially insured women who develop breast cancer. Policy makers, health insurers, and employers should consider implementing value-based features in HDHPs to encourage successful transitions through key stages of the cancer care pathway. This could take the form of increased HSA contributions or “population-tailored” exclusions of essential care so that women would pay minimal amounts for services such as breast diagnostic testing.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

We have serious problems with our health care financing system – a system that costs twice the average per capita of other wealthy nations yet falls miserably short in performance. In the meantime, the policy community busies itself with fixes that have clearly failed to bring our expensive system up to the standards of other nations. One of those fixes is high-deductible health plans.

Deductibles have fallen short as a policy tool, yet the policy community still insists that they have to be of benefit since they would make patients better health care shoppers by exposing them to more of the costs of their care. Their policy diagnosis is that, for deductibles to work, patients are going to have to feel more financial pain. Thus they have been increasing the deductibles to reach that threshold where pain occurs.

The policy community is quite smug now because moving to higher deductibles is working, according to their terms. People are limiting or delaying care because of these deductibles, thus meeting the goal of reducing health care spending. Or, in our terms, is it really working? Is it smart health care shopping if the financial exposure causes patients to delay diagnosis and treatment of breast cancer? Should women be waiting to be sure that they really need this care by seeing if they develop further invasive or metastatic disease? Just asking that question depresses and even nauseates me. Yet this study confirms through a “natural experiment” that women are delaying breast cancer care when they are shifted to plans with high deductibles.

As an individual obsessed with the study of health policy as it applies to our health care system, I am disappointed to see that the authors suggest implementing “value-based” features – perhaps increasing contributions to health savings accounts – as a means to reduce the stress of out-of-pocket spending for breast cancer. Not only is this a feeble response, it ignores the fact that these consumer-driven policies negatively impact the care of all serious medical problems, not just breast cancer.

We need a fundamental restructuring of our health care financing system. Right now with all of the talk about single payer Medicare for All it is almost impossible to avoid knowing what form that restructuring should take. A well-designed, single payer Medicare for All program, free at the point of service, would make essential health care accessible and affordable for absolutely everyone. And yet too many of today’s politicians and many in the policy community seem to think that an extreme measure would be to allow individuals to buy a Medicare plan as they exist today that would cover on the average only about half of health care costs, but don’t dare take away our private insurance (that relies on high deductibles and other perversities). Or rather, many say, we should just limit ourselves to building on the highly deficient Affordable Care Act.

Excuse me, but I have to barf.

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

Medicare for All, a plan to improve access and health disparities

Additional care would extend American lives

By Jessica Schorr Saxe, M.D.
The Charlotte Post, March 8, 2019

Would you like to improve health statistics for African Americans, as well as other residents of the United States?

Americans lag behind other wealthy countries in health, with lower life expectancy and more deaths in infants and in mothers around the time of childbirth. In Charlotte, infant mortality is about five times as high for African Americans as for whites, a statistic that should shock us all.

Almost half of Americans either are uninsured or underinsured, which means that, although they have health insurance, they are at risk for not getting health care due to cost or getting needed care and not being able to afford their bills. And these numbers are worse for minorities.

Fortunately, there is a solution in sight. Rep. Pramila Jayapal filed HR 1384, the Medicare for All Act of 2019 in the House of Representatives on February 27. The true Medicare for All bill, it would improve on current Medicare by adding additional coverage such as vision and dental care; and eliminating the deductibles and co-pays (which result in almost one out of four seniors having cost-related problems getting medical care) and would extend it to everyone.

By eliminating private insurance companies, it would also be simpler for patients and providers because it would eliminate the unending maze of differing eligibility, forms, formularies, prior authorizations, and networks of different insurance plans (which then have to be revisited when a patient changes insurance). The bureaucratic relief translates into savings. Currently 30 percent of health care spending in the US, about $1 trillion, is due to administrative costs, and half of that is wasted. That $500 billion savings could be used to actually deliver health care.

The concept of Medicare for All has now become so popular that we are besieged by imitations, such as the Medicare for All Choice Act and the Choose Medicare Act. Sometimes referred to as the Medicare for More bills, these purport to be more politically palatable because they would be gradual routes to insure more people. However, they have serious shortcomings.

Most are a variation of a public option, which allow some people to choose to buy into Medicare. Choice sounds attractive, but making it an option means it won’t be universal. We will still have uninsured people who won’t get adequate routine care. And, though they may feel invincible, they will still be at risk for motorcycle accidents or leukemia requiring a bone marrow transplant. And we will all end up paying for their care, in the most inefficient way.

Secondly, rather than cutting down on bureaucracy, a public option will create its own new bureaucracy with yet a new set of eligibility criteria, forms, etc.

Lacking the simplicity of true Medicare for All, it will maintain the headaches and expense of the current system.

Can our nation afford to implement Medicare for All? The question should be, “Can we afford not to?” Researchers at the Political Economy Research Institute found that it would reduce health care spending in the U.S. by 10 percent—while also covering every person in the nation.

Concerned about those employed by the insurance industry? The Medicare for All Act of 2019 contains funding for job retraining and transition. Those with jobs in the new system will actually have jobs that contribute to delivering health care, not denying it.

Some politicians are concerned that the public will object because they are attached to their employer-based insurance plans or because they fear increased taxes. Surely the public values their choice of doctors and hospitals, which would improve when all are in a single plan rather than fragmented networks, and would not mourn losing high deductibles and surprise medical bills. Surely they would rather see family health spending decrease by thousands of dollars even if taxes went up a little. And surely the public values health. If everyone had access to health care, we could probably live longer and have fewer babies and mothers dying, especially in the African American community.

We should remember we are that public. Call your member of Congress and tell them you want a comprehensive, universal system that saves money for individuals and the economy—and that they should support HR 1384, The Medicare of All Act of 2019, the real deal.

Dr. Jessica Schorr Saxe is a retired family physician in Charlotte and chair of Health Care Justice—North Carolina.

http://www.thecharlottepost.com…

Buffett, Bezos, Dimon & Gawande’s “Haven” not living up to the hype

Haven, accessed March 7, 2019

Haven was established by Amazon, Berkshire Hathaway, and JPMorgan Chase to bring together the resources and capabilities of the three companies to create better outcomes, greater satisfaction, and lower costs for their U.S. employees and families.

Frequently Asked Questions

Why was the name ‘Haven’ chosen?

It reflects our goal to be a partner to individuals and families and help them get the care they need, while also working with clinicians and others to make the overall system better for all.

How is Haven going to improve health care?

We are pursuing a number of common-sense fixes, as well as innovative approaches, to address issues like making primary care easier to access, insurance benefits simpler to understand and easier to use, and prescription drugs more affordable. We are also looking at new ways to use data and technology to make the overall health care system better.

Is Haven going to replace existing doctors or insurance companies?

We are interested in working with clinicians and insurance companies to improve the overall health care system. We will be an ally of anyone who is working to make health care better for patients.

Who is Haven going to help?

Our focus is the U.S.-based employees and families from Amazon, Berkshire Hathaway, and JPMorgan Chase. In time, we intend to share our innovations and solutions to help others.

https://havenhealthcare.com

Comment:

By Don McCanne, M.D.

When Warren Buffett (Berkshire Hathaway), Jeff Bezos (Amazon) and Jamie Dimon (JPMorgan Chase) announced that they would join together to address the problems with our health care system, there was considerable hype that, along with their CEO Atul Gawande, these titans of the private sector would finally bring us the solutions that we needed for our overpriced and underperforming health care system.

Now that their health care venture is getting underway it is no surprise that their efforts initially will be confined to meeting the health care needs of their own employees with no involvement for the rest of the nation, except perhaps to serve an example.

Given the limits of our current dysfunctional health care system, at first glance their approach seems reasonable: improve access to primary care, improve employee understanding of the health insurance benefits, attack the high prices of pharmaceuticals, and investigate ways that data and technology might be used to improve the health care system. Although aren’t we already doing these things, albeit not equitably and not very effectively? And doesn’t this fall terribly short of the comprehensive reforms that we desperately need?

One of their proposals that stands out is the dependence on employer-sponsored private health insurance – the clarion call of the opponents of single payer Medicare for All. That implicitly supports profound administrative waste, fragmentation of health care financing, perpetuation of limited health care choices through the restrictions of provider networks, and the perpetuation of deductibles and other cost sharing that create financial barriers to care and potentially expose patients to financial hardship and even personal bankruptcy.

It would be much more beneficial for theses titans to abandon support of the current dysfunctional health care financing system, and instead advocate for a system that would solve their and everyone else’s health care problems – a single payer Medicare for All program. They would not have to do it alone, but it sure would help if they decided to participate in the orchestration of a movement culminating in a truly beneficial national health program for all of us. What an opportunity they seem to be missing. It’s shameful.

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

Single payer improved Medicare for all

By Colleen C. Lyons, M.D.
Nevada Appeal (Carson City, Nev.), March 6, 2019

What?! U.S. taxpayers pay more ($6,500 per capita) than any other nation to provide healthcare to just two-thirds of our citizens (elderly, disabled, public employees, veterans, etc). And yet, unlike the other 15 highly developed nations, who provide care for all their citizens, we don’t get the national, universal, quality healthcare they get. In fact as of 2018 data, we spend another $4,200 for every man, woman and child in this country for a total of $10,700 for each and every one of us. For all this money, we get the worst care, as well. Study after study finds the U.S. ranking last among developed nations on overall health system quality, while some of the developing nations frequently rank better than America on numerous quality measures.

What is going on?! Three major things: 1) other nations have a single system of care verses our half-dozen plus; 2) other nations have healthcare systems that are NON-profit; 3) all other nations have far more primary care physicians than the U.S. does. They understand the importance of primary care and have a physician workforce compromised of 50-70 percent primary care physicians (family doctors, pediatricians and internists) versus the 30 percent we have in the U.S.

In America we keep chipping away at the problem of getting medical care. First, the Veterans Administration was created for our veterans who suffered military-service related injuries or illnesses, then Medicare for the elderly and Medicaid for the extreme poor and disabled in the mid-1960s. These were followed by CHIPS for children falling through cracks and FQHC clinics for urban and rural underserved areas. Most recently, “ObamaCare” (Affordable Care — ACA) has required insurance companies cover pre-exiting conditions, eliminate lifetime limits and cover our kids through age 26. The ACA, also, allowed states to expand Medicaid coverage for their citizens, which Nevada did, and provided the working poor and self-insured with possible subsidized insurance coverage, in the hopes of making insurance affordable. Of course, we do need to keep in mind health insurance isn’t actual healthcare, as so many people have experienced and can attest to.

Physicians for a National Health Program (PNHP.org) has proposed America adopt a “Single Payer Improved Medicare for All” program similar to what Canada adopted in the mid-1960s. A system of publicly funded, but privately provided care. Canada currently provides healthcare for all of its citizens at a cost of $4,800 per capita. PNHP’s plan eliminates the 15-20 percent cut our FOR-profit health insurance industry takes off the top from our premiums. Further, by essentially eliminating the health insurance industry, Canadian hospitals and doctors spend half what U.S. facilities and providers do to get paid with administrative expenses of 12 percent versus America’s 25 percent of revenues. Additionally, a single payer system has the leverage to negotiate significant discounts in the price of medications and medical devices, for an estimated savings of $116 billion a year. A mere savings compared with the $476 billion saved by eliminating the insurance middleman and the For-profit motive, while creating a single system of care. Enough savings to care for the one in three Americans who have no insurance or lack adequate insurance. Enough savings to improve our current Medicare, in which 20 percent of seniors forego care due to the associated costs. PNHP’s plan eliminates co-pays, deductibles, and the need for co-insurance, while covering the addition of dental care and long-term care, which aren’t currently provided by Medicare.

The Institute of Medicine estimates medical errors are the third leading cause of death in the U.S., due in large part to a lack of a coordinated single system of care. “Single Payer Improved Medicare for All” as proposed by PNHP.org would create a single national system of care. Thus, when you travel out-of-state, you won’t be out-of-network.

Dr. Colleen C. Lyons is a family physician and member of Physicians for a National Health Program.

https://www.nevadaappeal.com…