Prime Minister Keir Starter sets out NHS plans following Darzi report, YouTube, Sept. 12, 2024

Lord Darzi today has published his independent report on the state of our NHS.

As everyone in the country knows, the last government broke the NHS.

Let me be clear from the outset, what reform does not mean. First, it does not mean abandoning those founding ideals of a public service, publicly funded, free at the point of use – the basic principle of dignity. “When you fall ill, you should never have to worry about the bill.” Second, reform does not mean just putting more money in. Now, of course, even in difficult financial circumstances, a Labor government will always make the investment in our NHS if it is needed. But we have to fix the plumbing before turning on the tap. So, hear me when I say this, no more money without reform.

The last Labor government reformed the NHS to deliver better outcomes for patients and better value for taxpayers. The Conservative government then undid that good work, which only goes to prove, once again, that only a Labor government can reform the NHS.

If we get this right, people can look up and say, “this was the generation that took the NHS from the worst crisis in its history, got it back on its feet, and made it fit for the future.”

Independent Investigation of the National Health Service in England, September 2024, by The Rt. Hon. Professor the Lord Ara Darzi of Denham

The National Health Service is in serious trouble.

This report sets out where the NHS stands now, how we arrived at this point, and some of the key remedies.

The NHS budget is not being spent where it should be – too great a share is being spent in hospitals, too little in the community, and productivity is too low.

Conclusions:

The NHS is in critical condition.

Some have suggested that this is primarily a failure of NHS management. They are wrong.

Despite the challenges, the NHS’s vital signs remain strong.

Nothing that I have found draws into question the principles of a health service that is taxpayer funded, free at the point of use, and based on need, not ability to pay.

It has taken more than a decade for the NHS to fall into disrepair so improving it will take time.

There are some important themes that have emerged for how to repair the NHS, which will need to be considered alongside strategies to improve the nation’s health and reforms to social care:

• Re-engage staff and re-empower patients.
• Lock in the shift of care closer to home by hardwiring financial flows.
• Simplify and innovate care delivery for a neighborhood NHS.
• Drive productivity in hospitals.
• Tilt towards technology.
• Contribute to the nation’s prosperity.
• Reform to make the structure deliver.

The NHS is now an open book. The issues are laid bare for all to see. And from this shared starting point, I look forward to our collective endeavor to turn it around for the people of this country, and to secure its future for generations to come.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

For decades, progressives in the US have been striving to enact and implement an affordable, high-performance system which would provide health care access for everyone. We favored government control over the payment mechanism since private insurers have demonstrated an enduring desire and ever-increasing ability to divert our funds to their private wealth. This diversion would end with publicly funded and administered insurance.

In recent years, progressives have expressed renewed interest in public ownership of health care delivery itself, since entrepreneurial groups (e.g., private equity) entering the provider side have diverted payments for care to their own financial gain. In effect, progressive interest has expanded from universal public insurance as in Canada, to public ownership of the delivery system through a national health service such as the British NHS, valued since post-WWII.

Yet now both Canadians and the British are having problems with their public programs. A critical factor in both nations is ongoing political conflict over the proper role of government versus private sector in health systems. Patients who have great medical needs may find a public system to serve their interests very well by assuring that health care is always affordable. However, individuals with health care costs that are not personally burdensome may prefer to pay less in the taxes that make health care accessible and affordable for everyone.

In all nations and to varying degrees, voters align as either conservatives or progressives. When one of the political interests gains control, as with UK Conservative rule 2010-2024, the NHS suffered budget stasis and privatization. This conflicted with the core NHS goal of ensuring health care for all, regardless of personal financial means. This period of NHS austerity markedly damaged it, as noted in the YouTube and report above.

The lesson for US progressives is that when we propose either single payer or a national health service, it is imperative to create policies and controls that will ensure the maintenance of public programs regardless of the political control of the moment. The ordeal that the British are suffering to recover and repair their health care system demonstrates the consequences of failing this protection. The Conservatives took an electoral drubbing in part due to NHS problems, but the price to patients has been very high.

Recently we discussed a poll commissioned by Bernie Sanders demonstrating that views on public coverage of health care are more consonant across political divides than people realize. Wouldn’t it be amazing if individuals of all political persuasions could join and agree on a system that assures that we all have the health care that we need?

Realistically, we face challenges.

Major party politics in the US have shifted from a conservative-progressive spectrum to a narrower conservative-neoliberal spectrum. This reflects a Democratic understanding that more moderate political positions would be more appealing to voters. An example is the current US presidential election wherein one candidate remains conservative while the other has shifted from a progressive to a neoliberal political position, certainly on health care. We must empower progressive positions, as happened substantially (but insufficiently) under President Biden.

The progressive tax policies needed to power a government-run health care system appear to conflict with the wealth-enabling tax policies of conservatives and neoliberals. Yet, compared with the extremely progressive tax rates following WWII, the progressivity required for single payer is modest. Perhaps there’s a middle ground, whereby the already financially well-situated can continue to grow their wealth, albeit more slowly, while growing health and social cohesion via public insurance.

We should set limits on wealth accumulation, when it is at the expense of social welfare. Do we really need rockets that carry rich people to outer space? Real estate tycoons making fortunes while leaving people living in the streets? Trillionaires? Government and courts controlled by the wealthy?

What is a reasonable social contract? We believe that the wealthy have ample opportunity in this free market world to maintain and build their wealth. It’s time for a robust social contract that ensures that we meet health care and other social needs. Humanity and wealth can co-exist.

From a political perspective, can we mend divisions and work together on policies that serve our collective well-being? We need to be nimble as we pursued the very lofty goal of achieving health care justice for all, as a social consensus, robust across political fluctuations.

https://healthjusticemonitor.org…

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The “Concept of a Plan” President Trump Proposed to Replace the ACA, KFF QUICKTAKES, September 11, 2024, by Larry Levitt

When asked in the debate whether he had a replacement plan for the Affordable Care Act, former President Donald Trump said he had the “concepts of a plan.”

If you look at Trump’s record as president, there is truth in that statement. He did, in fact, propose the concept of an ACA replacement plan in his 2020 budget, though it has never gotten much attention.

Trump’s conceptual ACA replacement plan would have repealed the ACA’s premium subsidies and Medicaid expansion, replacing them with a block grant to states. It also would have capped federal Medicaid spending. All told, Trump’s plan would have reduced federal spending on the ACA and Medicaid by over $1 trillion over a decade.

Trump also proposed providing “relief” from the ACA’s “insurance rules and pricing restrictions.”

Trump has long talked about making the ACA less expensive, but the question is less expensive for whom. Trump’s past proposals would certainly have made the ACA less expensive for the federal government, but with the trade-off of higher out-of-pocket premiums for people, more uninsured, and higher spending and greater risk for states.

Polling: Harris v. Trump on Key Health Care Issues, KFF, September 10, 2024, by Ashley Kirzinger, et al.

How Voters Are Prioritizing Health Care Issues in 2024: The economy and inflation continue to dominate the list of issues that voters are focusing on during this year’s presidential election with four in ten voters (38%) saying it is the most important issue determining their vote in the 2024 presidential race. Following the economy is threats to democracy (22%), immigration and border security (12%), then several individual health care issues including: abortion (7%), Medicare and Social Security (7%), and health care costs including prescription drugs (5%). Altogether, health care issues are seen as the most important issue by about one in five voters (19%). Gun policy (3%) and the war between Israel and Hamas in Gaza (2%) rank the lowest among the issues included in the list provided to voters.

Voters Want to Hear Candidates Talk About Lowering Health Care Costs: An indication of how the economy and health care consistently overlap for voters, economic concerns also rear up when voters are asked what health care issue they most want to hear the candidates talk about. Across partisans, the recurring theme is costs. Responses related to health care costs are offered by four in ten (42%) Democratic and Democratic-leaning independent voters when asked to say in their own words what is the one health care issue they would most like Vice President Harris to talk about. This includes voters who mentioned general health care costs (20%), prescription drug costs (15%), and the cost of insurance or reducing their monthly premiums (6%). About one in seven offered abortion as the one health care issue they want Harris to talk about and 13% mentioned universal health care – an issue that was largely debated during the 2020 Democratic primaries.

Comment:

By Jim Kahn, M.D., M.P.H.

Health issues are fairly high profile In this presidential campaign – collectively, the most important issue for one in five voters. Abortion is seen as the leading election issue for 7% of voters. Medicare & social security (combined, oddly in my view) are also at 7%, and health care costs are at 5%.

Trump proposes to replace the ACA with something TBD cheaper and better. His actual approach, per his 2020 federal budget request, seems to be repealing ACA premium subsidies and Medicaid expansion, placing these programs into state block grants. Which would cut federal costs by >$1 trillion over 10 years. Also, end the ACA’s “insurance rules and pricing restrictions.” This is all consistent with Project 2025, as summarized in HJM. He waffles on abortion, but is largely seen as a threat to abortion rights.

Harris aims to strengthen the status quo. She proposes to strengthen the ACA: to make permanent COVID subsidy increases and fix a “family glitch”. For drug prices she favors accelerating Medicare drug price negotiations, and extending two caps in Medicare ($35 insulin copay and drug out-of-pocket total) to the entire population. She wants to end drug companies blocking competition and abusive practices of drug intermediaries. She avidly supports abortion rights.

See a side-by-side comparison here.

Drew Altman notes that the “do not mention” program is Medicaid, since Medicare and the ACA are considered higher priority for voters. Yet the consequences for Medicaid are substantial, per above.

Of course, Medicare for All / single payer gets no favorable mention – despite its ability to sharply reduce health care costs for families, a leading concern of voters. Instead, it is used by Trump to attack Harris since pre-2020 she endorsed Bernie Sanders M4A bill. Don’t expect Harris to return to single payer. But if state reform efforts, such as currently in Oregon and California, are to garner federal regulatory cooperation (“waivers”), a Harris administration may be more flexible.

https://healthjusticemonitor.org…

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Health shrinkflation: Patients wait more for less, Axios, September 3, 2024, by Tina Reed

The U.S. spends more on health care than almost anywhere else. But increasingly patients are getting less in return, and enduring long waits to get not as much face-time with their clinician.

Why it matters: Shrinkflation is hitting a sector that accounts for almost one-fifth of the economy, eroding the doctor-patient relationship and leaving many turning to urgent care clinics or telehealth services.

• Some who can afford it are gravitating to concierge practices that offer fewer hoop jumps and more add-on services with office visits.

The latest: The trend is being felt especially in primary care, but also in many specialties.

• An Axios-Ipsos survey last month found that nearly one in five respondents said they had to wait more than two months to see a primary care physician or specialist, with waits trending longest in the Midwest.
• NYC Health + Hospitals recently told primary care doctors to cut appointment times in half to 20 minutes, in order to squeeze in more patients, Gothamist reported.
• A spokesperson told Axios that the public health system is grappling with 50,000 more primary care patients who’ve been added since 2021. The average number of days to the third next available appointment jumped from 12 days to 22 days.

By the numbers: 17% of patients had to wait one to three months for their latest doctor’s appointment, per electronic health records company Tebra.

• The most frequently cited specialties with long wait times included neurology (26%), ear, nose, and throat (26%), psychiatry (20%), and OB/GYN (17%). Primary care stood at 19%.
• 43% of patients reported experiencing longer wait times for appointments since the pandemic, per the Tebra survey.
• The surge in demand for in-person care since the crisis has been well-documented. AMN/Merritt Hawkins found that the average wait time for a physician appointment in 15 large metro markets surveyed in 2022 was 26 days, up from roughly 24 days in 2017, and about 21 days in 2004.

The big picture: This is what shrinkflation in healthcare looks like as the industry struggles with supply and demand issues, Robert Pearl, a Stanford University professor and former CEO of The Permanente Medical Group, told Axios.

• There’s been across-the-board growth in patient volumes largely from pent-up demand for services many put off during the pandemic.
• At the same time, tens of thousands of doctors have left the field due to burnout and other factors, and surveys indicate even more plan to retire early.
• Red tape around insurance and rising out-of-pocket costs are leaving patients frustrated and confused, and in some cases burdened by more medical debt.

“You’re paying actually more for your health coverage, but you’re not getting more. You’re actually getting less,” Pearl said.

Comment:

By Jim Kahn, M.D., M.P.H.

The physician supply is steadily contracting, especially in primary care. This lengthens waits for clinical visits, not to mention the challenge of finding a new provider. Each year we pay more in premiums and cost-sharing, yet we suffer increasing challenges getting the care we need.

What’s going on? This tightening of physician supply reflects some simple math: more individuals leave clinical medicine than new trainees enter. Increasing the number of mid-level providers, like nurse practitioners, is a viable and valuable option. However, the physician flow dynamics remain critical. And recent trends are not encouraging:

This is ongoing: 7% of physicians left the workforce in 2021 and 2022. Nearly 1 in 4 physicians stated an intention to leave practice within two years. Long-term projections for physician supply are dire.

Why are so many doctors leaving? The short answer is growing burnout:

And why the burnout?

• Too many bureaucratic tasks (eg, charting, paperwork): 62%
• Too many hours at work: 41%
• Lack of respect from administrators / employers, colleagues, staff: 40%
• Insufficient compensation: 38%
• Lack of control / autonomy: 32%
• Full list here

All of these causes reflect, in substantial degree, our fragmented insurance system and the central role of for-profit insurers and provider groups. Here’s how single payer would help with each:

• Reduce bureaucracy: eliminate an hour/day of billing & insurance-related tasks done by physicians.
• Reduce hours at work: less time on bureaucracy; more providers especially in primary care.
• Build respect: bolster the clinical role of physicians, and foster clinician-run practices.
• Correct compensation inequities: Increase payment rates for primary care.
• Build autonomy: make clinician-run practices more financially and administratively viable.

Single payer isn’t a magic potion for physician emotional well-being. But it is a viable framework to build clinical focus and autonomy, and to foster equity among specialties (and of course among populations groups). It is the only way to break out of our burnout quagmire.

https://healthjusticemonitor.org…

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Is private practice collapsing? Congress can help stem the tide, AMA, August 23, 2024, by Tanya Albert Henry

It’s time for lawmakers to recognize the threats to independent medical practices and time to take “immediate and decisive actions” to stop driving physicians away from private practice, the AMA told Congress.

“The fabric of our health care system, woven with the dedication and expertise of these practices, is unraveling under the compounding pressures of unsustainable financial models, burdensome regulations and systemic inequities,” the AMA said in a statement submitted to the House Ways and Means Committee (PDF) for its hearing entitled, “The Collapse of Private Practice: Examining the Challenges Facing Independent Medicine.”

The AMA urged Congress to pass comprehensive legislative reforms that create:

• Equitable payment models.
• Reduced administrative burdens.
• Expanded support for rural and underserved areas.
• A health care infrastructure secured from emerging threats.

Re: The Collapse of Private Practice: Examining the Challenges Facing Independent Medicine, STATEMENT of the American Medical Association, U.S. House of Representatives Committee on Ways and Means, May 23, 2024

The American Medical Association (AMA) appreciates the opportunity to submit the following Statement for the Record to the U.S. House Committee on Ways and Means as part of the hearing entitled, “The Collapse of Private Practice: Examining the Challenges Facing Independent Medicine.” The AMA commends the Committee for addressing this critical issue that threatens the very existence of private medical practices. The AMA is fighting tirelessly to combat the financial and regulatory challenges that jeopardize the survival of these practices. The situation is dire and multifaceted, involving not only the fallout from the COVID-19 pandemic, but also drastic cuts in physician practice payments relative to inflation, surging practice costs, and overwhelming administrative burdens. These payment reductions and burdens are forcing more and more physicians to either close their doors or merge with larger health care systems, severely limiting competition and patient choice. While the pandemic has amplified existing financial pressures and highlighted the urgent need for continued legislative intervention, the relentless cuts in physician practice payments present an immediate and existential threat to private practices.

CONCLUSION

The AMA implores Congress and all stakeholders to recognize the imminent and severe threats to independent medical practices. The fabric of our health care system, woven with the dedication and expertise of these practices, is unraveling under the compounding pressures of unsustainable financial models, burdensome regulations, and systemic inequities. We urge immediate and decisive action to correct the course with comprehensive legislative reforms that ensure equitable payment models, reduce administrative burdens, expand support for rural and underserved areas, and secure our health care infrastructure against emerging threats. The AMA and physician community stand ready to work with Congress to preserve the legacy and future of independent physician practices, ensuring that they continue to provide high-quality, personalized care to all communities across the nation. This is not just a call for action; it is a plea to safeguard the heart of American health care before it is too late.

Comment:

By Don McCanne, M.D.

For well over half a century, the AMA has seemed to be opposed to government involvement in health care such as through a national health care program like single payer Medicare for All. Although the original Medicare program was accepted because it did provide coverage to all of our senior citizens, including those previously unable to afford medical care, there was some reluctance because of concerns about the government being involved in ensuring adequate funding and appropriate regulatory oversight. There was still strong support for private funding through cash payments or private insurance, especially employer-sponsored plans. There was also the recognition of a need for funding care for the truly indigent, such as Medicaid and other government programs.

So what has happened to this system that the AMA refused to replace with a comprehensive system for everyone? The physicians believed that, as long as they remained in control, they could continue to practice on their own terms, taking good care of the physicians, even though the patients may not have fared as well without more comprehensive government oversight.

But look at what has happened as they encouraged the private sector to maintain and expand control of health care in America. Private equity has moved in and managed to convert the primary mission of the health care system from maintaining the health of the patients to placing the creation of individual wealth of the owners as the highest priority. The private insurance industry has been particularly adept at gaining control of the medical-industrial complex with a private regulatory system that is designed to move those health dollars to their own coffers. The physicians who believed that they could continue to practice on their own terms have now found out that their terms are being dictated to them as they have actually been placed in a position of themselves being chattel that are bought and sold by this nefarious industry.

Now how does the AMA feel about the government being involved in the provision of health care? The system is such a disaster that has created a massive burnout of the profession that they are actually going to Congress – the government! – to plead that the government finally does something about it.

It is interesting that most of the requests are not simply to increase their net income, but also to make the system work better by creating an environment in which physicians are more comfortable in caring for their patients. Many of the these proposed changes will create a health care environment that does improve care for the patients as well. You see, though physicians want a system that works well for them, they are not opposed to a system that works well for the patients.

As you examine the list of improvements that the physicians are requesting (See Statement to Congress), you can see that the list could be readily modified to create a system that works well for both physicians and their patients. And we already know that enacting and implementing a single payer Medicare for All system would be the most effective for all parties concerned.

We really do want the government involved, and the AMA has now opened the doors as they stand ready to work with Congress. As they say in their Statement to Congress, “This is not just a call for action; it is a plea to safeguard the heart of American health care before it is too late.”

https://healthjusticemonitor.org…

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Comment:

By Jim Kahn, M.D., M.P.H.

This morning, as I pondered writing a broad update on our quest for single payer, I realized that the movement in California, and my involvement, is fast approaching its 30^th birthday. In November 1994, Proposition 186 was on the California ballot. We won … in San Francisco and Berkeley … but lost statewide, by the lopsided margin of 27% yes, 73% no. We were seriously outgunned by the insurers, abetted by various health care interest groups protecting their profitable interests in the existing system.

A lot has happened and changed in the intervening three decades. It’s not a pretty picture. US health care spending jumped from twice the average of other wealthy nations to three times as high, while our longevity fell from roughly equal to four years behind. The Affordable Care Act passed in 2010, cutting the uninsured rate from about 16% to 8%, while hugely boosting under-insurance by encouraging high deductible plans. Medicare Advantage, accelerated by the ACA, caught up and surpassed traditional Medicare, with annual overcharges in excess of $100 billion, making insurers the largest beneficiary of US government largesse. UnitedHealth, a massive insurer, became a multisector leviathan, adding pharmacy benefit management, pharmacies, and physicians. Private equity now controls broad swaths of the provider world. We spend at least $700 billion per year — $2000 per person – in profits and administrative waste, as nearly half of adults report financial barriers to care each year. Overall, we might say that the corporatization of medicine has triumphed over using health care funds for health care. All while three dozen other wealthy nations demonstrate the efficiency and effectiveness of providing universal standardized not-for-profit health coverage. American exceptionalism at its worst.

Has single payer reform definitively toppled? Amazingly, I’m not despondent with our chances. Instead, many factors favor its success. Public anxiety about access to (including affordability of) health care is higher than ever. Awareness of the structural failings of the system is pervasive. Pushback, e.g., against forced Medicare Advantage for union retirees, is rising. Political leaders in both parties are challenging private insurer abuses. Support for a central government role is inching up, with 2/3 support for Medicare for All, if the question is asked neutrally (“your taxes will rise, but you’ll no longer have premiums or cost-sharing, and you can choose your doctor”). Several states are actively pursuing major reform – single payer, or substantial steps on the path to single payer. There are federal bills. The leading candidate for president understands and has in the past supported single payer. Policy and advocacy experts are engaging with each other, as well as with elected officials and health agencies. I’m thrilled to be connected with these individuals and groups, doing all that I can with technical work like online household cost calculations and paths to slashing administrative waste (and, of course, with HJM).

There is a renewed determination to break the logjam, now that we clearly see the abject failure of “path dependence” – sticking with the approach started in World War II, when health insurance originated as an alternative to prohibited wage increases. We should have recognized long ago that the trajectory was off … since 1972, when the Nobel Prize in Economics went to Kenneth Arrow for showing that health care cannot work as a free market good. It’s not soybeans or mobile phones, it’s literally our lifeblood. Health care must be treated, as it is elsewhere around the globe, as a public good, to be disseminated, protected, and cultivated.

These times are fraught and exciting. The upcoming election is pivotal in US history: democracy, freedom, and community are at stake. Single payer is, likewise, resonant with American ideals of freedom (from worry and in choosing doctors) and, of course, community. The vitality we bring to the election and the vitality of health care reform efforts can, must, and will be reinforcing.

It’s hard to say when, but I see a tipping point ahead. I hope you do too. Stay the course.

https://healthjusticemonitor.org…

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Bernie Sanders: Democrats should run on a progressive economic agenda. Americans are ready., The Guardian, August 5, 2024

Bernie Sanders: In order to combat a political system which ignores so many of the most important concerns facing the majority of our people, my campaign recently commissioned a poll in the battleground states of Arizona, Georgia, Michigan, Nevada, Pennsylvania and Wisconsin. The results of the poll are not surprising, and not unlike other polls done over the years.

They show that, at a time of huge income and wealth inequality, unprecedented corporate greed, a failing healthcare system, a grossly unfair tax structure, an extremely high rate of childhood poverty, and too many seniors struggling to pay for their basic necessities, the American people want strong governmental action which addresses the longstanding needs of working families.

In other words, it turns out that progressive economic proposals are extremely popular – not only among Democrats but also among independents, Republicans and even the most ardent Trump supporters.

In fact, whether a candidate is running for the White House or a city council seat, endorsing policies that support working families is not only the right thing to do, it’s good politics.

Following are a few results from the detailed, 23-page poll:

Democrats have clear solutions for the biggest issues facing the country

• 84% of Democrats agree
• 9% of Republicans agree

Republicans have clear solutions for the biggest issues facing the country

• 8% of Democrats agree
• 88% of Republicans agree

Do you think large profitable corporations should pay more in taxes?

• 88% of Democrats agree
• 49% of Republicans agree

Do you think large profitable corporations should pay less in taxes?

• 4% of Democrats agree
• 15% of Republicans agree

Do you think the wealthy should pay more in taxes?

• 89% of Democrats agree
• 55% of Republicans agree

Do you think the wealthy should pay less in taxes?

• 3% of Democrats agree
• 9% of Republicans agree

Do you support or oppose establishing a Medicare for All single payer healthcare system?

• 85% of Democrats support
• 41% of Republicans support
• 7% of Democrats oppose
• 45% of Republicans oppose

Do you support or oppose cutting the cost of prescription drugs in half?

• 89% of Democrats support
• 79% of Republicans support
• 8% of Democrats oppose
• 13% of Republicans oppose

Do you support or oppose eliminating all medical debt?

• 77% of Democrats support
• 52% of Republicans support
• 16% of Democrats oppose
• 36% of Republicans oppose

For Third Year in a Row, PRI Survey Finds Vast Majority of Americans Are Satisfied with their Health Coverage, StreetInsider.com, August 5,2024

Based on a new national survey commissioned by Pacific Research Institute, a California-based, free market think tank, 91% said they were satisfied with their current health insurance plan.

Just 37% of respondents said they would support a complete government takeover of America’s health care system, where private health insurance would be banned, compared with 47% who were opposed.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

In this political season, it is imperative that we distinguish between the terms “policy” and “politics.” When policy concepts are totally removed from the political environment, the public, if they have a clear understanding of the policy, will generally choose what is right for them and not oppose what is right for the population as a whole as long as it does not have a significant negative impact on them. Although the intensity of the support for beneficial policies for others may vary based on political alignment, there is much more agreement in support of these beneficial policies than is commonly perceived. It is when special interest groups introduce more intense politics into the debate that deceptively larger differences in support will appear.

As an example, in health care, people support policies that make it universally accessible, with free choice of physicians and hospitals, making it efficient by eliminating administrative waste, eliminating barriers such as excessive cost sharing, or insurer prior authorization requirements, and, especially, making it affordable which can be most readily accomplished through progressive taxes, thereby eliminating the scourge of medical debt. As policies, these would all be widely accepted except for those concepts that have been tarnished by political attack, such as “taxes.” When these policies are combined, they would create the vastly superior single payer Medicare for All method of financing health care if it weren’t for the persistent political attack that has left part of our nation uncomfortable with the concept.

This bias in framing is evident in polling differences. Note the profoundly negative framing of the survey conducted by the right-wing Pacific Research Institute, asking about “complete government takeover of America’s health care system, where private health insurance would be banned” – employing frightening language, instead of highlighting the financial protections and health benefits of universal insurance. These framing debates will play out intensively in any attempt to win popular support for single payer, such as in ballot initiatives. We will see in the current presidential campaign if “joy” and shared responsibility for each other can win over doom-and-gloom government-is-your-enemy rhetoric.

Our more immediate task is to elect a President and a Congress that would be willing to enact and implement health policies (i.e., single payer) that would improve the cost, access and affordability of health care for everyone. For the next step we would need to intensify our education of the nation on precisely what these policies are, why they would be better for all of us, and then why we must change our politics and the rhetoric of our politicians so that the people would make it clear to the president and Congress that these are the policies (single payer) that they need to bring to us.

Education on policies will be the relatively easy part, but changing the politics so that we have a system to bring health to all of us instead of wealth to the select few will be the greatest task before us, but we have to do it.

https://healthjusticemonitor.org…

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The goal today is to provide maximally digestible and clarifying responses to this deeply problematic but often obscure agenda. There remains a fair amount of technical content. So, if you prefer, here’s a high-level summary:

The Project 2025 health policy roadmap is designed to increase the role of for-profit insurers, place a greater burden on individuals to pay for care, and cut public funding for health care for the poor, seniors, and the disabled. This will mean more medical debt and bankruptcies, less access to care, and worse health. The plan also targets abortion access, even where legal.

Or, more succinctly, perhaps social-media ready:

Project 2025 will weaken Medicare for seniors and people with disabilities, Medicaid for the poor, and private insurance for everyone. Insurance companies will do just fine, with a big boost to profits.

Private Health Insurance:

Project 2025: Promote direct primary care (DPC) by using health savings accounts (HSAs).

• What it means: Pay DPC doctors via HSAs set up with high deductible insurance.
• Why it’s bad: HSAs favor the healthy and wealthy, shifting unused funds to tax-free retirement accounts. This diverts money from health care to cushy retirements. (DPC itself is good: fosters continuity of the patient-doctor relationship and a focus on clinical care.)
• What we need: Don’t let DPC serve as an excuse to shift more HSA health care money into the pockets of wealthy retirees. Single payer would provide everyone with insurance for primary care along the line of DPC (and specialists, and all other care), and would grow the primary care work force. Funds not used for primary care would go to other health care needs.

Project 2025: End Affordable Care Act (ACA) regulation of private health insurance.

• What it means: Repeal ACA rules that: protect access to insurance (guaranteed issue); require community-rated premiums (sick individuals pay the same as everyone); assure broad benefits; and prohibit revoking insurance based on trivial errors when applying (recission). Also end restrictions on short-term insurance and health reimbursement / savings accounts.
• Why it’s bad: ACA rules make private health insurance much fairer and dependable, by assuring reliable broad coverage without discriminating against individuals with pre-existing illness. Removing the rules would hurt everyone, especially the sick.
• What we need: Single payer would provide identical, comprehensive health coverage to everyone, progressively financed. Meantime, keep private insurance effective and fair.

Project 2025: Use a “truth-in-advertising” approach to handle surprise medical bills.

• What it means: Replace formal dispute resolution with an approach that relies on publicly stated prices.
• Why it’s bad: The “No Surprises Act” payment resolution process has too much ambiguity and thus disputes. But “truth-in-advertising” won’t work: patients in emergency and high stakes medical situations can’t consider or act on complex price disclosures, and such disclosures will often be incorrect or misleading.
• What we need: A system where all care is covered by the same insurance. You know, single payer. Meantime, refine the “No Surprises” process.

Project 2025: Adopt free-market methods like price transparency and shared savings.

• What it means: Rely on providers to post prices and on patients to choose cheaper options (and share in the savings).
• Why it’s bad: Neither works. Most hospitals don’t comply with current price disclosure rules, and the posted lists are so complicated as to be unusable by consumers – far too many procedures and variants, price elements, and health plans. On the patient side, higher prices are seen (incorrectly) as a marker of higher quality, which everyone demands when it comes to medical care. “Skin in the game” strategies don’t control health care costs. Indeed, medical care can not work as a “free market” (Ken Arrow, 1972 Nobel Prize in Economics)
• What we need: Proven ways to reduce health care costs – eliminate our massive and massively expensive billing and insurance-related administrative bloat. Negotiate drug and equipment prices. Adopt global budgets.

Medicaid:

The proposed changes, despite being couched in bureaucratic buzzwords, have a straightforward and nefarious intent: Reduce health insurance coverage for the poor, by restricting both eligibility and benefits. And, equally worrisome, use Medicaid to suppress access to abortion.

I’m committed to making the phrase “medical insurance for the poor” archaic, by covering everyone well under one system. Meantime, let’s keep this insurance generous.

Project 2025: Reform Medicaid funding with “balanced” match rates, block grants, and caps.

• What it means: “Balanced” federal-state funding means that Medicaid would get less federal money (now 65% of the total). “Block grants” and “caps” mean fixed funding, regardless of the size of eligible populations and their medical needs, and slow or no growth over time.
• Why it’s bad: This deprives our main health insurance for the poor – already underfunded – of important resources.
• What we need: Keep Medicaid robustly funded. Indeed, increase as we did during the COVID pandemic. And end the idea of “health insurance for the poor” – with single payer for all.

Project 2025: Improve Medicaid eligibility standards to protect those in need.

• What it means: Cover only the very poorest and sickest, leaving out many who currently qualify and Who, in today’s fragile health insurance environment, meaningfully benefit from Medicaid.
• Why it’s bad: The financially and medically *merely* needy – but not in desperate straits – go without insurance and thus with major financial barriers to care.
• What we need: Keep Medicaid eligibility so that it reaches all the needy, kindly defined. With single payer, everyone would be covered.

Project 2025: Incentivize personal responsibility: require work & match benefits to individual needs.

• What it means: Impose preconditions on program eligibility, and limit coverage to the minimum necessary given financial status and medical need.
• Why it’s bad: Work requirements fail – they don’t increase work rates, but do kick people off Medicaid and thus impair access. Limiting coverage is complex, conjectural, and stingy – assuring that tens of millions of beneficiaries will experience significant barriers to care.
• What we need: Keep Medicaid eligibility so that it reaches all the needy, reasonably defined. With single payer, everyone would be covered.

Project 2025: Allow Medicaid to contribute to flexible private insurance accounts for families.

• What it means: Medicaid money can be used to support health savings accounts instead of public insurance.
• Why it’s bad: This represents shifting already inadequate public insurance funds to an approach that benefits private insurers and families with fewer medical needs. This will further weaken the Medicaid mission to protect the poor and sick. It endorses a skin-in-the-game market approach that, as noted elsewhere in this post, does not work.
• What we need: Sustain the Medicaid mission to pay for health care for the poor, especially those with greatest medical needs. Once again … with single payer, public funds would pay for health care according to medical need.

Project 2025: Redesign eligibility, financing, and service delivery of long-term care.

• What it means: I admit, I’m confused. It elaborates a reasonable sounding goal: “serve the most vulnerable and truly needy and eliminate middle-income to upper-income Medicaid recipients.” Except that, to qualify for Medicaid support for long-term care, there are already strict income and wealth criteria, which work to focus efforts on the needy (although admittedly with gaming by some families).
• Why it’s bad: It would be fine to reduce gaming, so that resources are not diverted to families who don’t need them. However, I worry that this serves as a pretext to limit eligibility to the poorest of the poor, impoverishing individuals and spouses.
• What we need: Maintain the long-term care benefit. Under single payer, long-term care is an affordable and essential benefit.

Project 2025: No funding for providers that conduct abortions, and severe financial penalties for states that pay for abortions.

• What it means: To be clear, this is not refusing to use Medicaid funds to pay for abortion; that’s already in place. This is about penalizing providers and states that in any way support access to abortion.
• Why it’s bad: It’s punitive, and contradicts the Right’s supposed deference to states on abortion issues. Thus it further compromises abortion rights, beyond the Supreme Court’s Dobbs reversal of Roe v. Wade.
• What we need: Federal funds should not be used to penalize states that permit abortion. Single payer would pay for abortion where legal, and IMO that should be everywhere.

Medicare:

Project 2025 proposals focus on increasing the role of private insurers and market solutions. Both, we’ve seen, fail. This approach increases prices, enabling massive financial gains for corporate executives and shareholders.

Project 2025: Increase beneficiary control of care via information about providers & insurance.

• What it means: Make it the patient’s responsibility to review and interpret complex information about provider quality and prices.
• Why it’s bad: Choice of provider, yes! However, it’s a debunked myth that valuing health care is like valuing cars or phones. Health care is complex and often emotionally fraught. It’s unsuited for this free market approach.
• What we need: Let’s stop pretending that a “free market” can fix health insurance. Under single payer, everyone would have free choice of providers, fully paid for, and quality improvement would be a program priority.

Project 2025: Rely on intermediate entities to control costs and improve quality. Make Medicare Advantage the default plan.

• What it means: Medicare Advantage private insurance plans and traditional Medicare ACOs & direct contracting entities should operate between beneficiaries and providers.
• Why it’s bad: It’s not working, quite the opposite. Medicare Advantage results in >$100 billion in excess spending each year, and huge profits for insurers, while beneficiaries often can’t afford care. ACOs don’t control costs. Neither improves quality.
• What we need: Let’s strengthen traditional Medicare by reducing cost-sharing (such as lowering drug prices) and rein in Medicare Advantage abuses. Single payer uses direct funder to provider approaches, with no intermediary profits, shown to work in 32 wealthy nations.

Project 2025: Shift to value-based payments, within traditional Medicare.

• What it means: Use VBPs of various types to control costs and raise quality.
• Why it’s bad: Value-based payment is a loosely defined idea that financial incentives should foster efficiency in selection and implementation of care. This works for many goods and services, but not for health care – which for patients is driven by pressing need, and for providers is driven by technical expertise and a desire to heal. Health care is not widgets. ACOs, the premier VBP model, failed to achieve goals. VBP is misplaced in health care and distracting.
• What we need: Medicare should pay for care, and abandon the failed experiment with VBP. Under single payer, costs are controlled with administrative efficiency, price negotiations, and global budgets; quality is enhanced through research, training, and oversight.

Project 2025: End drug price negotiations; lower the Medicare role for catastrophic drug costs.

• What it means: Terminate or subvert the drug price negotiations created by the Inflation Reduction Act. Reduce the program portion (thus raising beneficiary burden) when drug costs accelerate.
• Why it’s bad: The IRA provides baby steps toward the much-needed and widely-used (in other nations) drug price negotiations. Pharma can well afford prices that align better with global levels. And it’s especially cruel to abandon beneficiaries when costs are highest.
• What we need: Continue to implement and expand drug price negotiations in Medicare. Under single payer, as around the world, that’s how the system assures affordability while allowing solid Pharma profits.

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