By Peter Sullivan
The Hill, December 11, 2018

The incoming chairman of the powerful Ways and Means Committee, Rep. Richard Neal (D-Mass.), said Tuesday that he is open to holding hearings on “Medicare for all” next year.

“The first thing we’re going to try to do is to address the issue of pre-existing conditions,” Neal told reporters when asked about Medicare for all. “But I don’t see how we can’t evolve into a hearing on many of these other proposals and discussions. I think they deserve a conversation.”

The comments, while not a firm commitment, are some of the most encouraging toward Medicare for all supporters from a top House Democrat to date. Democratic leaders and key committee chairmen have so far not given support to Medicare for all, despite a push from the progressive wing of the party.

Neal said the details of a hearing are not yet clear, and there are also other health-care issues he wants to explore.

But he said of Medicare for all, “I’m not going to ignore it, that’s for sure.”

“I think we should hold a hearing on the ACA, I think we should have a hearing on the mandate, I think we should hold a hearing on pre-existing conditions,” Neal said.

“I think we ought to have a hearing on all of it,” he added.

Progressive House Democrats are pushing for a vote on Medicare for all after Democrats take back the House next year.

House Democratic Leader Nancy Pelosi (Calif.) has not offered any commitment beyond saying earlier this year that Medicare for all would have to be “evaluated” and “it’s all on the table.”

Neal’s comments on Tuesday also go farther than those of Rep. Frank Pallone Jr. (D-N.J.), the incoming chairman of the other key committee overseeing Medicare for all, the Energy and Commerce Committee.

Pallone said last month that Medicare for all did not have the votes to pass so he would focus on the Affordable Care Act instead.

“I’ve always been an advocate for Medicare for all or single-payer, but I just don’t think that the votes would be there for that, so I think our priority has to be stabilizing the Affordable Care Act, preventing the sabotage that the Trump administration has initiated,” Pallone said last month.

https://thehill.com…

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Comment:

By Don McCanne, M.D.

In spite of candidate support for Medicare for All in the midterm elections, there has been concern that Congressional efforts would be limited to ensuring that preexisting conditions would be covered and perhaps holding hearings on a Medicare public option buy-in. Some have seemingly dismissed any consideration of Single Payer Medicare for All as not being politically feasible with Republican control of the Senate and The White House. Considering that, this report is really good news.

The incoming chairman of the powerful Ways and Means Committee, Rep. Richard Neal, says that he is open to holding hearings on “Medicare for All” next year. Even House Democratic Leader Nancy Pelosi says, “it’s all on the table.”

Although these are not promises, they are openings for us to organize grassroots efforts around to be be sure that we diplomatically remind the legislative leaders that such hearings must be of the highest priority, even if they are not expected to result in passage of legislation in this next session of Congress. The hearings are important because they can be used to refine the future legislation, and, most importantly, to educate the less-well-informed public just what it is about Single Payer Medicare for All that is deservedly making it so popular.

Who knows? With the observed increasing support amongst Republican voters maybe the legislators and President Trump will have an epiphany and finally decide to do the right thing.

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

By Adam Gaffney
The Guardian, December 11, 2018

If you can’t undercut a popular proposal as undesirable, make it sound impossible. That, in any event, has been the tack of opponents of single-payer healthcare, also called improved “Medicare-for-all”.

“[W]e got to get away from these falsehoods and start talking about the truth …” opined billionaire Starbucks CEO Howard Schultz on CNBC last June, while contending that single-payer healthcare was economically infeasible. “I think a lot of the analysis has shown it’s unaffordable,” claimed Seema Verma, head of the Centers for Medicare & Medicaid Services, last summer, quoted by Kaiser Health News.

Yet casting Medicare-for-all as an economic impossibility is becoming a sisyphean pursuit: a slew of studies – including one released just the other week – are confirming that, yes, we can afford real universal healthcare in America. But if that’s the case, why haven’t we already achieved it? Well, the real stumbling block is not that single-payer advocates’ arithmetic is poor, it’s that American politics are dominated by the rich.

Still, the numbers matter. On 30 November, a team of economists with the Political Economy Research Institute (Peri) at the University of Amherst published a highly credible, nearly 200-page economic analysis of Senator Bernie Sanders’ single-payer bill. The Peri study received essentially none of the media coverage lathered on the last such analysis – a flawed piece of work published by the conservative Mercatus Center last summer. But here’s the funny thing: though these two analyses came from economists from opposite ends of the political spectrum, they shared a similar finding: single-payer would reduce our nation’s healthcare spending bill by trillions of dollars over a decade (around $2tn and $5tn, respectively).

The numbers are big, but they shouldn’t come as a surprise. Yes, single-payer imposes some new costs: when people don’t have to worry about ruinous medical bills or ravenous debt collectors, they tend to use more healthcare, increasing costs. But such rises in utilization are likely to be modest (even more modest than these analyses predict). There are only so many doctors and hospital beds, which limits theorized surges in utilization. Anyway, there are hundreds of billions in potential savings in moving to single-payer, such as slimming down on the massive administrative bloat of the privatized American healthcare system and bringing down our sky-high drug prices.

Going back decades, studies have found that, at worst, these costs and savings will balance out under a Canadian-style single-payer reform. “In Canada, each provincial plan provides for universal insurance coverage with no deductibles or copayments, controls on provider reimbursement, and administration by a single, public payer,” the United States General Accounting Office noted in an analysis of a single-payer bill way back in 1992. “We found that if these features were applied in the United States, the administrative savings could offset the added costs.”

In a review of the Peri study that I co-authored with Professors David Himmelstein and Steffie Woolhandler at the City University of New York, we commended the robustness of the team’s much-needed and highly thorough analysis, while offering differing opinions on some of the specific assumptions. We also contended that it would be prudent to cautiously assume that overall healthcare spending would remain roughly stable (rather than fall) shortly after implementation.

But here’s the thing: a single-payer system allows cost growth to be directly controlled over time in a way that’s not possible with a privatized system. So even if a Medicare-for-all system only allows us to keep overall healthcare spending where it is today (as a proportion of the US economy), a quick back-of-the-envelope calculation using figures from the National Health Expenditures accounts shows that it would still save some $2tn over a decade.

To be clear, even as we reduce overall health spending by trillions, new taxes will be needed to replace most of the private spending – eg premiums, copays, and deductibles – that suddenly and permanently evaporate. To this end, the Peri analysis proposes a sensible mix of taxes, including payroll taxes paid by businesses, a sales tax on non-essentials, and a wealth tax on the richest among us. It would also treat capital gains like ordinary income. In exchange, we would have a healthcare system that covers everyone in the nation, without copays or deductibles, with comprehensive benefits, with no insurance networks or interruptions in coverage – and a permanent end to the soul-sucking hassle of medical bills.

There is another benefit of this system, albeit one that helps explain why we haven’t achieved it yet. A more progressive system of healthcare financing can, over time, reduce inequalities not only in health, but in wealth, helping to close our nation’s disastrous economic divide. It’s not surprising, then, that billionaires don’t much like it. Nor is it unexpected that the corporate behemoths that have the most to lose are already sharpening their swords, pouring cash into a new anti-single-payer lobbying group that, as the Intercept recently reported, is maneuvering to “influence Democratic party messaging and stymie the momentum toward achieving universal health care coverage”.

So as important as rigorous analyses and funding proposals are, we miss the forest for the trees if we see this mainly as a fight among policy wonks or dueling funding proposals. This is a struggle against the “economic royalists”, as Franklin D Roosevelt once termed them, of our day – and for the interests of ordinary working people. Good numbers do not a political movement make.

Adam Gaffney is President of Physicians for a National Health Program.

https://www.theguardian.com…

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Comment:

By Don McCanne, M.D.

Those who are up to date on the health policy literature may not find much new here, but there are a few points worth emphasizing:

• It is irrefutable that a well designed, single payer Medicare for All program would meet our health reform goals of affordability, universality, equity, effectiveness and efficiency.
• The barrier to reform is not financing since we are already spending enough to pay for such a system, especially once administrative efficiency is factored in.
• Using taxes to pay for the system should not be a problem since our current public spending on government-financed health programs, on tax expenditures for employer-sponsored plans, and on the purchase of health care for public employees would already pay for much of the system, and the remaining taxes needed would be offset by the elimination of insurance premiums, deductibles and other cost sharing.
• The fact that the taxes would be progressive would be a small step to help offset the egregious inequities in income that hold back too many of us who are contributing our fair share of effort to society while too often having to scrimp on essential needs. Tax policies should be used to adjust inequities that result in a select few being able to accumulate obscene levels of wealth – amounts far, far in excess of what their personal efforts contribute to society. They will not suffer from a very modest reduction in their excesses.
• The primary barrier to reform is political. Although Adam Gaffney says, “Good numbers do not a political movement make,” they sure do help. Advocacy is much easier when the facts are on the side of the people. So let’s all get out and nurture that political movement that we need.

The policy fight should be over. It is a political battle that we now face.

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

By Adam Cancryn
POLITICO, December 10, 2018

The united front that helped Democrats save Obamacare just a year ago is falling apart over single-payer health care.

Deep-pocketed hospital, insurance and other lobbies are plotting to crush progressives’ hopes of expanding the government’s role in health care once they take control of the House. The private-sector interests, backed in some cases by key Obama administration and Hillary Clinton campaign alumni, are now focused on beating back another prospective health care overhaul, including plans that would allow people under 65 to buy into Medicare.

This sets up a potentially brutal battle between establishment Democrats who want to preserve Obamacare and a new wave of progressive House Democrats who ran on single-payer health care.

“We know the insurance companies and the pharma companies are all putting tens of millions of dollars into trying to defeat us,” said Rep. Pramila Jayapal (D-Wash.), who co-chairs the Medicare for All Congressional Caucus. “Which I take as a badge of honor — that they’re so concerned about a good policy that they’re going to put so much money into trying to defeat it.”

The rift could come into full view in the opening weeks of the new Congress, as the party long bound by a need to defend the Affordable Care Act tries to embrace a new health care vision it can carry into the 2020 presidential campaign.

House Democratic leaders already are emphasizing the need to align behind a more pragmatic agenda focused largely on shoring up Obamacare, without peering too far into the future.

“We want to continue promoting the idea of accessibility and improving the Affordable Care Act,” said incoming Ways and Means Committee Chairman Richard Neal (D-Mass.). “That should be the primary goal that we have.”

It’s a sentiment shared by the major lobbies that fought alongside Democrats against Obamacare repeal and now want to reap the benefits. These interest groups contend that, after a decade of upheaval in health care, the public would prefer simple fixes that strengthen the ACA over a headlong rush into another dramatic overhaul of the system.

But House progressives, buoyed by voter enthusiasm and a surge of single-payer support among the party’s base, have other ideas. Among their high-profile agenda items is “Medicare for All” legislation, an idea until recently on the fringes of policy debates that polling shows captivated voters during the 2018 election cycle, despite potentially staggering costs.

“It’s more of a mainstream position than it’s ever been before,” said Adam Green, co-founder of the Progressive Change Campaign Committee, which maintains close ties to House progressives. “There’s this hugely rapid advancement toward Medicare for All — single-payer — as not just an eventual North Star goal, but as something that’s increasingly possible.”

But major lobbies that fought shoulder-to-shoulder with Democrats last year are working now to derail such liberal ideas in order to preserve the status quo.

More than a dozen groups intend to press their point next year through The Partnership for America’s Health Care Future, a vehicle to combat an expanded government role in health care.

America’s Health Insurance Plans and the BlueCross BlueShield Association helped found the coalition alongside the Federation of American Hospitals, the big drug lobby PhRMA and the American Medical Association.

Since then, it’s added another 13 organizations — most representing companies with much to lose under a system that shrinks or in some cases eliminates private health care.

The Partnership, some of whose members began discussions within weeks of Senate Republicans’ failed Obamacare repeal vote in July 2017, is planning to launch a campaign featuring ads, polling and white papers playing up the private sector’s role and warning against further disruptions to the health system, people involved with the group said. Avalere, a consulting firm Democrats often leaned on to highlight the dangers of GOP repeal bills, is producing research for the coalition.

Avalere founder Dan Mendelson — a former Clinton White House official — declined to comment on the firm’s work, citing a policy of not talking about its clients.

The Partnership has also received support from Lauren Crawford Shaver, a veteran of the Obama administration’s Health and Human Services Department and Hillary Clinton’s 2016 campaign, who is running its operations out of the lobbying shop Forbes Tate Partners.

“We believe all Americans deserve access to affordable, high-quality health care. But a one-size-fits-all, government-controlled system like Medicare for All isn’t the answer,” Shaver said, predicting it would restrict choice and innovation and put “decisions regarding our health care in the hands of politicians in Washington.”

Other groups that fought Obamacare repeal are quietly working to limit Democrats’ ambitions by highlighting the practical complexities and political risks inherent in rewiring the entire national health care system — including an employer-sponsored insurance market that serves 151 million Americans.

Officials from several groups expressed confidence that public support for Medicare for All will plunge as people become more aware of the trade-offs it would require.

“We are convinced here that, whether it’s on the state basis or federal basis, incremental change is a real possibility and is doable,” said Kenneth Raske, president of the Greater New York Hospital Association, one of the loudest voices in 2017 against both ACA repeal and a state-level single-payer effort. “In New York, we have 5 percent uninsured. Why do we want to have a 100 percent solution to a 5 percent problem?”

Liberals concede their effort faces institutional roadblocks but maintain they’re undaunted by the firepower aimed their way.

The House Democrats’ progressive wing is increasingly influential, the party has a clear advantage on health care for the first time in years and polls show the once-fringe concept of a single-payer system is captivating a growing portion of the nation.

“We want to make sure we shore up protections for pre-existing conditions [and] do everything we can to make sure the Affordable Care Act is effective as possible,” Jayapal said. “But, in the end, we still have a problem with the cost of health care for ordinary people. And so that’s what we’re trying to address.”

The progressive movement’s own lobbying campaign inside and outside Congress is just getting started, she added. That gives the party time to balance shoring up the ACA with figuring out a path to universal health care that could range from incremental steps like adding a public option all the way up to a full single-payer system.

And in the meantime, progressives say they’re more concerned about courting voters than winning over big business. For as much as the industry lobbies contributed to defending Obamacare, they argue, the repeal fight demonstrated even more convincingly that Democrats can win any health care battle if the public is on their side.

“People across this country have worked through for themselves the public debate on the government’s role in health care, and America has shifted,” said Sen. Elizabeth Warren (D-Mass.), a Medicare for All supporter and likely 2020 presidential candidate. “So the importance of persuading every one of the insiders that this is going to be a great deal for them has diminished.”

https://www.politico.com…

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Comment:

By Don McCanne, M.D.

This article gives us a brief update on the politics of Medicare for All. The opposition by certain vested interests is understandable since some of them stand to have their highly lucrative roles displaced partially or completely by a system that instead places patients first.

As Sen. Elizabeth Warren states, “People across this country have worked through for themselves the public debate on the government’s role in health care, and America has shifted. So the importance of persuading every one of the insiders that this is going to be a great deal for them has diminished.”

Patients first.

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By Sara R. Collins and David C. Radley
The Commonwealth Fund, December 7, 2018

Recent national surveys show health care costs are a top concern in U.S. households. While the Affordable Care Act’s marketplaces receive a lot of media and political attention, the truth is that far more Americans get their coverage through employers. In 2017, more than half (56%) of people under age 65 — about 152 million people — had insurance through an employer, either their own or a family member’s. In contrast, only 9 percent had a plan purchased on the individual market, including the marketplaces.

Highlights

• After climbing modestly between 2011 and 2016, average premiums for employer health plans rose sharply in 2017. Annual single-person premiums climbed above $7,000 in eight states; family premiums were $20,000 or higher in seven states and D.C.
• Rising overall employer premiums increased the amount that workers and their families contribute. Average annual premium contributions for single-person plans ranged from $675 in Hawaii to $1,747 in Massachusetts; family plans ranged from $3,646 in Michigan to $6,533 in Delaware.
• Average employee premium contributions across single and family plans amounted to 6.9 percent of U.S. median income in 2017, up from 5.1 percent in 2008. In 11 states, premium contributions were 8 percent of median income or more, with a high of 10.2 percent in Louisiana.
• The average annual deductible for single-person policies rose to $1,808 in 2017, ranging from a low of $863 in Hawaii to a high of about $2,300 in Maine and New Hampshire. Average deductibles across single and family plans amounted to 4.8 percent of median income in 2017, up from 2.7 percent in 2008. In three states (Florida, Mississippi, and Tennessee), average deductibles comprised more than 6 percent of median income.
• Combined, average employee premium contributions and potential out-of-pocket spending to meet deductibles across single and family policies rose to $7,240 in 2017 and was $8,000 or more in eight states. Nationally, this potential spending amounted to 11.7 percent of median income in 2017, up from 7.8 percent a decade earlier. In Louisiana and Mississippi, these combined costs rose to 15 percent or more of median income.

Worker payments for employer coverage are growing faster than median income.

The average employee premium cost across single and family plans amounted to 6.9 percent of median income in 2017, up from 5.1 percent in 2008.

Average deductibles are also outpacing growth in median income.

In many states, even though costs are rising, people are not getting insurance that protects them more because deductibles are also increasing.

From the Conclusions

Families’ costs for employer health insurance are rising faster than median income. Moreover, even as costs climb, many families aren’t receiving higher-quality insurance. The amount they have to spend out of pocket before their insurance coverage kicks in also continues to climb. While this study only considered families with middle incomes, lower-income families with employer coverage will use an even larger share of their income for health insurance costs.

Higher costs for insurance and health care have implications. People with low and moderate incomes may simply decide to go without insurance if it competes with other critical living expenses like housing, food, and education. In 2017, average per-person expenditures on food in the U.S. amounted to 13 percent of median income and housing costs were 32 percent. People with coverage but deductibles that are high relative to income are nearly as likely as those uninsured to skip needed health care, like filling prescriptions or going to the doctor when they are sick.

Health care cost growth is the primary driver of premium growth across all health insurance markets. Policymakers will need to recognize that the increasing economic strain of health care costs facing middle-income and poor Americans is driven by multiple interrelated factors and will require a comprehensive solution.

https://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

When the Affordable Care Act (ACA) was crafted, the sector of the private insurance market that the legislators most wanted to protect was the employer=sponsored plans. It was perceived as the private insurance sector that was still working well and the private plans with which satisfaction was the greatest (leading to the unfortunate promise, “if you like your health plan, you can keep it”).

The disappointing conclusions of this study should surprise no serious student of health policy. The excessive growth rate in health care spending needed to be addressed in the ACA legislation, but it included only token “wish-it-would-work” policies such as accountable care organizations and other value-based policy proposals. The only measures that would actually work were those that expanded barriers to beneficial care such as excessive, unaffordable deductibles and other cost sharing, and penalties for obtaining care outside of restrictive provider networks. These concepts defeat the purpose of a program that should be designed to assist patients in accessing the care that they need.

With perpetually increasing costs, it is no wonder that employees and their families are faced with higher premiums and higher deductibles. Not only that, they are paying for the increased premium contributions of their employers through their own forgone wage increases. It is easy to see how employer-sponsored insurance is a growing burden, especially for middle- and low-income families.

It is no secret that the policy design of our current health care financing system has caused it to fall far short of the goals of reform, and the tragedy is that these defects were known when ACA was crafted. But, at this stage, instead of crying over spilt milk (more accurately, spilt blood), we should promptly move forward with enacting policy improvements that will fix our system. Those improvements, of course, would be inherent in a well designed Single Payer Medicare for All program. That strategic move would automatically bring affordable, accessible care to absolutely everyone. Burdens, such as those that the employer provided plans are placing on us, would no longer be necessary.

The authors state, “Policymakers will need to recognize that the increasing economic strain of health care costs facing middle-income and poor Americans is driven by multiple interrelated factors and will require a comprehensive solution.” Obviously, that comprehensive solution would be Single Payer Medicare for All.

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

By Anne B. Martin, Micah Hartman, Benjamin Washington, Aaron Catlin, and The National Health Expenditure Accounts Team
Health Affairs, December 6, 2018 (Published Ahead of Print)

Abstract

Total nominal US health care spending increased 3.9 percent to $3.5 trillion in 2017, slowing from growth of 4.8 percent in 2016. The rate of growth in 2017 was similar to the increases between 2008 and 2013, which preceded the faster growth experienced during 2014–15—a period that was marked by insurance coverage expansion and large increases in prescription drug spending. Slower growth in health care spending in 2017 was mainly attributable to the use and intensity of goods and services, particularly for hospital care, physician and clinical services, and retail prescription drugs. Nearly all major sources of insurance and sponsors of health care experienced slower growth in 2017. On a per capita basis, spending on health care increased 3.2 percent and reached $10,739 in 2017. The share of gross domestic product devoted to health care spending was 17.9 percent in 2017, similar to the share in 2016.

Conclusion

Health care spending grew 3.9 percent in 2017, about the same rate at which the overall economy increased, and as these two growth rates converged, the health spending share of GDP stabilized. This was the first year since 2013 that this share did not increase, as 2014 and 2015 were marked by insurance coverage expansion and expensive new drug treatments that produced faster growth in health care spending, while 2016 was affected by low economic growth.

Viewed from a longer historical perspective, the rate of growth in health spending over the past decade contrasts with the experience of the prior ten-year period. Health care spending growth averaged 4.3 percent per year during 2008–17, compared to an average annual rate of 7.3 percent over the 1998–2007 period. For this most recent decade, growth in both excess medical-specific inflation and the use and intensity of health care goods and services was slow relative to historical trends, despite the fact that this period included the largest increase in health insurance coverage since the 1960s.

However, the past ten years were also marked by lower overall economic growth (which averaged 3.0 percent) and lower economywide inflation (which averaged 1.6 percent), both strongly influenced by the Great Recession. As a result, the health spending share of GDP increased by 1.6 percentage points from 2008 to 2017 (compared to a 2.6-percentage-point increase from 1998 to 2007). For a health sector that now accounts for nearly one-fifth of the US economy, future increases in health care expenditures will likely lead to policy decisions focused on affordability and sustainability.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Health spending continues to gradually increase as a share of our gross domestic product – 1.6 percent over the past decade (though lower than the 2.6 percent increase over the previous decade). The authors state, “For a health sector that now accounts for nearly one-fifth of the US economy, future increases in health care expenditures will likely lead to policy decisions focused on affordability and sustainability.”

Those policy decisions should also address the high rates of uninsurance, underinsurance, administrative waste due to our financing model heavily dependent on a multitude of private insurers, and barriers to beneficial health care services due to restrictions of insurer provider networks and excessive deductibles and other cost sharing.

Most of these problems can be resolved simply by enactment of a single legislative package: Single Payer Medicare for All. Let’s do it.

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

By Robert Pear
The New York Times, December 1, 2018

Older Americans have been flocking to Medicare’s private plans, which promise predictable costs and extra benefits.

But the private Medicare Advantage plans have also been getting an unpublicized boost from the Trump administration, which has in the last few weeks extolled the virtues of the private plans in emails sent to millions of beneficiaries.

The officials deny that they are steering patients to private plans, but the subject lines of recent emails read almost like advertisements. “Get more benefits for your money,” says a message dated Oct. 25. “See if you can save money with Medicare Advantage,” said another sent a week later.

“You may be able to lower your out-of-pocket costs while getting extra benefits, like vision, hearing, dental and prescription coverage,” said an email sent to beneficiaries on Wednesday.

“With Medicare Advantage,” says another email, “one plan covers all of your care.”

Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, said the agency was not favoring private plans over the original government-run Medicare program.

“We are not steering any Medicare beneficiary anywhere,” she said.

But Richard S. Foster, who was for many years the nonpartisan chief actuary of the Medicare program, said the emails sounded “more like Medicare Advantage plan advertising than objective information from a public agency.”

https://www.nytimes.com…

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Medicare Advantage Checkup

By Patricia Neuman, Sc.D., and Gretchen A. Jacobson, Ph.D.
The New England Journal of Medicine, November 29, 2018

The emerging role of Medicare Advantage, the private-plan alternative to traditional Medicare, is gradually changing the Medicare program in ways that have important implications for beneficiaries, providers, and spending. Fueled by policy changes adopted by both Democrats and Republicans, enrollment in Medicare Advantage plans has more than tripled since 2005, from approximately 6 million to 20 million beneficiaries.

Policymakers have articulated a number of goals for having private plans in Medicare, one of which is to provide beneficiaries access to extra benefits not available in traditional Medicare. Thanks to a number of policy and payment changes adopted over the years that have not only required plans to offer a richer set of benefits to their enrollees but also offered incentives for plans to do so, this goal has generally been achieved. Since 2011, the Centers for Medicare and Medicaid Services (CMS) has required all Medicare Advantage plans to provide out-of-pocket limits for Medicare-covered services.

Medicare payment policy requires plans to use “rebate” dollars to provide enrollees enhanced benefits or lower premiums (allowing plans to keep a portion to cover administrative costs and profit). Rebates accrue when a bid submitted by a Medicare Advantage plan for Medicare-covered benefits is below the “benchmark” (the maximum federal payment to plans in that geographic area); the federal government keeps a portion of the excess and remits the remainder (the rebate) to the plan. As a result of rebates, most Medicare Advantage enrollees receive benefits not covered by traditional Medicare.

Studies suggest that the current rebate-based method may not be an economically efficient way of providing extra benefits to beneficiaries because plans are retaining a fairly large share of the rebate for administrative costs and profit, passing on to enrollees only 54% of the rebates, on average.

Medicare has evolved into a program that provides benefits that are more generous to beneficiaries in Medicare Advantage plans than to their counterparts in traditional Medicare.

Discussion

Medicare Advantage plans are now firmly established in the fabric of Medicare. Under the assumption that Medicare Advantage enrollment will continue to climb, the Medicare of tomorrow could look much different than it does today — more like a marketplace of private plans, with a backup public plan, and less like a national insurance program. This may or may not be the program that people envision when they talk about Medicare for All.

Policymakers, both Democrats and Republicans, are generally supportive of Medicare Advantage plans because they are popular with their constituents. More and more seniors are signing up for Medicare Advantage to get the extra benefits, the financial protection of an out-of-pocket limit, and the convenience of one-stop shopping for all their coverage. Despite the substantial reductions in federal payments to plans required by the ACA, health insurers have been growing their Medicare Advantage lines of business and new insurers are breaking into the Medicare Advantage market, which suggests that it remains among the more lucrative health insurance products.

Yet, several issues are on the horizon. The current payment environment that attracts insurers and provides extra benefits to enrollees comes at a cost to taxpayers and may reemerge as an issue down the road, when federal spending becomes a more pressing policy concern. The equity issue that arises from providing stronger financial protections, with an out-of-pocket limit, for beneficiaries in Medicare Advantage than in traditional Medicare could also gain traction as an issue, particularly as seniors’ out-of-pocket spending continues to rise. With respect to quality, the wide variation across plans, a paucity of data pertaining to sicker patients, and eyebrow-raising disenrollment rates among higher-need patients appear to warrant attention and oversight. Still to be determined is how the growing role of private insurance in Medicare, and the diminishing role of traditional Medicare, is likely to affect beneficiaries’ out-of-pocket spending, satisfaction, and health outcomes over time.

https://www.nejm.org…

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Reforming America’s Healthcare System Through Choice and Competition

U.S. Department of Health and Human Services, U.S. Department of the Treasury, U.S. Department of Labor

When it comes to healthcare, Americans should expect more value for the dollars they spend. This report details many opportunities to increase the value provided throughout our healthcare system through the actions that create greater choice and competition.

For the full 114 page report:
https://www.hhs.gov…

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Comment:

By Don McCanne, M.D.

The NYT article describes CMS’s efforts to market the private Medicare Advantage plans in an effort to displace the traditional, government-run Medicare program, although CMS Administrator Seema Verma denies that they are favoring the private plans. That is a difficult assertion to accept in the face of their marketing efforts.

The NEJM article confirms that the government has continued to give the private Medicare Advantage plans a marketing edge over the traditional Medicare program by granting the private plans greater benefit packages and especially the extra financial protection of limitations on out-of-pocket costs.

The report from the Departments of HHS, Treasury, and Labor confirms that the current administration is dedicated to the ideological goal of using choice and competition in the private marketplace as a basis for reforming America’s health care system. The gradual transformation of Medicare into a market of private health plans is evidence of the support for privatization of Medicare. However this is not new since the neoliberal players in the Obama and Bush administrations were already advancing the private Medicare Advantage plans.

Under a Single Payer Medicare for All program, private plans are eliminated, leaving in place only a single publicly-financed and publicly-administered program. The adherence to market choice and competition ideology is sending us in the opposite direction, shifting control to a market of private health plans.

The people are going to have to lead, but not through exclusive alignment with either the Democrats or the Republicans. The Choice and Competition report shows where the Republicans stand, but many of the Democrats who claimed they supported Medicare for All are now indicating that they want to preserve the individual and employer-sponsored private health plans while merely adding a public option with a deceptive Medicare label. That’s no solution.

No, we the people are going to have to join together across party lines and take a firm, unified stand, telling all of our politicians that we want health care for everyone. Do you think we can pull that off? I mean, it’s for our health – all of us.

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By Sanjay Kishore, Micah Johnson, Don Berwick
Health Affairs Blog, December 3, 2018

Health care was the most important issue for voters in the 2018 Congressional elections, in which Democrats won a significant majority in the US House of Representatives. A major health care proposal supported by many Democrats is “Medicare for All”, which would create a publicly-financed, single-payer health insurance system for all Americans.

Many observers dismiss single-payer health care as a political non-starter, but this traditional view ignores an explosion of support for the idea in recent years. In one recent poll, over 70 percent of Americans said they would support “a policy of Medicare for All”, including 85 percent of Democrats and even 52 percent of Republicans. A subsequent poll asked “do you support providing Medicare for every American” and found nearly identical results, including majorities of support from respondents in the South, those who live in rural areas, and those who say they “lean conservative.”

What insights do the 2018 elections provide into the future political prospects of Medicare for All?

(The authors discuss the support for Medicare for All in the House of Representatives and in the Senate.)

Implications For The 116th Congress

Medicare for All will not become law in the next two years, but the incoming 116th Congress could play an important role in determining the future of the proposed reform.

First, this Congress will have an opportunity to distinguish Medicare for All from other Democratic proposals to expand public coverage. To capitalize on the popularity of Medicare for All, some organizations have released more moderate proposals with sound-alike names such as “Medicare Extra for All”; others have started to brand Medicare buy-in proposals with slogans like “Medicare Available to All” or “Medicare for Anyone.” These alternatives are essentially variations on a public option. These proposals vary in their details and scope, and their relative merits are worthy of debate in the upcoming Congress. However, they differ substantially from the actual Medicare for All bills that have been proposed in Congress for many years. The 116th Congress will have an opportunity to clarify these differences, and to build further public understanding of Medicare for All.

Second, the 116th Congress can start building consensus on key policy elements of a Medicare for All proposal, including knotty issues such as determining the covered benefits of the plan, exploring alternative revenue sources and cost controls, deciding how providers would be paid and at what prices, how to pave a practical transition pathway from current health plans, how to craft a soft landing for the employees of the current insurance industry, and more. Ideally, this exploration will help foster a deeper and more mature discussion of Medicare for All among legislators in the future.

Implications For 2020 Elections And Beyond

It is time to re-frame the public debate: the path to Medicare for All is difficult, not impossible. In a democracy, it is strange and basically untenable to insist that an idea at least nominally supported by 70 percent of the citizenry is not even worthy of serious consideration. Medicare for All, though difficult, is now within the realm of political possibility, and the surge of enthusiasm among new members in the House of Representatives is evidence of renewed public interest in expanding access to health coverage and controlling costs.

As Presidential contenders enter the 2020 primaries, Medicare for All will almost certainly become a focal point of national discourse. Instead of pretending that Medicare for All is impossible, health policy experts and Congressional leaders should deepen their knowledge of the promise and challenges of single-payer health reform, and start working seriously on the hard job of crafting the best possible version of Medicare for All.

Sanjay Kishore and Micah Johnson are fourth-year MD candidates at Harvard Medical School and Don Berwick, MD, MPP, FRCP is President Emeritus and Senior Fellow at the Institute for Healthcare Improvement, and is the former Administrator of the Centers for Medicare & Medicaid Services.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

How could you ask for a more credible voice on the topic of Medicare for All than Don Berwick and two senior medical students at Harvard?

Their concluding remark: “Instead of pretending that Medicare for All is impossible, health policy experts and Congressional leaders should deepen their knowledge of the promise and challenges of single-payer health reform, and start working seriously on the hard job of crafting the best possible version of Medicare for All.”

Sage advice. Let’s go with it.

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