By Diane Archer
The Hill, March 11, 2019

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

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

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

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

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

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

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

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

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

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

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

https://thehill.com…

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Comment:

By Don McCanne, M.D.

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

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BlueCross BlueShield Association, Issue Brief, March 2019

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

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

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

1. Revise federal assistance to help more people afford coverage

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

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

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

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

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

https://s3.amazonaws.com…

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Comment:

By Don McCanne, M.D.

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

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

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

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

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

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

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

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

Abstract

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

From the Discussion

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

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

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

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

Conclusion

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

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

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

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

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

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

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

Excuse me, but I have to barf.

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Haven, accessed March 7, 2019

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

Frequently Asked Questions

Why was the name ‘Haven’ chosen?

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

How is Haven going to improve health care?

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

Is Haven going to replace existing doctors or insurance companies?

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

Who is Haven going to help?

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

https://havenhealthcare.com

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Comment:

By Don McCanne, M.D.

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

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

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

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

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

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By David J. Meyers, MPH; Emmanuelle Belanger, PhD; Nina Joyce, PhD; John McHugh, PhD; Momotazur Rahman, PhD; Vincent Mor, PhD
JAMA Internal Medicine, February 25, 2019

From the Introduction

More than one-third of Medicare beneficiaries are now enrolled in MA (Medicare Advantage), an increase from 19% in 2007. Medicare Advantage differs from TM (Traditional Medicare) in that private insurance plans are paid by the Centers for Medicare & Medicaid Services (CMS) on a capitated basis to cover the care of their enrollees. Because payments are fixed, this model incentivizes payers to reduce spending. Medicare Advantage plans may emphasize better primary care and care management services for high-need enrollees to prevent expensive acute services down the line. Two potential barriers to these benefits exist: capitated payments when not properly risk adjusted may incentivize “cream skimming” and “lemon dropping” (ie, attracting healthier individuals and dropping those with higher needs). Medicare Advantage plans may also restrict physician networks and require prior authorization for care. These policies may be challenging for high-need enrollees, potentially leading to poorer experiences. Understanding the experiences of high-need beneficiaries enrolled in MA is vital if the benefits of managed care are to work for this group.

A growing body of literature suggests that concerns remain regarding MA plans for high-need enrollees. Although some disenrollment may be driven by error in plan choice, MA switch to TM occurs at higher rates after significant health events and kidney failure. Evidence from the nursing home industry suggests that MA enrollees have access to lower-quality nursing homes and have high rates of disenrollment after admission. The Government Accountability Office has expressed concern that sicker patients disenroll in a biased manner. This possibility is of particular concern for patients with complex chronic conditions or multiple morbidities who stand to lose the most in disruptions to continuity of care. Disenrollment is often a sign of revealed preference, perhaps even more so if disenrollment rates are differential by patient type, which might suggest that the program does not address the preferences of these enrollees with high use of medical services.

From the Results

Across all groups, high-need enrollees had the highest rate of MA disenrollment by the end of 2015, with 2.6% (95% CI, 2.4%-2.7%) non– dual-eligible enrollees leaving the highest-rated plans and 10.6% (95% CI, 10.0%-11.2%) non–dual-eligible enrollees leaving the lowest rated plans. Disenrollment rates tended to be higher among those enrolled in lower-quality plans. Full dual-eligible enrollees left MA at the highest rates, with 11.1% (95% CI, 10.6%-11.6%) leaving the highest-rated plans and 18.5% (95% CI, 17.8%-19.3%) leaving the lowest-rated plans. However, dual-eligible beneficiaries also left TM to enter MA at the high rates, with more than 15% of non–high-need, fully dual-eligible TM enrollees switching to MA during the study period.

23.0% (95% CI, 22.3%-23.9%) of non–dual-eligible, high-need enrollees in low-rated MA plans disenrolled to TM, and disenrollment was even higher at 42.8% (95% CI, 40.5%-45.1%) among comparable high-need dual-eligible enrollees. Generally, enrollees in lower-rated plans disenrolled at higher rates than enrollees in higher-rated plans. Even in 5.0-star plans, however, high-need enrollees were more likely to disenroll (4.9% [95% CI, 4.6%-5.2%] of non–dual-eligible high-need enrollees compared with 1.8% [95% CI, 1.8%-1.9%] of non–dual-eligible and 2.4% [95% CI, 2.1%-2.7%] of dual-eligible non–high-need enrollees).

From the Discussion

We find that high-need and dual-eligible enrollees have substantially higher disenrollment rates when compared with non–high-need enrollees. This finding aligns with that of the recent Government Accountability Office report on disenrollment and other recent examples from the literature that suggest that MA plans may not currently meet the preferences of high-need enrollees. We also found large movement of TM enrollees into MA during the study period, particularly among dual-eligible beneficiaries, indicating a high level of switching in this population.

Several factors may explain differential disenrollment during this study period. Although risk adjustment has mitigated some cream skimming, plans may still not have an incentive to retain their high-need enrollees, leading to adverse selection not on who enrolls in plans but on those who disenroll. The limitations (eg, narrow networks, prior authorizations, etc) enacted by MA plans to control costs may not align with the preferences of enrollees who have complex care needs. Lower disenrollment rates from high-rated plans may be indicative of these plans providing fewer restrictions in access to care or other benefits to such enrollees. Beneficiaries with better health and socioeconomic status may also be better equipped to make more informed plan choices when first enrolling in MA. High-need enrollees may select suboptimal contracts when they first enroll in the program, and, when faced with the limitations those contracts contain, may be prompted to switch more often than healthier enrollees. High-need enrollees may also be enrolled in lower-rated plans because their more serious health needs exert a downward pull on the overall contract rating.

The largest changes in enrollment status from TM to MA and from MA to TM occurred among enrollees with dual eligibility with Medicaid. This finding is likely explained in part by dual-eligible enrollees being able to switch plans at any point during the year. An interplay between a state Medicaid managed care program and an MA plan may encourage more switching.

Conclusions

We find that high-need enrollees, particularly those who are dual eligible, disenroll from MA at substantially higher rates than other enrollees. Thus, our findings suggest that caution is warranted when evaluating the performance of MA plans owing to the potential for selection bias stemming from differential disenrollment. As of now, disenrollment is only 1 of 35 to 45 measures included in the MA star ratings system. Weighting disenrollment more heavily may help incentivize plans to address these concerns further. Although MA may have the potential to provide greater care coordination to address complex patient needs, it is unclear whether high-need enrollees who stand to benefit the most from care coordination are in fact benefiting.

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

The private Medicare Advantage insurers have been successful in marketing their plans, presumably because the enrollees perceive the plans to be superior to the traditional Medicare program, perhaps partly because of the touted benefits of managed care. However, this study shows that high-need enrollees, particularly those who are dual eligible (enrolled in both Medicare and Medicaid) disenroll from Medicare Advantage plans at substantially higher rates than other enrollees.

Supporters of privatization of Medicare through Medicare Advantage plans claim that patients are very satisfied with their coverage, but this report suggests that may be true only for individuals who do not have high health care needs. If they do have greater needs, they disenroll at higher rates.

Back in the days of the managed care revolution and the earlier Medicare + Choice plans, it quickly became evident that the healthy go into the plans and the sick come out. It appears that the tools of the current private Medicare Advantage plans have not reversed this trend. The plans seem to succeed primarily by keeping the low-cost healthy patients happy (lower cost sharing and extra benefits funded by the taxpayers), but shouldn’t we expect more out of our health care system?

Why don’t we improve Medicare and then expand it to cover everyone while using equitable public financing to make it affordable for each of us? Then everyone would be happy with the system, regardless of their medical needs.

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