PNHP

House Democrats introduce ‘Medicare for All’ bill

House Democrats introduce ‘Medicare for All’ bill

By Robert King
Modern Healthcare, February 27, 2019

House Democrats on Wednesday rolled out an ambitious proposal to extend Medicare to all Americans, eliminate private insurance and drastically overhaul reimbursement for doctors and hospitals.

Rep. Pramila Jayapal (D- Wash.) told reporters that the goal of the Medicare for All Act of 2019, which has more than 100 co-sponsors, is to completely overhaul the U.S. healthcare system and convert it to a government-run entity.

The legislation provides an outline of the thinking of some congressional Democrats on “Medicare for All,” an issue that has been highly debated among Democrats running for president in 2020.

“We believe that the market is broken and that is the core idea that we would like to fix,” She said on a call with reporters Tuesday. “We love to buy our coffee from Starbucks…but there are some things that should not be provided through the for-profit marketplace and we believe healthcare is one of them.”

The legislation would expand Medicare to provide insurance coverage to every American and would ban private insurers from offering any benefits that duplicate the benefits covered by Medicare, likely eliminating most of the private insurance market.

It would also drastically revamp how hospitals and doctors get reimbursed by Medicare.

Each hospital would get an annual prepaid budget to cover all healthcare costs for the facility for the given year. HHS would appoint regional directors that would oversee all hospitals and doctor offices in a specific region.

The director and the hospital would negotiate the budget. Nursing homes, health centers, home health agencies and independent dialysis facilities would also get an annual budget.

The budget would be determined by a host of factors that include the historical volume of services the hospital provided in the area, Jayapal told reporters.

“It is a common practice of most of the developed countries around the world and it has been very successful,” she said of global budgets. “It increases accountability over hospital spending.”

The annual budget could also be changed if there are certain circumstances, Jayapal said.

Doctor offices would still be paid under a fee-for-service model, however some physicians included in certain group practices can opt to get a salary from a hospital or another provider that gets a global budget.

Jayapal expects that around one to two million people would be out of work if the legislation becomes law because of the elimination of most private insurance. She said that 1% of the global budget for hospitals will go to a fund to provide services to displaced workers in the insurance industry.

“This could include pension benefits, include any number of things that would take care of these workers as we transition,” Jayapal said. “I do think there will be a boon to the economy once we get healthcare under control.”

Jayapal added that a private insurance industry could still exist, but they couldn’t cover the same benefits as Medicare, which include coverage of prescription drugs, hospital and physician services and long-term care services. However, an insurers could cover services such as cosmetic surgery or other types of elective benefits.

Healthcare sector lobbyists are expected to put up a vigorous fight against any “Medicare for All” proposal.

America’s Health Insurance Plans, the top lobbying group for the insurance industry, issued a pre-emptive strike on Tuesday in anticipation of the bill’s introduction.

“The vast majority of Americans are satisfied with the coverage they have today,” the group said in a statement. “They have choice and control over their coverage, options, and treatment.”

Jayapal said that money from industry groups would be the biggest obstacle to getting the bill through Congress.

But it’s unclear whether the bill will come up for a vote in the Democratic controlled House. Jayapal said that the legislation will first get a hearing in the House Rules Committee and in the House Budget Committee.

The bill has been referred to the House Energy & Commerce Committee and Ways & Means Committee, which both have healthcare jurisdiction. So far no hearing has been scheduled.

https://www.modernhealthcare.com…

PNHP endorses the Medicare for All Act of 2019

Doctors say Rep. Jayapal’s single-payer House bill is the only way to achieve universal, comprehensive coverage while saving the nation billions in health costs

Physicians for a National Health Program, February 27, 2019

WASHINGTON, D.C. – Physicians for a National Health Program (PNHP), a nonprofit research and education organization whose 23,000 members support single-payer national health insurance, endorses the Medicare for All Act of 2019, filed today by its lead sponsor Rep. Pramila Jayapal (D-Wa.) along with more than 100 co-sponsors.

“Accept no substitutes — only single-payer, Medicare for All can fix the grave dysfunctions and injustices of the American health care system,” said Dr. Adam Gaffney, PNHP’s president and a critical care physician and faculty member at Harvard Medical School. “Congress shouldn’t be distracted with incremental plans like a Medicare buy-in or public option. The only way to achieve universal and comprehensive coverage is to eliminate the profits and waste of the private insurance industry, which drains hundreds of billions of dollars from our health care system each year.”

The Medicare for All Act would improve Medicare by providing comprehensive, first-dollar health benefits inclusive of dental, vision, hearing, mental health, and long-term care, as well as the full spectrum of women’s reproductive health care. It would then expand Medicare to cover everyone living in the U.S., regardless of age, income, or employment. Coverage would be lifelong, portable, and seamless; services would be covered free at the point of service without copays or premiums, which serve only to keep patients from the care they need.

Experts predict that single-payer Medicare for All would would save more than $600 billion annually by slashing the administrative waste of private insurance and the paperwork insurers impose on hospitals and doctors ($504 billion) and bargaining down drug prices ($155 billion). These efficiencies would free up enough money for universal, first-dollar coverage without any overall increase in U.S. health spending, while controlling its growth over time.

Currently, the U.S. spends $3.65 trillion per year on health care, double the per-capita spending of other industrialized nations that provide universal coverage. Without single-payer reform, U.S. health spending is projected to reach $5.96 trillion — 19.4 percent of GDP — by 2027.

“Even single-payer opponents admit that, compared to Medicare for All, the status quo will cost U.S. $2 trillion more over the next decade,” said Dr. Claudia Fegan, a Chicago-based internal medicine physician and PNHP national coordinator. “How do they propose we pay for that?”

Dr. Fegan added that although the Affordable Care Act — which relies on a system of private and employer-provided insurance — expanded coverage to many, it failed to reduce the proportion of bankruptcies driven by medical problems, while doing little to expand the health security of all Americans.

While endorsing the Medicare for All Act as a strong single-payer bill, PNHP notes an area for improvement: Since for-profit providers (including hospitals, dialysis centers, nursing homes, home care agencies, and hospices) have been shown to provide inferior care at inflated prices, PNHP recommends moving to a fully nonprofit health system in addition to the bill’s current constraints on profit-making. To achieve an orderly transition of for-profit providers to nonprofit status, the doctors’ group recommends a bond-funded buyout of investor-owned facilities.

Dr. Gaffney welcomed this moment as a key step forward in the movement towards a sustainable, just health care system for the nation. “The system is failing both physicians and patients,” he said. “We can do better. In fact, we have to: The health and future of our nation hangs in the balance.”

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization whose 23,000 members support single-payer national health insurance.

https://pnhp.org…

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Physicians group endorses the Medicare for All Act of 2019

Doctors say Rep. Jayapal’s single-payer House bill is the only way to achieve universal, comprehensive coverage while saving the nation billions in health costs

FOR IMMEDIATE RELEASE: February 27, 2019

Contact: Clare Fauke, communications specialist, clare@pnhp.org or 312-782-6006

WASHINGTON, D.C. – Physicians for a National Health Program (PNHP), a nonprofit research and education organization whose 23,000 members support single-payer national health insurance, endorses the Medicare for All Act of 2019, filed today by its lead sponsor Rep. Pramila Jayapal (D-Wa.) along with more than 100 co-sponsors.

“Accept no substitutes — only single-payer, Medicare for All can fix the grave dysfunctions and injustices of the American health care system,” said Dr. Adam Gaffney, PNHP’s president and a critical care physician and faculty member at Harvard Medical School. “Congress shouldn’t be distracted with incremental plans like a Medicare buy-in or public option. The only way to achieve universal and comprehensive coverage is to eliminate the profits and waste of the private insurance industry, which drains hundreds of billions of dollars from our health care system each year.”

The Medicare for All Act would improve Medicare by providing comprehensive, first-dollar health benefits inclusive of dental, vision, hearing, mental health, and long-term care, as well as the full spectrum of women’s reproductive health care. It would then expand Medicare to cover everyone living in the U.S., regardless of age, income, or employment. Coverage would be lifelong, portable, and seamless; services would be covered free at the point of service without copays or premiums, which serve only to keep patients from the care they need.

Experts predict that single-payer Medicare for All would would save more than $600 billion annually by slashing the administrative waste of private insurance and the paperwork insurers impose on hospitals and doctors ($504 billion) and bargaining down drug prices ($155 billion). These efficiencies would free up enough money for universal, first-dollar coverage without any overall increase in U.S. health spending, while controlling its growth over time.

Currently, the U.S. spends $3.65 trillion per year on health care, double the per-capita spending of other industrialized nations that provide universal coverage. Without single-payer reform, U.S. health spending is projected to reach $5.96 trillion — 19.4 percent of GDP — by 2027.

“Even single-payer opponents admit that, compared to Medicare for All, the status quo will cost U.S. $2 trillion more over the next decade,” said Dr. Claudia Fegan, a Chicago-based internal medicine physician and PNHP national coordinator. “How do they propose we pay for that?”

Dr. Fegan added that although the Affordable Care Act — which relies on a system of private and employer-provided insurance — expanded coverage to many, it failed to reduce the proportion of bankruptcies driven by medical problems, while doing little to expand the health security of all Americans.

While endorsing the Medicare for All Act as a strong single-payer bill, PNHP notes an area for improvement: Since for-profit providers (including hospitals, dialysis centers, nursing homes, home care agencies, and hospices) have been shown to provide inferior care at inflated prices, PNHP recommends moving to a fully nonprofit health system in addition to the bill’s current constraints on profit-making. To achieve an orderly transition of for-profit providers to nonprofit status, the doctors’ group recommends a bond-funded buyout of investor-owned facilities.

Dr. Gaffney welcomed this moment as a key step forward in the movement towards a sustainable, just health care system for the nation. “The system is failing both physicians and patients,” he said. “We can do better. In fact, we have to: The health and future of our nation hangs in the balance.”

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization whose 23,000 members support single-payer national health insurance.

More than 100 House Democrats to unveil ‘battle-ready’ Medicare-for-all plan as 2020 election looms

By Jeff Stein
The Washington Post, February 26, 2019

More than 100 House Democrats plan to unveil a new “Medicare-for-all” plan Wednesday to provide government health insurance to every American, according to a copy of the bill provided to The Washington Post, as a number of Democratic-leading presidential candidates for 2020 feud over the party’s health-care platform.

Rep. Pramila Jayapal (D-Wash.), co-chair of the Congressional Progressive Caucus, is expected to release legislation Wednesday that incorporates key policy demands of single-payer activists, aiming to overhaul the U.S. health-care system even faster and more dramatically than legislation proposed in 2017 by Sen. Bernie Sanders (I-Vt.).

Jayapal’s Medicare-for-all would move every American onto one government insurer in two years, while providing everyone with medical, vision, dental and long-term care at no cost. Similar proposals have been projected to increase federal expenditures by at least $30 trillion but virtually eradicate individuals’ health spending by eliminating payments such as premiums and deductibles. About 30 million Americans do not have insurance, while tens of millions more are “underinsured,” meaning they cannot afford or do not seek care, according to the nonpartisan Kaiser Family Foundation.

The bill has 106 co-sponsors but essentially no chance of passing the House or Republican-controlled Senate this term. It comes amid a wider debate about the meaning of Medicare-for-all in Democratic policy circles, as some presidential candidates and center-left think tanks have said they support both Medicare-for-all while also aiming to preserve private insurance that currently enrolls about 150 million Americans. Jayapal’s plan would leave only a minimal role for private insurance in the United States, similar to Sanders’s bill in the Senate.

“We have a plan. We have a real plan,” Jayapal told reporters, calling the state of U.S. health care “atrocious” and dominated by a handful of wealthy corporate interests. “Americans are literally dying because they cannot afford insulin and can’t get the cancer treatments they need . . . I think this Medicare-for-all bill makes it clear what we mean by health care for all. We mean a complete transformation of our health-care system.”

The plan is, in a number of ways, more aggressive than the Sanders plan co-sponsored by more than a dozen Democratic senators, including presidential candidates Sens. Cory Booker (D-N.J.), Kamala D. Harris (D-Calif.) and Elizabeth Warren (D-Mass.). It is also significantly more detailed than the previous single-payer bill in the House introduced by then-Rep. John Conyers Jr. (D-Mich.), which at about 30 pages outlined only a set of goals with few legislative specifics.

Tim Faust, a single-payer advocate, said it was the first “comprehensive, battle-ready” single-payer plan to be introduced in Congress.

“The idea of Medicare-for-all has become extremely popular, but it’s at risk of being co-opted by those who want modest, incremental proposals that fall well short of true universal health care,” said Adam Gaffney, president of Physicians for a National Health Program, a group of doctors supporting single-payer that provided input to the Jayapal plan. “What we’re doing here is a big step forward to clarify exactly what Medicare-for-all means.”

Critics say the plan would require impossibly large new taxes, given its estimated $30 trillion price tag, and question the political wisdom of forcing nearly half the country to switch from the current private plan to a public insurer. Conservatives have also argued that a single-payer system could impede quality of care for those who have it, pointing to the potential for longer wait times.

Supporters point out that U.S. health-care spending per capita is more than two times as large as the average for developed nations, even as Americans have below-average life expectancy at birth and lag on a number of other key health outcomes. Single-payer advocates say one government insurer would have the bargaining power to drive down costs, while giving free health care to those who lack coverage.

Jayapal’s plan, about 120 pages, would transition every American to Medicare-for-all over two years, cutting the four-year transition in Sanders’s Senate bill in half. Sanders is currently working on an updated version of his legislation, according to Josh Miller-Lewis, a spokesman for the senator.

Some health policy experts fear that dramatically disrupting the health markets over four years could lead prices to explode in the private market, increasing the urgency of a quicker transition.

Jayapal’s bill also includes two big new provisions left out of the Senate legislation: a crackdown on the pharmaceutical industry aimed at lowering drug prices, and new government-run long-term care to help people with disabilities. It does not specify how it would finance the new legislation.

The number of Americans who require long-term care is expected to explode over the next few decades as the baby-boom generation ages, with the number of Americans with a disability projected to more than double from 2015 to 2065. Jayapal’s new Medicare-for-all bill, unlike the one Sanders introduced in the Senate in 2017, would guarantee free long-term care, including home health care, for Americans with disabilities as part of the single-payer system.

“This one part of it is, in some ways, as complicated and expansive as the Affordable Care Act itself,” said Harold Pollack, a University of Chicago health expert. “It’s an unbelievably complicated and fraught issue.”

Jayapal’s bill will include a proposal from Rep. Lloyd Doggett (D-Tex.) aimed at bringing down prescription drug prices by allowing Medicare to negotiate the price of drugs. The bill would give the government the ability to issue a generic license to produce the medication if negotiations fail, a provision known as “compulsory licensing.”

The previous version of the Medicare-for-all bill called for the elimination of all for-profit hospitals, and it called on the government to give financial compensation to providers that would be forced to become nonprofits. That provision was removed from the new Jayapal bill, in part because House aides feared it would lead the government to compensate hospital shareholders. In December 2018, Politico reported that hospitals, insurance companies and other health-care lobbies had launched a unified front to beat back the push for Medicare-for-all, raising the political stakes for Democrats who embrace the plan.

The new bill specifies that funds from the government’s Medicare-for-all could not be used “for profit,” union-busting, marketing or federal campaign contributions. Many hospitals with the biggest budget surpluses are also nonprofit, which seems to diminish the case for converting all hospitals to that model.

Jayapal also said between 1 million and 2 million people currently work in the private health insurance system, and that 1 percent of the new Medicare-for-all fund would go to a five-year transition program to pay for pension benefits, job training programs and other assistance for affected workers.

Congressional Democrats have proposed a number of incremental health reform provisions recently, including a plan by Sen. Debbie Stabenow (D-Mich.) and Tammy Baldwin (D-Wis.) that would create a public option for Americans from ages 50 to 64 to buy into Medicare. Sen. Brian Schatz (D-Hawaii) has proposed a Medicaid expansion via a state-based buy-in program. The recent push leftward on single-payer has made those plans, which would still use the federal government to expand health insurance to millions of people, seem more modest by comparison.

“Even though it’s still extremely unlikely to pass, Medicare-for-all has moved the political landscape so suddenly, it’s created a window for these other proposals to seem quite feasible,” said Pollack, a single-payer skeptic.

Hearings on the legislation are expected to begin later this year.

https://www.washingtonpost.com…

Livestream launch of single payer bill Wed., Feb. 27, 11:15 a.m. EST, 8:15 PST

PNHP, Feb. 26, 2019

Dear colleague,

After months of dialogue with single-payer advocates, Rep. Pramila Jayapal will file the Medicare for All Act of 2019 in the U.S. House of Representatives on Wednesday, Feb. 27. The PNHP Board of Directors has endorsed this legislation, which would achieve both the universal coverage and long-term cost control needed to fix our broken health care system.

Tomorrow, I will join Rep. Jayapal in a press conference announcing the new bill. PNHP will broadcast the press conference via Facebook Live, and will also live-tweet the event.

Watch the press conference LIVE, Wednesday at 11:15am EST.

I hope you can join us for this historic moment, and are inspired to continue pushing for single-payer reform.

Onward,

Adam Gaffney, M.D., M.P.H.
President

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

Did the Affordable Care Act reduce amenable mortality?

The Effect of Health Insurance on Mortality: Power Analysis and What We Can Learn from the Affordable Care Act Coverage Expansions; NBER Working Paper No. 25568

By Bernard Black, Alex Hollingsworth, Leticia Nunes, and Kosali Simon
National Bureau of Economic Research, February 2019

Abstract

A large literature examines the effect of health insurance on mortality. We contribute by emphasizing two challenges in using the Affordable Care Act (ACA)’s quasi-experimental variation to study mortality. The first is non-parallel pretreatment trends. Rising mortality in Medicaid non-expansion relative to expansion states prior to Medicaid expansion makes it difficult to estimate the effect of insurance using difference-in-differences (DD). We use various DD, triple difference, age-discontinuity and synthetic control approaches, but are unable to satisfactorily address this concern. Our estimates are not statistically significant, but are imprecise enough to be consistent with both no effect and a large effect of insurance on amenable mortality over the first three post-ACA years. Thus, our results should not be interpreted as evidence that health insurance has no effect on mortality for this age group, especially in light of the literature documenting greater health care use as a result of the ACA. Second, we provide a simulation-based power analysis, showing that even the nationwide natural experiment provided by the ACA is underpowered to detect plausibly sized mortality effects in available datasets, and discuss data needs for the literature to advance. Our simulated pseudo-shocks power analysis approach is broadly applicable to other natural-experiment studies.

From the Introduction

We do not find a statistically significant pattern of results consistent with Medicaid expansion causing mortality changes, but we also cannot rule out large effects in either direction. We note here that prior evidence on the effects of insurance expansion on mortality lead one to expect modest effects of incremental insurance expansions on mortality. Reasons for modest overall effects include: many of those in greatest need of healthcare are already insured; and many uninsured persons already receive substantial healthcare. One reason for our “null result” is that the first stage on insurance coverage is weak: our principal identifying variation (the relative change in uninsurance rates for Medicaid expansion versus non-expansion states) amounts to a very small fraction of the population. The average increase in health insurance coverage attributable to Medicaid expansion over 2014-2016 is only around 1.1% for persons aged 50-64, and only around 4% even when we hone in on low-educated populations; precise income measures used to determine ACA eligibility are unavailable in mortality data. A second reason for failure to reject the null of no effect is a high level of “noise” – substantial background variation in mortality, and mortality trends, across states and demographic groups. A third reason is that mortality is a low-frequency outcome. We note too that effects of health insurance on mortality are more likely to emerge over a long time frame.

Our second contribution is to highlight that observational studies can often benefit from performing and reporting power analyses. We use a simulation-based power analysis, in which we impose treatment effects of varying sizes on actual data during the pre-treatment period, and assess whether ACA expansion effects on mortality of plausible size can be detected with our data. We conclude that even the nationwide natural experiment provided by the ACA is severely underpowered to detect effects on mortality of plausible size in county-level death certificate data. To reliably detect effects of insurance coverage on mortality, one would need very large-sample panel data on individuals, which is not currently available. Such data could include information on health, income, and insurance status, which would allow the study to focus on subsamples with a larger first stage and/or higher sensitivity of health and mortality to healthcare use. Even with such hypothetical data, it is likely that only fairly large effects of health insurance on mortality could be reliably detected.

From the Discussion

In this paper, we examine the relationship between mortality and health insurance, principally using the DD research design used in many prior ACA studies. This design exploits the natural experiment created by variation between those states that expanded Medicaid insurance and those that did not. We also exploit variation that results from counties having varying uninsurance or poverty levels prior to 2014. We focus on persons aged 55-64 years, whose mortality rates are the most likely to be affected by health insurance. We study effects of the first three years after expansion by type of mortality (healthcare amenable vs non amenable), demographics (gender, race, and ethnicity), education level, cause of death, and residence in counties most likely to gain from the ACA expansion).

We find large confidence intervals with no statistically significant evidence of an ACA- induced decline in mortality in Medicaid expansion states. Instead, there are important non-parallel pre-treatment trends, and standard errors are far too large to allow detection of effects of plausible sizes. We confirm lack of power through a formal, simulation-based power analysis.

While it is possible that the mortality effect of the ACA health insurance expansion variation we study may materialize with more time, other factors make it unlikely they too could be statistically detected; lengthening the study period would increase likelihood that other sources of variation, including cross-border moves, the instability of insurance status over time, and the underlying causes of the non-parallel pre-treatment trends we observe, will pose challenges for credible causal inference. Moreover, our power analysis implies that an extra few years would still be insufficient to attain reasonable power, given plausible effect sizes.

https://www.nber.org…

Comment:

By Don McCanne, M.D.

This meticulous, technically complex, 187 page economic paper attempted to look at changes in amenable mortality (mortality that could be reduced by beneficial interventions) from implementation of the Affordable Care Act. Their somewhat shocking result: “Our estimates are not statistically significant, but are imprecise enough to be consistent with both no effect and a large effect of insurance on amenable mortality over the first three post-ACA years.”

Before discussing this further, it is important to take note of the authors’ caveat: “Thus, our results should not be interpreted as evidence that health insurance has no effect on mortality for this age group, especially in light of the literature documenting greater health care use as a result of the ACA,” and keep this in mind when others report that this study failed to show any benefit of ACA. Stating that the study showed no statistically significant benefit is not the same as stating that there was no benefit.

Could it be that health care provides no benefit? Clearly not. Management of major trauma, use of antibiotics for potentially lethal diseases, surgical interventions for potentially disabling of lethal disorders, preventive measures that reduce the risk of chronic diseases, and vaccines that prevent epidemics of serious diseases are just a few examples of the benefits of modern health care. Of course, health care is dynamic in that new beneficial measures are continually introduced and measures that prove to be detrimental are abandoned.

So can it be that health insurance provides no benefit? The answer here is a little bit more complicated. Health insurance is clearly beneficial when it prevents financial hardship for individuals who clearly need health care. Yet it can be detrimental when it erects financial barriers to care or when it impairs access by denying care outside of the insurer’s provider networks. Also wasting funds on administrative excesses can be detrimental when those funds could have been diverted to more beneficial purposes.

In the case of the implementation of ACA, some people did benefit by gaining insurance protection while avoiding financial hardship through government subsidies or through enrollment in Medicaid. On the other hand, some faced greater financial risk by being shifted to plans with lower actuarial value (paying a lower percentage on the medical bills), plus some lost access to their usual health care because of narrow provider networks. There is some suggestion that care was impaired for many Medicaid beneficiaries who were transferred to private Medicaid managed care plans that seemed to be more concerned about cost containment rather than care provision.

Could these deficient policies of ACA have resulted in the failure to come to statistically significant conclusions on the impact of ACA on amenable mortality? Although that is highly unlikely it would be interesting to compare the impact of a well designed single payer Medicare for All system on amenable mortality since such a system is crafted to benefit patients and not designed to enhance the market success of insurers and other sectors of the medical-industrial complex. But then, amenable mortality should not be the sole criterion for judging the beneficial effects a health care financing system. Good health outcomes and financial security also matter.

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Fixing Our Health Care System

By Claudia Fegan, M.D.
The New York Times, Letters, Feb. 24, 2019

To the Editor:

Re: “What’s Good Health Care Worth?” (editorial, Feb. 17):

Thirty-six thousand Americans die prematurely each year because they are uninsured. And more than half a million households declare bankruptcy each year because of illness or medical bills. Who could possibly benefit from such an inhumane system?

Private insurers.

High deductibles and co-pays, narrow networks of doctors, and prior authorization paperwork keep patients from getting the care they need, while funneling more money into the pockets of insurance companies. Private insurers add nothing of value to our health care system and drain billions of dollars that should be spent on patient care.

A single-payer “Medicare for all” system would end this needless loss of life and life savings.

Dr. Claudia Fegan is the chief medical officer of Cook County Health and the national coordinator of Physicians for a National Health Program.

https://www.nytimes.com…

Soaring insulin costs are a symptom of our bigger health care crisis

By the Editorial Board
St. Louis Post-Dispatch, February 24, 2019

Soaring insulin prices are a genuine emergency in America. Many diabetics, suddenly unable to afford their prescribed doses, are self-rationing or using expired supplies. In the world’s most advanced nation, some are dying because they can’t afford a simple injection.

Critics allege artificial price inflation by the insulin industry. Congress finally is conducting hearings to rein it in.

But on this medical topic and so many others, the underlying problem is a health care system obsessed with profit, even if it means suffering or death for patients who can’t pay the asking price. The insulin crisis is one symptom of a wider emergency that won’t end until America fundamentally changes its health care delivery system.

Type 1 diabetes develops when a person’s pancreas stops producing insulin, which regulates blood sugar. Diabetes was virtually always fatal until, almost 100 years ago, scientists discovered how to process injectable insulin from animal pancreases. Synthetic insulin followed.

Type 1 diabetes still can’t be cured, but that it can be managed remains one of medical science’s greatest achievements. For the 1.25 million Americans living with type 1 diabetes today — and for many of the roughly 30 million more living with the less severe type 2 — consistent access to insulin is a matter of life or death.

Insulin prices have skyrocketed recently, far beyond rates of inflation or most other prescription drugs. One vial of insulin that sold for $31 in 2001 now costs $270. One father told a congressional hearing in December that the cost of his 13-year-old son’s three-month supply rose from $300 to more than $900 in one year.

Uninsured diabetics, or those with high insurance deductibles, have responded by using less insulin than they’re supposed to, tempting a range of health hazards. Victims include people like Alec Smith, 26, of Minneapolis, who died in 2017, weeks after aging out of his parents’ insurance coverage. He couldn’t afford a $1,300 insulin refill and tried to self-ration his existing supply.

The causes of the price spikes are maddeningly unclear. Major insulin manufacturers like Eli Lilly have blamed supply chains, the insurance industry and others. Critics allege the manufacturers engage in underhanded strategies to fix prices, obfuscate pricing methods and keep generic insulin out of the U.S. market. Congressional Democrats and some Republicans have vowed to get to the bottom of it. They must; lives depend on it.

But the insulin crisis is just one element of a broader problem: America’s entire health care system is far more expensive and far less accessible than in other developed countries. The claim that market-based medical care works just fine grows more dubious by the day.

When otherwise healthy 26-year-olds are dying because of the terms of insurance policies, it’s time to look seriously at alternatives closer to the “Medicare for all” model.

https://www.stltoday.com…

Let’s address the real problems in our health-care system

By David L. Rabin, M.D., M.P.H.
Washington Post, Letters, Feb. 24, 2019

Universal health-care coverage is an essential social goal, as David Kendall and Jim Kessler noted. Their plan is politically pragmatic but denies the limitations of the Affordable Care Act upon which their plan is based.

As a physician, I can attest that the ACA does not resolve our system’s failures. The distinguishing features of U.S. health care are its high cost and poor performance compared with systems in other developed nations. Universal health care, to be cost-effective and sustainable, must pay for care in a rational manner, be administratively efficient and balance health promotion, disease treatment and health investments. Health-insurance money must be spent on health, not overhead and profit.

Only a single-payer system responsible for the health of the population, with budgetary constraints and payments for care based on defined costs rather than negotiated prices, can address our health – system failures and be sustainable.

https://www.washingtonpost.com…

Paying for universal health care isn’t difficult

By Philip Caper, M.D.
Sun Journal (Maine), Feb. 24, 2019

At Maine AllCare we are often asked “How are we going to pay for health care for all Americans?” The simple answer is: “We will redirect the more than $750 billion per year that we currently waste.”

In 2012, The Institute of Medicine (now the Academy of Medicine, part of the National Academy of Science) published a report that estimated the amount and sources of inefficiency (they called it “waste”) in the American health care system. At that time it amounted to $750 billion per year nationwide. That amounts to about $3 billion per year in Maine alone. There is more than enough money in the health care system in the United States to cover everybody, including Maine, and significantly improve the coverage we all deserve in the bargain.

Replacing our fragmented mixed public-private insurance system with improved Medicare for all could effectively address each of these sources of waste:

Excess administrative costs: First, by replacing insurance policies with a single publicly financed system, we will eliminate the need for medical underwriting, the core, high cost business of insurance companies. The unpopular practice of excluding “pre-existing conditions,” the setting of deductibles and scaling premiums based on age, medical history or geography are a few examples of the worst medical underwriting practices. People know that the obligation of insurance companies is to deliver profits, not health care. Administrative costs for Medicare in 2016 were just 1.2 percent and the overhead at for-profit insurance companies is estimated to be between 17 and 25 percent — much of it due to medical underwriting.

Second, such a change will eliminate the costs of enforcing compliance with multiple insurance plans, each with its unique benefits and eligibility requirements. The tracking of deductibles, copays and various unique twists by doctors, hospitals and other entities provides no health benefit, and costs are estimated at more than $200 billion. Put another way, each doctor in the U.S. requires more than $80,000 per year in administrative support, but in Canada it is just over $20,000.

Excessively high prices and unnecessary and inefficiently delivered services: By centralizing funding, we will create new tools to restrain overall health care costs. Putting the entire system on a budget will control costs by setting firm (but flexible) limits on the total resources available. By constraining growth in overall spending (currently much higher than any other developed country), we will put downward pressure on the very high prices for medical goods and services. That will include reining in the documented excess of lab tests and procedures currently being done. Why should a test or procedure cost one amount at one hospital and, 100 miles away, cost a third of that figure? The growing practice of traveling to other countries to have a procedure and having the medical vacation cost half of the same procedure here at home shows that the for-profit system simply doesn’t work for patients.

Missed prevention possibilities: We will create a pool of money to invest in primary disease prevention — an activity that is now badly underfunded. We do fund early detection, but not the primary prevention of disease. One reason prevention is so underfunded is that insurance companies have little or no incentive to invest in practices with mostly long-term payoffs, due to short-term churn in insurance coverage. Primary prevention is a public good and should be financed through public sources.

Fraud: Centralizing health care financing, as in Medicare, will create a unitary and universal database to assist in the detection of waste, fraud and abuse. The current system of medical coding is fraught with abuse, but it is often hard to detect because data is so fragmented. From procedures and services never performed to overcharging for drugs and devices, there is significant waste and abuse.

Together, the above factors account for more than $750 billion a year (as of 2012), and rising. Recouping that wasted money in our dysfunctional system will allow us to provide high quality health care for everyone. Of course, we must not penalize the people now in administrative jobs that do not add value. Transition to value-added jobs can be funded with a portion of the existing waste.

By putting everybody in the same system, we will replace the balkanized system that is constantly subject to political attack and bickering and causes the public so much suffering. It would assure extending the broad public support and funding that Medicare currently enjoys.

This is economically sound, common sense, conservative economics. We can save money and have universal coverage providing long-needed peace of mind to all Americans. That sounds to us like a pretty good deal!

Dr. Phil Caper is an internist and founding board member of Maine AllCare.

https://www.sunjournal.com…

Kansas demonstrates why we need a national health program

Kansas GOP pushes for cheaper health plans that may not cover pre-existing conditions

By Andy Marso
The Kansas City Star, February 21, 2019

Kansas Republicans and trade associations, empowered by changes President Donald Trump’s administration made to the Affordable Care Act, are pushing for health plans that are less expensive because they don’t have to cover pre-existing conditions.

One such bill, requested by the Kansas Farm Bureau, passed the Republican-controlled state Senate 28-11 Wednesday. It now heads to the House.

“According to a Gallup poll, citizens are more concerned about rising health premiums than pre-existing conditions,” said Sen. Mary Pilcher-Cook, a Republican from Shawnee who voted for the bill. “We should support lower cost of acquiring health care coverage, so people can have it before they develop what would otherwise be pre-existing conditions.”

Unlike plans under the ACA — commonly called Obamacare — alternatives like the Farm Bureau health plan could exclude people with pre-existing conditions. Such plans also wouldn’t have to cover things like maternity care, mental health and prescription drugs, which are required in ACA plans.

A number of measures have been introduced in Topeka to expand “association health plans,” which are offered to members of professional trade groups, many of whom are small business owners.

The most extreme example is the bill that would allow Kansas Farm Bureau to sell coverage that not only would circumvent ACA rules but also would not fall under the jurisdiction of the Kansas Insurance Department and therefore not be subject to any state rules either.

Kansas Farm Bureau CEO Terry Holdren told legislators that in a national survey, 65 percent of farmers and ranchers said the cost of health coverage was the top obstacle to being able to stay on a farm.

Several farmers testified for the bill, including Sarah Schmidt, whose family grows corn, wheat and soybeans across four counties near Junction City.

Schmidt said that before the ACA, she, her husband and their four kids paid about $525 a month in premiums for a plan that covered most local providers.

After the ACA their premiums doubled, and many of their providers were out-of-network.

“This has been one of our greatest struggles since coming back to my family’s fifth generation farm,” Schmidt said, “not only financially but also physically and emotionally.”

Association health plans have been available for some time, but the ACA required most of them to cover 10 “essential health benefits” (hospitals, outpatient physician visits, emergency services, maternal and neo-natal care, mental health and substance abuse treatment, prescription drugs, lab tests, federally recommended preventative care, pediatric care and rehabilitation).

Now they can get out of those federal requirements.

Lobbyists for Kansas health insurance companies have come out strongly against the Farm Bureau plan, saying it would be impossible for them to compete.

Kari Rinker, a spokeswoman for the MS Society, said that before the ACA, association plans had “a long history of fraud and insolvency which have historically harmed small employers and individuals the most.”

“Many of these plans collected premiums for health insurance coverage that did not exist and did not pay medical claims — leaving businesses, individuals, and providers with millions of dollars in unpaid bills,” Rinker said. “For people with chronic illnesses or disabilities such as MS, the results have been disastrous.”

Dana Bacon, a spokesman for the Leukemia and Lymphoma Society, said short-term plans often have fine print that allows the insurer to look back into a person’s medical history to find things that could justify denying claims.

Democrats and patient groups said that even if everyone knows the limitations of the coverage they’re buying, people with pre-existing conditions or people who need things like maternity care will still be harmed by something called “adverse selection.”

That’s when healthy people leave the ACA markets for things like association plans or short-term plans. The people left behind, for whom those plans aren’t a viable option, then end up paying higher premiums.

https://www.kansascity.com…

Comment:

By Don McCanne, M.D.

It is easy to understand how a Kansas farmer and her family, living on a modest household budget, would have been upset with the Affordable Care Act that doubled the family’s insurance premium while taking away choices of their health care providers because of network limitations. Something needed to be done.

What is difficult to understand is why the Kansas state legislators responded with policies that would only make things worse. Coverage of essential health benefits is no longer guaranteed. Preexisting medical conditions can be excluded from coverage. As people leave the plans to enroll in junk insurance, premiums for those remaining will go up because those with greater needs will stay in the plan – classic adverse selection. The death spiral that results can cause insurers to leave the market, leaving residents with not much in the way of options, especially when the legislators refuse to expand the Medicaid program thus leaving the desperate, well, desperate.

What this cries out for is a national program of social insurance – include everyone in a national health program automatically and pay for it equitably. A Single Payer Improved Medicare for All would cover everyone and make it affordable for each, based on ability to pay. Although some states make the effort, no state has yet been able to include everyone equitably. Other states, such as Kansas, don’t even try, often leaving their residents high and dry. Anyone who needs health care should have health care, including the residents of Kansas. We can do it.

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

Drug rebates don’t fall from trees

By Ed Weisbart, M.D.
St. Louis Business Journal, February 22, 2019

On Feb. 6, the Department of Health and Human Services published a new rule that diminishes the leverage pharmacy benefit managers have when negotiating prices with drug manufacturers on behalf of Medicare and Medicaid patients.

Manufacturers offer rebates to PBMs in exchange for preferred placement on PBMs’ formularies. Preferred placement means lower copays for patients and increased market share for the manufacturer. An unverifiable percentage of these proprietary rebates is retained by PBMs, with an unclear impact on the at-the-counter cost of prescription drugs.

HHS’s new, restrictive rule is being promoted as necessary to transfer those hidden rebates away from PBMs and into the pockets of patients, but in reality, the negotiating table and profits would abruptly tilt towards the manufacturer. Even in the best case scenario, the rule change would only benefit people on publicly administered programs and would have no impact on anyone with private insurance or those consumers paying out of pocket.

Currently, drug manufacturers must negotiate with a PBM industry that is well armed with massive resources of data analysts, clinicians and contractors. Under the new rule that handcuffs PBMs, manufacturers have better relative negotiating leverage, and that’s far more likely to lead to higher retained earnings for the manufacturers than savings for consumers.

The Trump administration’s proposal would allow manufacturers to charge whatever price can be borne by individual patients.

PBMs have brought this on themselves. Their negotiations are confounded, conflicted and held behind closed doors. The system needs far more sunshine and a more effective advocate to genuinely lower the cost of pharmaceuticals.

There is, however, a fair solution: Medicare should be allowed to hold meaningful negotiations on behalf of all Americans. The United States should do as every other modern nation does: Establish a uniform national formulary with ready access to evidence-based medical exceptions. Rather than expect mandated skin-in-the-game copays to mysteriously reduce the cost of pharmaceuticals, prices should be determined through national negotiations that are based on real evidence of value and the true cost of research, development and production.

Prescription drug prices in the United States are double what is charged in the rest of the modern world. The governments of most leading industrialized nations negotiate on behalf of their citizens, and it’s way past time that we come together and demand the same from our government.

Dr. Ed Weisbart is a family physician in Olivette and chair of the Missouri chapter of Physicians for a National Health Program.

https://www.bizjournals.com…