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Did the Affordable Care Act reduce amenable mortality?

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…

National Health Expenditure Projections

National Health Expenditure Projections, 2018–27: Economic And Demographic Trends Drive Spending And Enrollment Growth

By Andrea M. Sisko, Sean P. Keehan, John A. Poisal, et al, Office of the Actuary, Centers for Medicare and Medicaid Services
Health Affairs, Published Ahead of Print, February 20, 2019

Abstract

National health expenditures are projected to grow at an average annual rate of 5.5 percent for 2018–27 and represent 19.4 percent of gross domestic product in 2027. Following a ten-year period largely influenced by the Great Recession and major health reform, national health spending growth during 2018–27 is expected to be driven primarily by long-observed demographic and economic factors fundamental to the health sector. Prices for health care goods and services are projected to grow 2.5 percent per year, on average, for 2018–27—faster than the average price growth experienced over the last decade—and to account for nearly half of projected personal health care spending growth. Among the major payers, average annual spending growth in Medicare (7.4 percent) is expected to exceed that in Medicaid (5.5 percent) and private health insurance (4.8 percent) over the projection period, mostly as a result of comparatively higher projected enrollment growth. The insured share of the population is expected to remain stable at around 90 percent throughout the period, as net gains in health coverage from all sources are projected to keep pace with population growth.

Conclusion

During the past ten years the lingering effects of the Great Recession, coupled with the coverage and payment provisions of the Affordable Care Act, have significantly influenced the trends in health care spending and enrollment in the United States. Over the next decade, however, the outlook for health spending and insurance coverage is expected to be primarily driven by long-observed demographic and economic factors fundamental to the health sector. While the national health spending growth rate is projected to average 5.5 percent per year for 2018–27, annual growth is expected to generally accelerate over much of the projection period. Medicare spending growth is expected to accelerate and be the fastest among the major payers, reflecting not only the continued enrollment shift of the baby-boom generation into the program but also the growth rate for use and intensity, which is projected to gradually increase toward the rates observed during Medicare’s long-term history. Growth in health care prices, reflecting both economywide and relative personal health care price inflation, is also expected to rebound somewhat toward rates more consistent with the period before the Great Recession and to return to a state in which personal health care price growth exceeds that of economywide price inflation. Finally, recent and anticipated faster growth in disposable personal income is expected to lead to an increased demand for services, albeit with a lag, and put upward pressure on the pattern of private health insurance and out-of-pocket spending growth over the projection period.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

National health expenditures are projected to grow at an average annual rate of 5.5 percent for 2018–27 and represent 19.4 percent of gross domestic product in 2027, driven primarily by long-observed demographic and economic factors fundamental to the health sector.

There are a couple of items of special interest:

  • Annual growth is expected to generally accelerate over much of the projection period as we leave behind us the lingering effects of the Great Recession.
  • Growth in health care prices is expected to rebound somewhat toward rates more consistent with the period before the Great Recession and to return to a state in which personal health care price growth exceeds that of economywide price inflation.
  • Medicare spending is expected to grow faster than Medicaid or private insurance spending because of higher projected enrollment growth and an increased growth rate in use and intensity of services.
  • The percentage of uninsured is expected to remain around ten percent.

Of these, perhaps the most alarming is the fact that the authors anticipate that a decade from now we will still have tens of millions uninsured. Apparently they do not predict enactment of major health reform legislation. We should press for an all out effort to screw up their prediction by finally making Single Payer Medicare for All a reality.

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

An “Exciting But Dangerous Moment” for Medicare for All

All human beings have a right to healthcare, but powerful forces remain dead set against it. An interview with PNHP president Dr. Adam Gaffney.

By Michael Winship
Common Dreams, February 20, 2019

Dr. Adam Gaffney is the brand new president of Physicians for a National Health Program (PNHP), the national, Medicare for All advocacy group of medical professionals and others committed to single-payer—universal healthcare “provided equitably as a public service rather than bought and sold as a commodity.”

In the announcement of his election, Dr. Gaffney said, “We’ve been so successful in popularizing the idea of ‘Medicare for all’ that everybody wants in on the slogan—even if they have something completely different in mind, like a public option. But tweaks won’t solve the fundamental problems of American health care: persistently high uninsurance, rising underinsurance, unaffordable drugs, narrow provider networks, and the growing corporate domination of health care that prioritizes profits over patients.”

Adam Gaffney is a pulmonary specialist at Cambridge Health Alliance in Massachusetts who earned his bachelor’s and medical degrees from New York University and a master’s in public health from Harvard. He’s been active in the single-payer movement for several years, writing numerous articles and research papers and co-chairing a working group that developed PNHP’s “Physicians’ Proposal for Single-Payer Health Care Reform.”

We spoke recently while he was in New York for a meeting of the commission on public policy and health in the Trump era, a group brought together by the medical journal The Lancet. Our conversation has been edited for length and clarity.

Talk a bit about your medical background and how it has made you such a strong Medicare for All advocate.

I think that my politics preceded my medical career. In college I was very progressive. In 2000, when I was a freshman in college, I supported Ralph Nader in that election. I think that’s when I first heard the term “single payer,” although I certainly supported universal healthcare as a concept earlier than that, back to my years in high school.

But I would say that everything I’ve seen since embarking on my medical career has reinforced my feelings about why we need single-payer and universal healthcare: all the patients I’ve seen who have gone without care because they couldn’t afford it, who have skipped inhalers for their emphysema because they couldn’t afford the copay, have shown up in the ICU because of complications of illness that didn’t get treated because they had gone without insurance or because their insurance had lapsed. Everything I’ve seen since embarking on a medical career has definitely reinforced what I had thought before I started it.

People often say why do we need one public payer? Why can’t we have a number of different insurance companies? There are many downsides to that. It’s not just that fragmentation produces waste, which it does, it’s not just the enormous burden of billing and administration that imposes on hospitals and doctors and that generates as much as $500 billion a year in wasted spending on administration. It’s also the fact that often people don’t even know what’s covered. Physicians won’t even know what’s covered. People show up at the pharmacy and it turns out the drug they need isn’t covered.

Literally the last thing I would want a patient or family to have to think about are the financial consequences of their healthcare. And they don’t have to.

So you are completely convinced that single-payer is the best way to go?

Yes. I am also completely convinced that imposing costs on patients at the time of healthcare use has no useful purpose. That seems like a radical idea, and even people on the liberal-left side of the spectrum sometimes say, well, having a reasonable copay is not such a bad idea to ensure that healthcare is not used sort of frivolously. I think some people think a system where you don’t impose costs is pie-in-the-sky and unrealistic. It’s of course not unrealistic, considering that in the UK this already exists. In the UK, there are no copays for doctor’s visits, no deductibles, no payments to hospitals. In Scotland, you don’t even pay for parking at the hospital if you’re visiting a loved one. It’s clearly doable and I think it’s a better system.

At the end of the day, maybe people paying for healthcare only really affects working class and poor people because well-off people are always going to be willing to pay a forty-dollar copay, right? It really is just a way of punishing the sick and the poor.

When your presidency was announced, you described it as an exciting but also dangerous moment in the history of single-payer. Why?

Exciting in that we’re farther along than we ever have been. Single-payer has made incredible strides in just the last few years, from a position that was mostly on kind of the fringe of respectable politics to a position that’s now very close to center that’s being embraced by politicians running for president. That was not the case in 2008.  In 2008, basically all the major candidates had no interest in single-payer, they already had their minds made up that healthcare reform was going to be a sort of Obamacare-like proposal, which it was. That’s not the case anymore.

I think it’s part of a larger, progressive swing. In many ways our politics have become more regressive with the election of Trump, with the domination of Congress by Republicans. But there has been a progressive swing with exciting, new left-wing candidates in the House of Representatives. The move of single-payer to the center of the conversation is part of that.

But it’s a dangerous moment as well. Think about this: Even while we get excited about the prospects of single-payer, Republicans in Congress are now pushing dangerous new programs. States like Arkansas are imposing work requirements on a Medicaid program that’s squeezing out of the program, I think the latest figure was 18,000 people, by creating bureaucratic barriers and paperwork.

There’s obviously going to be an ongoing effort by the right to dismantle existing, public healthcare systems – whether that takes the form of another attempted repeal of the Affordable Care Act seems unlikely given the change in Congress in November.

In December, the Trump administration released a white paper that was mostly not noticed in the news, but it was a wish list or manifesto for a conservative healthcare future. It gives you a sense of what corporate opposition would do if it could: Further privatize the system or further privatize Medicare, it would increase high deductible health plans; it would just take an overall, laissez-faire, deregulatory approach to the health care system.  So there are both promises and dangers on the horizon.

Let’s talk about the 2020 elections. In the PNHP announcement of your presidency it’s said that Medicare for All has become such a catchphrase that some candidates may be misusing it.

We’ve had the idea for a long time. But what happened was that the idea has become very popular, something that everyone is rallying behind. So I do think there’s an effort to steal some of that thunder and use the branding on other types of healthcare proposals that fall well short of what we’re talking about.

We’re talking about a national health insurance program that covers everyone in the country. These other proposals are not that.  Some of them still might help many people but they’re not what the country needs. They wouldn’t fix the fundamental problems of the US healthcare system.

There has been a long-standing debate over whether calling this Medicare for All is the right approach. On the pro side, Medicare is a familiar system, something that people understand, a term people are familiar with. Historically, the people who designed Medicare first envisioned it as a national health care system. It was the progeny of a national health insurance model. The architects of national health insurance under the Truman administration, when that fell through, they basically said, all right, let’s at least make this into a program for seniors. So in terms of the historical, ideological lineage, there is something to be said for calling single-payer Medicare for All.

The cons are that it can be confusing, because we’re not talking about replicating Medicare in its current form, we’re talking about going beyond it. Medicare has copays, this system will not. Medicare doesn’t cover dental, this system would. Medicare has somewhat privatized; there’s Medicare Advantage, and Medicare part D, the drug benefit. In contrast, this would be a single, solitary public plan, so there are significant differences between Medicare and what we’re talking about.

Would you say that Bernie Sanders’ Medicare for All legislation in the Senate or the House bill comes closest to your organization’s position?

The House bill comes closest. The Sanders bill has a couple of areas for improvement that we’d like to see. They’re mostly sort of wonky design issues that most people don’t get too excited about but that we think are very important.

Overall, the Sanders bill is a single-payer bill; it gets most of it right. We would like to see a change in the way hospitals are financed so that they get global budgets that cover all their operating expenditures rather than replicating the current Medicare payment system which incentivizes profit-oriented activities. We’d like to see no copays on drugs. The Sanders bill has almost no copays but it has small residual copays for some drugs. It’s pretty minor but we’d like to see that out. We’d like to see the inclusion of long-term care, which the Sanders bill does not have. It is a lot of money but we  need to deal with long-term care and make sure that’s covered.

Ryan Grim had a piece in The Intercept recently reporting that Nancy Pelosi’s top healthcare aide had met with representatives of Blue Cross Blue Shield and told them that the House would move on drug prices over single payer or changing the ACA.

I think there’s some truth that we’re not going to pass single-payer under the Trump administration. It isn’t realistic to think that it’s going to happen with this current government. But it is disturbing that those assurances are being given to the industry. It suggests that not all Democrats are on the same page.

There’s longstanding resistance among some in the establishment to sweeping ideas like Medicare for All. I talk about all the huge strides that have been made but there are still many obstacles ahead. As you’re probably aware, there’s a new corporate group funded by Big Pharma and the insurances companies that is spoiling for a fight, sharpening its swords, gearing up to tackle single-payer. The industry is not going to go down without a fight. Obviously, they’re going to pour money into Washington, they’re going to pour money into lobbying, they’re going to pour money into candidates, they’re going to take out ads, they’re going to smear it left and right, so our work is cut out for us.

Senator Sherrod Brown, a progressive on most things, has said that he’s for Medicare for All, but thinks it should be incremental, starting by lowering the Medicare age to 55.

I understand those arguments but I think what’s often not understood is that many of the savings that a single-payer system would achieve really come from a systemic shift and not from the incremental. Let’s say you create a public option that’s one more option people can buy into as a choice of healthcare insurance. That may achieve somewhat lower premiums, by virtue of paying Medicare rates instead of private insurance rates, but it’s actually not going to take the profit orientation out of the system. It’s not going to achieve the administrative savings that you get from a single payer system, it’s not going to allow us to reduce the armies of billers and coders that are employed by hospitals. So I think that some of those arguments fail to realize the real policy issues.

You just mentioned this new corporate group that wants to come down hard on single-payer because you’re advocating for the complete elimination of private insurance.

There may be some small residual role for private coverage of cosmetic surgery or things like that. That’s basically how it is in Canada. In Canada, the system doesn’t cover drugs or vision, there are supplementary plans for those things, but that’s a weakness of their system, not something we should emulate. So there’s really no need to have a private health insurance industry in this country. You’d have one public payer that covers everybody.

You’re going up against a behemoth.

Yes. They’ll need to find a new line of work (laughs). I don’t know what to say. The workers in those industries definitely need to be taken care of. The Sanders bill and the House bill both have provisions to take care of displaced workers. It’s not their fault that these industries don’t really have value. [What happens to] the CEO’s, I really don’t care too much about.

But how do you go about buying out for-profit hospitals and nursing homes? How do you keep owners from simply converting hospitals and nursing facilities into apartments or hotels?

There’s an ongoing debate about this among supporters of single payer. PNHP’s position is that we should have a plan for how to buy out for-profit healthcare providers as we transition into single-payer. We think that you could take out a large bond, use it to buy out for-profit providers, convert them to not-for-profit and that would be a way to ensure that for-profit owners don’t say to heck with this, I’m selling off all my dialysis machines to Europe.

Unions are a bulwark of the Democratic Party and I know that a lot of union members are going to say that my union healthcare plan is really good, why would I give it up for single-payer?

My response would be that you’re never going to give it up for something that’s not better. We and our allies would never support a plan that replaced people’s existing plans with something inferior. If you look at the bills, they have comprehensive benefits and no cost sharing. That essentially beats every private plan out there and goes beyond them.

For at least the next two years, the Republicans will keep trying to destroy the Affordable Care Act. As you see it, is there value in continuing to work to shore up Obamacare until changes can be made?

I think we should join forces with everyone who’s fighting to defend existing programs that help people. I think you saw that during the 2017 repeal effort when single-payer supporters linked arms with people who supported ACA or supported other forms of universal coverage and we fought together to push back against the repeal of the Affordable Care Act. I don’t think that doing that retards the advance of single-payer and I don’t think that fighting for single-payer gives an opening for those who want to attack the ACA.

So how do you pay for single payer?

There was a 200-page report on the economics of single payer that came out of the University of Massachusetts, Amherst, led by economist Robert Pollin. They suggested a mix of taxes that would cover its costs. It’s by no means definitive, there are other approaches to the problem, [but] their proposal includes redirecting all existing public health monies into the new system. Roughly two thirds of current public health dollars are already taxpayer-financed. So you divert those funds into the new system and for the remaining, yes, you need a mix of taxes. They propose a modest sales tax on non-essentials, an employer-side payroll tax and some new taxes on the very wealthy.

What you call “truly progressive taxation.”

Which has the added benefit of doing something about soaring economic inequality, which in itself is a cause of bad health. So actually, publicly financing our healthcare system has benefits by helping to confront the problem of inequality.

The other side screams “socialized medicine,” just as they did when Medicare and Medicaid and Obamacare began.

Call it what you will (laughs). Medicare and Medicaid were historic advances as was the Affordable Care Act, improving people’s lives. But they have left big holes, and for some people, things actually are getting worse. There just was a report from the Commonwealth Fund in which they looked at the inadequacy of insurance and they found that 45 percent of non-elderly American adults are inadequately insured or underinsured. People with insurance from their employers have seen their deductibles triple over the last decade, and the portion of people who are underinsured continues to rise. The Affordable Care Act helped to reduce the uninsured by 20 million people but it obviously left huge holes.

You alluded to “global budgets,” also known as global operating plans. Explain.

There are different ways to pay a hospital. The existing way is per patient billing. Sometimes that means having to add up every single service they used or every single Tylenol and so on, which obviously is a huge waste.

So what are the downsides of that? For one, you need an enormous infrastructure of people adding up the costs on a per patient basis. US hospitals spend a quarter of their revenue on administration and billing. That is double the proportion that Canada and Scotland spend.

The other problem with existing hospital payment methods is that they incentivize a profit-oriented approach focusing on the kinds of patients or the kinds of care. I’m not saying every hospital does this; my hospital, Cambridge Health Alliance, certainly does not.

Overall, it creates an incentive for hospitals writ large to engage in some profit-oriented activities – supplying services that generate the highest revenue, neglecting those that do not. This is something that PNHP co-founders David Himmelstein and Steffie Woolhandler have written a lot about. Even non-profits are sort of beholden to this sort of system. Not only that, but for hospitals to expand, to build new infrastructure, to get new machines, new equipment, they need to generate profits because the way that new healthcare infrastructure is funded in America is from profits for hospitals.

So the whole system is designed to encourage even non-profits to engage in profitable activities because if they don’t they’ll go under. They won’t be able to buy the new equipment, they won’t be able to build the new wing, they won’t be able to attract patients and the patients will go elsewhere. This is why we need to get away from a discussion that focuses on bad actors and start thinking about the way the system is designed, the defects in the system.

What do we need to do to change that? First, we need global operating budgets. Himmselstein and Woolhandler have rightly emphasized this. It’s a lump sum that a hospital gets to cover all its operating expenses. This is how it works with the VA, this is how it works in Europe, in Canada, for the most part. You get a lump sum and you can use it to take care of all your patients and then you’re not trying to say, well, I’ll do more invasive surgery that makes a lot more money. Instead, I’ll spend it where it’s needed, take care of patients in response to community needs.

At the same time, what we propose and what is in the House bill is a system where the capital expenditures I mentioned are separately funded, where hospitals don’t have to try to seek a profit on their operating revenues in order to have money left over to build stuff. Capital expenditures are determined based on medical need when and where the structure is needed.

So you move away from this whole profit ethos toward one that’s focused on community needs. In the current system, new hospitals get built where revenues are highest, new wings get built where revenues exceed costs. Hospitals in rural areas are going under because it’s hard to turn a profit in a rural

What we call single-payer incorporates things beyond just where the money comes from. It envisions a reconfiguration, a reformulation of the healthcare system away from profit-oriented activities towards one that is oriented toward community and patient needs.

People ask questions like, when do you see this happening, how do you see this happening – frankly, I have no idea. No one knows. The reality is that when we achieve single-payer there still are going to be areas for improvement. We’re not going to get it perfect the first time, and there are always going to be efforts to dismantle it. But I think the single-payer system is particularly resilient against that.

You see that in Europe – even when there have been right wing governments, try as they may, they often stumble in their efforts to dismantle public systems of healthcare. Margaret Thatcher, her people certainly would have loved to have dismantled NHS but they knew they couldn’t. They tinkered with it, they made it worse, they added some market elements to it…

And then the conservative Brexiteers lied and used as an argument that all the money saved from leaving the EU would be put into the NHS.

It does show how achieving real solid victories that help people on an everyday basis create the constituencies that support it. That doesn’t make it invincible, I understand that. But the NHS is socialism! (laughs)

Talk a bit about PNHP’s education efforts.

We have a sort of split focus, both on the medical profession and on the general public. Our members do grand rounds at hospitals, we speak to colleagues, we give talks, we disseminate materials, we produce research.  We are one part of the single payer movement that does focus on the medical profession. But the reality is that we don’t just want doctors to be on board, we need doctors to be on board.

There are some polls that show majority support for single payer among physicians. A lot has changed from the late 1940’s when the American Medical Association was the main force that defeated Truman’s national health insurance plan.

For one thing, there are more voices, it’s a more pluralistic profession than it was, it’s certainly a far more diverse profession than it was. There are still elements in the medical profession that are opposed to single-payer but there are elements like ours that powerfully support it. There also have been changes in the political economy of healthcare. Relatively recently, it was reported that a majority of physicians are now employees, which is a tremendous shift in the political economy of healthcare. Traditionally, physicians were essentially archetypal small business people, typically businessmen.

There have been real downsides for physicians, in terms of the quality of their work. They spend more time on clerical activities, on fighting with insurance companies, on checking boxes – interacting with the computer instead of interacting with the patients. I think it has resulted in a lot of burnout with physicians and it has resulted in job dissatisfaction, so I think there is a real desire among physicians to imagine a better world for their patients and for themselves. I think that has created an opening within the medical profession to support single-payer.

And about educating the general public?

Our members do media, write op-eds, give talks, engage in debates and also some of our members engage in policy research that our organization helps to get out there.

Drs. Himmelstein and Woolhandler were the lead authors of single-payer proposals that were published in the New England Journal of Medicine and JAMA [the Journal of the American Medical Association] that actually became the foundation for the House single-payer bills. They have done a lot of studies – the statistic that the majority of bankruptcies are medical bankruptcies was their work, just to give one example.

I’m doing healthcare research. For one project, we’re focusing on patients with lung disease, at how deductibles affect people with COPD. We’re also looking at how one of the big concerns with single-payer is that it would create an enormous explosion in expense because people would use more healthcare because it was free. We’re not sure, so we have done some research on the effects of the Affordable Care Act an Medicare in the 1960’s. Stay tuned on that.

I’m going to continue the work that previous presidents have done. If you look at some of these polls that sort of get cited where the bottom line is yes, single-payer polls really well, but when you start asking people this or that, the support is malleable. It’s true that many people don’t understand all of the design aspects, that it will be one public plan that covers everybody instead of an option, so there is an enormous amount of education of the public that has to take place to make single-payer a reality.

Finally, I wanted to ask you about immigration. PNHP is calling for coverage of all undocumented and documented immigrants.

We are calling for coverage of all US residents. I think that’s important. Look, everyone needs healthcare. You’re not going to deny people healthcare simply by virtue of the country they were born in, nor should we. Healthcare is a human right. That’s imperative. At the end of the day, the reality is that unless you’re willing to push people away from the doors of hospitals and call in the goons to throw them into the streets, you need to take care of people, right? It’s just common decency.

The irony is there’s also some research that immigrants actually pay more into the healthcare system. If that wasn’t the case it wouldn’t change my opinion but it is a funny irony. The reason is pretty simple – immigrants in general are younger and healthier, they use less healthcare and they pay more into the system.

But that’s not the motivation. The motivation is to envision healthcare as a human right that everyone deserves by virtue of belonging to the human race.

https://www.commondreams.org…

Michael Chernew explains the health care world without single payer

Curbing Health Care Spending: The Provider's Role

By Harvard Health Care Policy Professor Michael Chernew
NEJM Catalyst

The basic goal: Build payment models like population-based payment, where the delivery system assumes accountability for the full amount of spending and individual clinical outcomes, and bundled payments, assuming accountability, for an episode of care, and allow the provider system to rearrange the resources they need to provide that service or care for that patient more efficiently and share some of the fiscal savings it generates.

“We call those payment models, commonly, value-based payment, but in my view it’s just a misnomer,” says Chernew. “The word ‘value’ is simply the sugar that makes the medicine go down. This is about risk transfer.” Someone has to control what goes on, and someone has to have the incentives to control what’s going to go on.

“Frankly, as providers, you’ve drawn the short straw,” he says. “You may not have gone to medical school to learn how to save money, but increasingly the delivery system is put in the situation where they need to save money or at least control the rate of growth and spending.”

From the NEJM Catalyst event Disrupting the Health Care Landscape: New Roles for Familiar Players, held at NewYork-Presbyterian, October 25, 2018.

Nine minute video and transcript:
https://catalyst.nejm.org…

Comment:

By Don McCanne, M.D.

Nowhere in his comments does Harvard Professor Michael Chernew even mention single payer, and that’s the point. He is describing the status quo of the prevalent health policy views on health care financing – a vision with which we will have to live indefinitely as there would be no future role for single payer.

Set aside nine minutes to watch this video, and then a few more minutes to recover, but use that recovery time productively by thinking about the following. Instead of a vision of a system in which the “providers” are put at risk to control spending for the benefit of the payers, refresh your vision of a system in which health care professionals and institutions are dedicated to providing optimal care for the patients in a system which automatically allocates health care spending with that goal in mind – efficiently, effectively, equitably, and affordable for all – with no necessity to give thought as to how the care will be financed, any more than you would give thought about how the fire department will be paid as they are putting out a fire in your home.

Do we really want to live with a system in which the provider’s role is to curb health care spending? No? Then it’s time for bold action.

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

Adam Gaffney explains why we don’t need private health insurance

We Don’t Need Private Health Insurance

New single-payer plans don’t need to worry about carving out roles for health-care profiteers.

By Adam Gaffney
The Nation, February 18, 2019

Does achieving “Medicare for All” mean mostly eliminating private health insurance? Single-payer proponents say yes: After all, if a public plan provides comprehensive, no-deductible coverage for everyone, nobody would want—much less be willing pay for—duplicative private coverage.

Let’s assume we agree on the need for a universal public-insurance plan that covers everyone, as in Canada, Great Britain, or France. Would there still be a role for private insurance? If so, what would it be?

In nations that have universal public-insurance programs, private health plans fall into three categories: “duplicative” plans, “supplementary” plans, and “complementary” plans.

Let’s start with “duplicative” coverage, which refers to private plans that “duplicate” benefits of the public plan, like covering doctor visits or procedures that are also covered by the single-payer plan.

At first glance, it might seem odd that insurers would offer such plans, much less that anyone would pay for them. You wouldn’t, for instance, buy a private plan hawked by a company that promises you “access” to Central Park. You already have that. Obviously, such plans must offer some advantage to be viable.

And they do: In the single-payer context, they let individuals jump to the front of the line, gaining wider or quicker access to physicians’ services or other care covered by the public plan.

Should a scarce bed go to a less sick person over a sicker one who needs it more, just because the former has better-paying insurance? Most, I believe, would find that appalling.

But essentially, that’s what duplicative plans promise, albeit usually for non-emergency care.

Whether you’re talking about access to a primary-care doctor or a specialist, a psychiatrist or a hospital bed, health—not wealth—should be the factor determining access.

Duplicative plans, in other words, are not desirable, but they are also unnecessary. We should not embrace them.

But how about “supplementary” coverage, the private plans that provide benefits for services not covered by the public system? As Sarah Kliff of Vox notes, in Canada, the public system doesn’t offer universal drug benefits or dental care, so people need supplementary private plans to cover their medicines and their teeth. Similarly, in the United States, Medicare doesn’t cover dental-care benefits, and until 2003 didn’t cover prescription drugs.

The single-payer bills in Congress do not ban supplementary private coverage. However, because both the forthcoming bill in the House and (with the exception of long-term care) the bill in the Senate have comprehensive benefits—including dental care, prescription drugs, and vision care—there is not much left for supplementary plans to cover. Perhaps cosmetic surgery, or trips to Swiss medicinal spas?

When fashioning any new health program, we should pick and choose the best policies. For instance, the United Kingdom does have universal drug coverage (mostly without co-pays) and, consequently, basically everyone gets the medicine they need. That should be our model. The underlying question is simple: Do we offer comprehensive benefits in the universal public system, or do we drop benefits at random so as to give Aetna and Cigna something to do? The answer, to my mind, seems clear.

Finally, many nations have “complementary” private plans, which cover the co-pays and deductibles imposed by some (but not all) public systems.

For instance, many Medicare beneficiaries take out so-called “Medigap” plans today, which cover that program’s often substantial out-of-pocket expenses. In France, almost everyone has a complementary plan that covers the cost-sharing (e.g., co-pays) imposed by the single-payer program. The United Kingdom and Canada, in contrast, have no co-pays for physician care, diagnostic testing, emergency-room care, surgical procedures, or hospital care.

But far more importantly, let’s not forget how bad co-pays and deductibles are. It’s not just that they are unnecessary for cost control: Canada and the United Kingdom provide no-deductible universal coverage and have lower overall health-care costs. And it’s not just that they squeeze family budgets, effectively worsening inequality: By deterring the use of needed care, they are also harmful to health itself.

The presence of complementary private plans requires the erection of unnecessary financial barriers to care. Without the latter, we won’t need the former.

In other words, the only way to make room for a significant role for private insurance in the American context is to make the public system paltrier or skimpier, to impose onerous co-pays and deductibles, or to let the rich preferentially displace working-class people from hospital beds and doctors’ offices. But it doesn’t seem to make sense to punch holes in your own floor just to create work for a carpenter. That is particularly true if your floor is your health care—and your carpenter is an extractive insurance giant.

Adam Gaffney is a pulmonary and critical care specialist at the Cambridge Health Alliance and Harvard Medical School, and President of Physicians for a National Health Program.

https://www.thenation.com…

Comment:

By Don McCanne, M.D.

It has often been said that even if we enacted and implemented a single payer Medicare for All program there would still be a need for additional private insurance, whether duplicative, supplementary or complementary. That is not true.

Not only would a well designed single payer system obviate the need for additional coverage, we also would not have to face the additional costly administrative excesses of superfluous insurance, plus we would not be introducing the inequities that are often characteristic of such plans.

A single, publicly-funded, universal risk pool that provides comprehensive benefits for everyone is the most effective, most efficient, and least expensive on a per capita basis of all models of health care financing that would truly ensure that all of us receive the health care that we need. As Adam Gaffney explains, we shouldn’t compromise in the design of a single payer Medicare for All program simply to accommodate the desires of the expensive, intrusive and administratively inefficient private insurance industry. We need them out of our system.

An excerpt from yesterday’s Quote of the Day seems appropriate here:

“Particularly hot right now is the meme that people would have to sacrifice by giving up their private insurance if we switched to single payer. But private insurers are intermediaries that use administrative mechanisms designed to reduce utilization of health care no matter how beneficial that care may be. High deductibles and other cost sharing create financial barriers to care. Narrow provider networks limit access to health care professionals and institutions. Administrative interventions such as prior authorization requirements create additional barriers to care. And for this we pay more because of these expensive administrative functions that provide no health benefit. Besides, how many people do you know who have been able to keep their same precious private insurance plan throughout their lives? Nobody. Private insurance is an unstable method of financing health care with constant changes in providers, benefits, and in the insurers themselves, especially with inevitable changes in employment. Switching from private insurers to stable, life-long coverage is not a sacrifice, but rather it is another benefit of a single payer system.”

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Single-payer health care is the only moral prescription for America

Cure America's medical-system disparities with single-payer system.

By Devesh Madhav Vashishtha, M.D.
The Seattle Times, February 19, 2019

My third patient of the afternoon was a smiling 43-year-old woman with a painful lump in her right wrist. She works as a medical assistant at a Seattle hospital.

Her wrist pain started three days earlier, after a long day lifting and transporting patients. I diagnosed her with bursitis. I typically would have sent her home with conservative treatment – splinting, rest and anti-inflammatory medications. But I was concerned that she would struggle financially with co-pays for this visit and follow-ups.

I helped my patient open a state Department of Labor and Industries claim for a work-related injury to help her pay for care, since L&I involves no co-payments or deductibles. However, to qualify , she would have to jump through multiple hoops, including complex forms in English (her second language) and meetings with her employer.

Her story is emblematic of our country’s medical care, which is unnecessarily fragmented and bureaucratic, and overwrought with barriers to providing quality, affordable health care.

In a single-payer health-care system, her employer would not be treated as part of the insurance-coverage system. One entity, such as the government, would have clear guidelines on what is covered.

Single-payer improves health care in other ways. A colleague of mine recently cared for a young child with attention-deficit/hyperactivity disorder. She had to try three different ADHD medications before finding one that didn’t require expensive co-pays. This trial-and-error style of care wasted precious time for the doctor, her patient and the pharmacist.

In a single-payer system, doctors would have one formulary of medicines to choose from for any given condition, for all patients. For a diagnosis such as ADHD, the formulary might have five medications covered for all children, instead of 18 medicines with questionable coverage. Imagine a health-care system where nobody is denied medicine based on their insurance.

Single-payer would also address disparities in access to sub-specialists based on income. For instance, Medicaid patients have decreased access to sub-specialty care. With single-payer, we could eliminate these disparities: everybody, irrespective of their socioeconomic status, gets access to the same sub-specialists.

Historically, physician lobby groups such as the American Medical Association have been staunch opponents of single-payer healthcare because they fear it would limit doctors’ autonomy and decrease physician salaries. This is probably true; single-payer would require a leaner system with fewer opportunities for interest groups, including pharmaceutical companies and physicians (particularly sub-specialists), to make a profit.

This is where the moral question arises. Our country has noticeable health disparities by socioeconomic class, related to race and geography. A single-payer system that provides equitable care irrespective of these demographic factors paves the way to a more equal America. Decreased physician salaries and pharmaceutical profits are a small price to pay for such an important goal. This is especially true in the international context, as America has the highest prices in the world for pharmaceuticals and medical care.

I am growing tired of practicing two versions of medicine: one for well-insured patients who receive all the doctor visits and prescriptions they want, and another for poorly insured patients who pay more out-of-pocket and work harder to get health care. If we want to address the moral crisis in our health-care system, it’s time we sign America’s much-needed prescription: single-payer now.

Dr. Devesh Madhav Vashishtha is a family medicine resident physician at Swedish Cherry Hill in Seattle and a member of the American Academy of Family Physicians’ Commission on Quality and Practice.

https://www.seattletimes.com…