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

Abstract

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

Conclusion

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

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

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

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

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

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

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

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

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

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

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

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

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

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

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

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

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

https://www.nytimes.com…

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Medicare Advantage Checkup

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

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

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

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

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

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

Discussion

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

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

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

https://www.nejm.org…

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Reforming America’s Healthcare System Through Choice and Competition

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

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

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

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Comment:

By Don McCanne, M.D.

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

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

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

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

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

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

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

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

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

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

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

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

Implications For The 116th Congress

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

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

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

Implications For 2020 Elections And Beyond

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

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

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

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

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

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

Sage advice. Let’s go with it.

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

By Robert Pollin, James Heintz, Peter Arno, Jeannette Wicks-Lim, and Michael Ash
University of Massachusetts Amherst, Political Economy Research Institute (PERI), November 30, 2018

Abstract

This study by PERI researchers Robert Pollin, James Heintz, Peter Arno, Jeannette Wicks-Lim and Michael Ash presents a comprehensive analysis of the prospects for a Medicare for All health care system in the United States. The most fundamental goals of Medicare for All are to significantly improve health care outcomes for everyone living in the United States while also establishing effective cost controls throughout the health care system. These two purposes are both achievable. As of 2017, the U.S. was spending about $3.24 trillion on personal health care—about 17 percent of total U.S. GDP. Meanwhile, 9 percent of U.S. residents have no insurance and 26 percent are underinsured—they are unable to access needed care because of prohibitively high costs. Other high-income countries spend an average of about 40 percent less per person and produce better health outcomes. Medicare for All could reduce total health care spending in the U.S. by nearly 10 percent, to $2.93 trillion, while creating stable access to good care for all U.S. residents.

To access the full 198 page report:
https://www.peri.umass.edu…

PERI press release:
https://www.peri.umass.edu…

Reviewer Assessments of Economic Analysis of Medicare for All:
https://www.peri.umass.edu…

PNHP’s assessment by Steffie Woolhandler, David Himmelstein and Adam Gaffney:
https://pnhp.org…

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Comment:

By Don McCanne, M.D.

This is the report that we have been waiting for: an economic analysis of Medicare for All done by the team at the Political Economy Research Institute (PERI) at the University of Massachusetts Amherst. This meticulous report concludes that “Medicare for All could reduce total health care spending in the U.S. by nearly 10 percent, to $2.93 trillion, while creating stable access to good care for all U.S. residents.”

Although it is 198 pages long, the initial 3 pages present the highlights, followed by a 13 page summary of the study. For most, that will provide the information you need, but those interested in particular policy details may want to read selected sections of the report. Those of us obsessed with health care justice for all would likely want to read the full report.

Of special note is the “Reviewer Assessments of Economic Analysis of Medicare for All.” It provides critiques by several of the most authoritative policy experts in the nation. Although some of these experts express minor reservations about some of the technical aspects of the report, as should be expected with any study of this magnitude, their overall view confirms the very high credibility of this project. There can be no question about the conclusion. We can have affordable health care for all.

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

By Joan Alker
Georgetown University Health Policy Institute, November 28, 2018

For the past eight years, CCF has published a report tracking health coverage rates for children across the country. This year, for the first time since we began writing this report, the number and rate of uninsured children in the United States went up.

For many years, that rate has been declining thanks to bipartisan efforts to extend coverage through Medicaid and the Children’s Health Insurance Program (CHIP). But in 2017, approximately 276,000 more children became uninsured, leading to a total of 3.9 million uninsured children nationwide. The rate for children age 18 and under went up from 4.7 percent in 2016 to 5 percent in 2017, according to our analysis of U.S. Census Bureau’s American Community Survey data.

While this may not seem like a huge change, both of these increases are unprecedented in the past decade. Even more troubling, the number of uninsured children increased during a time of economic strength – in fact, at a time when one would expect the uninsured rate to go down, as more children were covered by employer-sponsored insurance in 2017.

However, coverage for children from public sources, Medicaid and CHIP, and in the individual market – inside and outside the Marketplace – decreased during this time period. That caused the number of uninsured children to go up – despite the strong economy.

I’ve written this report for eight years in a row now, and I found it even more notable that no state, except for the District of Columbia, saw any measurable progress in reducing the number of uninsured children in 2017. Never before have we seen such uniformity in state behavior. This finding underscores that even states with the best of intentions were not able to overcome the negative national currents that are affecting children’s health coverage.

Why do we think this is happening? We can’t know for sure, but here are some of our best guesses:

The majority of uninsured children are already eligible for Medicaid or CHIP but are not currently enrolled. The name of the game here is to make sure that families are aware that their child has a path to coverage and that these kids get enrolled and stay enrolled. For these families, 2017 was a year of constant news about the President and Congress wanting to take coverage away – first with the attempt to repeal the Affordable Care Act and make drastic cuts to Medicaid, all of which continued with a last gasp effort in September 2017.

Then on September 30, funding for CHIP expired and, in an unprecedented delay, Congress did not extend funding until early 2018 – again with families hearing that their state might have to close its CHIP program. At the same time, the Trump Administration began efforts to sabotage the ACA’s Marketplace including cuts to advertising, outreach and enrollment funding for navigators – who were playing an important role connecting families with public coverage, with the repeal efforts raising insurer uncertainty and driving up premiums.

The Trump Administration also began a series of actions hostile toward immigrant families. One quarter of children living in the United States has a parent who is an immigrant. For these “mixed status” families, there is likely a heightened fear of interacting with the government and this may be deterring them from signing their eligible children up for government sponsored health coverage.

As a result, the “welcome mat” for coverage has been pulled back and we see the results – more uninsured children.

With an improving economy and low unemployment rate, the fact that our nation is going backwards on children’s health coverage is very troubling. Without serious efforts to get back on track, the decline in coverage is likely to continue in 2018 and may in fact get worse for America’s children.

Joan Alker is the Executive Director of the Center for Children and Families and a Research Professor at the Georgetown McCourt School of Public Policy.

https://ccf.georgetown.edu…

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Comment:

By Don McCanne, M.D.

Imagine if everyone were automatically enrolled in a national health program for life. No resident would be uninsured. We could do this if we enacted and implemented a Single Payer Medicare for All program. Yet, because we insist on perpetuating our unstable, unsatisfactory system of financing health care, we are leaving almost 4 million children without any insurance coverage at all. Our health policy decisions border on the criminal.

Medicare for All has become a very popular concept and was used in the recent election to secure votes for proponents of reform. Yet before the next session of Congress has even begun, we are already seeing widespread efforts to suppress talk of Medicare for All and instead to support mere tweaks to our current grossly inadequate model, though some would cut coverage back even further.

Suppose Congress were to pass an alternative proposal such as a public option Medicare for Some, will all of those 4 million children be automatically enrolled? Of course not. By merely tweaking our current dysfunctional system we will perpetuate a large unnamed category of the uninsured. Perhaps we should label this group, “No Medicare for Them.” Those supporting deficient proposals should be the ones to explain to these uninsured children and their parents why, in a democracy, we support health financing policies that leave them out. In fact, someone needs to explain it to me. Why do we?

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

By Nathaniel Weixel
The Hill, November 29, 2018

Momentum is building among House Democrats for a more moderate alternative to single-payer health-care legislation.

The legislation, which would allow people aged 50 to 65 to buy Medicare, is being championed by Rep. Brian Higgins (D-N.Y.), who supported House Minority Nancy Pelosi (D-Calif.) for Speaker in exchange for a commitment to work on his bill when Democrats take control of the House early next year.

“We agreed in principle to get this done,” Higgins told The Hill.

Under Higgins’s plan, anyone aged 50 to 64 who buys insurance through the health-care exchanges would be eligible to buy in to Medicare.

Rep. Frank Pallone Jr. (D-N.J.), the likely chairman of the Energy and Commerce Committee next year, said he thinks a Medicare buy-in should be on the agenda next year.

“We certainly would consider a Medicare buy-in,” Pallone told The Hill. “I think we’ve got to wait and see what the caucus wants to do and what the committee wants to do, but I’ll just say it’s certainly something we should consider.”

“Medicare for all” supporters are energized after sweeping Democratic victories in the midterm elections, however, and see the Medicare buy-in bill as too small a step.

“We are dead set against any buy-in or public option,” said Kenneth Zinn, political director of National Nurses United. “Our goal as RNs is to ensure a universal system of guaranteed health care for everyone and this does not accomplish that. I would urge Congress to reject it.”

Zinn said private insurance shouldn’t have any role in health coverage moving forward. A single-payer plan covers everyone, regardless of income, and eliminates copays, deductibles and premiums. It also eliminates private insurance.

Rep. Pramila Jayapal (D-Wash.), who is co-chair of the Medicare for All Caucus in the House, told The Hill said she has spoken with Higgins and expressed her concerns about his bill.

“We have to be careful not to perpetuate the system we have,” Jayapal said. “I would prefer to have a reduction of the age of Medicare so that more people could qualify but not a buy-in, because that continues the problems that we have right now.”

Jayapal added that lowering the eligibility age “would be an appropriate way to go where we’re taking a step forward towards a system that will ultimately cover everybody.”

Higgins said a Medicare buy-in is quicker and cheaper to implement than single-payer. It can also be a bridge to Medicare for all, he said.

“I support the exploration of Medicare for all, but you have to be well balanced and practical about this. Establishing a brand-new health insurance program is going to take time,” Higgins said.

Adam Green, co-founder of the Progressive Change Campaign Committee, said he supports giving everyone the option to buy in to Medicare, and thinks the legislation from Higgins will start a conversation. He wants a “buy-in for all” to be the “new floor” in the debate.

“It’s ironic that it took a conservative Democrat to jumpstart the momentum for Medicare buy-in but now that it’s there, there will be a huge push for Medicare option for all,” Green said.

“It’s jumpstarting the concept of a buy-in in 2019 and will lead to momentum of a buy-in for every family and small business.”

https://thehill.com…

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Comment:

By Don McCanne, M.D.

Many Democrats were elected after campaigning for “Medicare for All” which most of us presumed meant single payer reform. A Medicare buy-in is not single payer but rather it is merely a version of the public option. It simply adds another option to our highly dysfunctional financing system while correcting virtually none of the defects. It is not even an incremental step towards single payer since it takes us down a different pathway. If momentum seems to be building for a Medicare buy-in as a wedge to dismiss consideration of single payer, then Congress needs to hear from us – in a big way.

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

By Miranda Dietz Laurel Lucia, Dylan H. Roby, Ken Jacobs, Petra W. Rasmussen, Xiao Chen, Dave Graham-Squire, Greg Watson, Ian Perry, Gerald F. Kominski
UC Berkeley Labor Center and UCLA Center for Health Policy Research, November 2018

California’s successful implementation of the Affordable Care Act (ACA) resulted in historic increases in health insurance coverage. Over one million Californians have subsidized insurance through Covered California, the state’s ACA marketplace. The state’s Medicaid program (Medi-Cal) now covers approximately one out of three Californians, millions more than prior to the ACA.

Despite this success, 10.4 percent of non-elderly Californians (those under age 65) lacked insurance in 2016. Without state action to protect and build upon these coverage gains, we project that the uninsurance rate could grow to 11.7 percent in 2020, or approximately 4.02 million people, and to 12.9 percent in 2023, or 4.4 million people. These rates are based on a definition of insurance that excludes restricted-scope Medi-Cal for undocumented Californians.

The federal law zeroing out the ACA individual mandate penalty beginning in 2019 will result in lower individual market and Medi-Cal enrollment, but significant uncertainty exists about how much enrollment will decline in California. Using our California Simulation of Insurance Markets (CalSIM) microsimulation model and a range of assumptions about the extent to which the penalty influences enrollment decisions, we project that between 150,000 and 450,000 more Californians will be uninsured in 2020, growing to between 490,000 and 790,000 more uninsured in 2023, compared to the projected number if the ACA penalty had been maintained. The most substantial enrollment changes will occur in the individual market, where we project enrollment will decline by 10.1 percent in 2020 and 14.4 percent in 2023.

To protect the progress made under the ACA in expanding health coverage and to reduce the remaining coverage gaps, the state could expand Medi-Cal to all low-income residents regardless of immigration status, provide state subsidies to improve affordability of individual market premiums and out-of-pocket costs, implement a state individual mandate, and continue to support and strengthen outreach and enrollment efforts, among other strategies. As federal decisions threaten to reverse health coverage gains around the country, these policies would help to ensure that California continues to build on its successes and drive toward its goal of achieving universal health coverage.

http://laborcenter.berkeley.edu…

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Comment:

By Don McCanne, M.D.

California has been a leader in implementing the Affordable Care Act. As such, it would be useful to estimate the impact of the law that is eliminating the penalty for not having health insurance. This meticulous study estimates that five years from now over half a million additional Californians will be uninsured when compared to estimates were the penalty to remain in place.

Many studies have demonstrated that being uninsured results in impaired physical and financial health for far too many individuals who lose their insurance. Obviously we need to pursue different policies that instead would improve access and affordability of health care.

The primary criticism of this otherwise excellent report is that the authors’ recommendations, though reducing the negative impact of eliminating the individual mandate penalty, would still fall far short of the goals of reform. Many would still be uninsured. Many would still face financial hardship due to underinsurance. Many would be deprived of their choices of health care professionals and institutions because of the perpetuation of restricted provider networks. We would all be paying more because of the costs of administrative excesses which would only increase under the authors’ recommendations, not to mention the burden placed on us by having to comply with these excesses.

So the primary defect in this 32-page report is that they left out any discussion of a proposal that would meet the crucial goals of reform: Single Payer Medicare for All. We can only speculate that the reason is that these distinguished policy experts still limit their recommendations based on their perceptions of political feasibility. It is true that President Trump and the Republican-controlled Senate would be barriers to such comprehensive reform, but with certainty only for the next two years. That is a very short time to mobilize the public into a frenzy that offers politicians no choice but to fulfill the wishes of the majority: enact Single Payer Medicare for All.

If we can show success in grassroots organizing, these authors would no doubt concur that Single Payer Medicare for All is the way to go. These policy wonks certainly understand the different impacts of a policy that financially penalizes a person for being uninsured versus a policy that automatically insures absolutely everybody for life. In fact, you don’t even have to be a policy wonk since that’s a no-brainer.

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

By Lydia Ramsey
Business Insider, November 2, 2108

Dr. Steven Corwin knows what he does is expensive.

Corwin is the CEO of NewYork-Presbyterian Hospital. Surgeries, intensive care, and other costly procedures are constantly taking place within its walls. Hospital care cost about $1.1 trillion in 2016 — that’s 32% of health spending in the US.

“We do a lot of very expensive things,” Corwin told Business Insider. “We have to figure out how to reduce our costs.”

“We have to have universal coverage,” Corwin said. “Let’s forget the mechanism of getting universal coverage, but I think everybody’s gotta be insured.”

While Corwin doesn’t support Medicare for All, it’s a concept he has on his mind, in part because of how much simpler what is known as a single-payer system would be on the administrative side of the hospital. Instead of worrying about the variability in different plans, hospitals would have only one plan to keep in mind.

But to him, there are two big questions around Medicare for All:

Logistically, what’s the tax structure the US would need to support that?

Does Medicare for All makes sense for the US as a country?

“I think we should have that debate,” Corwin said.

https://www.businessinsider.com…

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A group of students at Weill Cornell and Columbia explain why their CEO is wrong to oppose ‘Medicare for All’

Business Insider, Letter to the Editor, November 26, 2018

In a recent article, NewYork-Presbyterian Hospital CEO Dr. Steven Corwin commented on rising healthcare costs. He stated that “We do a lot of very expensive things…We have to figure out how to reduce our costs.” In the same article, he stated that he opposes “Medicare for All,” but that “We have to have universal coverage,”

As medical students training at the institution Dr. Corwin leads, we agree: we do need it – and we need it urgently. Unlike Dr. Corwin, we, along with a growing number of hospital leaders, believe “Medicare for All” is the only solution for universal coverage and cost reduction.

Medicare for All is a universal, comprehensive single-payer system in which healthcare is financed by one public agency but privately delivered. It would cover all medically necessary services and eliminate co-pays, premiums, and deductibles, leading to improved financial security when individuals or families get sick. It would also give patients the freedom to choose their doctor.

HR 676, a bill introduced in the US House of Representatives with 123 Democratic co-sponsors last year, and the NY Health Act, a state bill that has passed the New York State Assembly in each of the past four years, would both establish such a system.

In his interview, Dr. Corwin first asks “what’s the tax structure the US would need to support [Medicare for All]?” Both HR 676 and the NY Health Act have well-defined funding mechanisms. Each proposes a progressively graduated payroll tax paid by employers and employees, as well as a progressive tax on non-employment income such as capital gains. HR 676 also includes an increase in personal income taxes on the top 5% of earners and a small tax on stock and bond transactions.

While many recent headlines claim that Medicare for All comes with a hefty price tag for taxpayers, it is vital to understand that this increase will be more than offset by the elimination of co-pays, premiums, and deductibles, resulting in net savings for 95% of U.S. households. Studies on the fiscal feasibility of HR 676 and the NY Health Act predict that the proposed funding mechanisms will sustain a Medicare for All system while saving billions of dollars annually.

The business community is also warming up to the idea of Medicare for All. Employer spending on healthcare continues to rise dramatically: the average employer contribution to premiums per worker has risen nearly 70% in the past decade.

Despite repeated claims of government inefficiency, Medicare currently operates at roughly 2% overhead cost, compared to 12.4% overhead for private insurers. These lower administrative costs, along with reasonable limits on drug prices, procedures, and devices will result in billions of dollars of savings for businesses and consumers that can be redirected into the private sector.

Dr. Corwin also asked “Does Medicare for All make sense for the US as a country?” We believe it does—as do 70% of Americans, including 84.5% of Democrats and 51.9% of Republicans.

Medicare is a national treasure: before age 65, when most Americans are insured by private companies, the U.S. has the worst mortality rates of any comparable countries; shortly after 65, when Americans become eligible for Medicare, the U.S. shoots to the top of the rankings. Additionally, Medicare beneficiaries have much higher satisfaction rates than those insured by private companies. Medicare for All will expand these benefits to the entire country.

Medicare for All is something all Americans can get behind, because it is for all Americans. It is bigger than any one hospital, insurer, or patient. As future physicians, our goals align with Dr. Corwin’s: we want universal healthcare coverage and we want to reduce costs. Medicare for All will do both. Is it time for Medicare for All in the U.S.? Dr. Corwin said “I think we should have that debate.” We wholeheartedly agree.

Sincerely,

William Ford, Emilie George, Alex Irace, Rachel Madley, Graham Wehmeyer, and Michael Zingman; Students at Weill Cornell Medicine and Columbia University Vagelos College of Physicians & Surgeons, Members of Students for a National Health Program (SNaHP)

https://www.businessinsider.com…

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A personal message:

By Don McCanne, M.D.

The future of health care in America rests with the nation’s students in medicine and in the other health professions. When you read the letter above written by members of Students for a National Health Program (SNaHP) you can be assured that the future is in very good hands.

Those of us at Physicians for a National Health Program (PNHP) who worked with Nicholas Skala were very impressed with “his incisive mind, wide-ranging knowledge and formidable skills of argument that were devoted entirely to bringing about a better world for everyone.” He was “an extremely witty and compassionate human being, and a great source of inspiration and encouragement.” He was so gifted that I personally thought that his name someday would be widely associated with the single payer Medicare for All program that would eventually be enacted. We are still reeling from his loss due to a cardiac event. We remember his legacy through multiple programs, including the Nicholas Skala Health Activist Award, Memorial Fund, and Student Scholarship Program.

On Giving Tuesday it seems appropriate to consider the contributions of Students for a National Health Program, and I am doing so through a contribution to the Nicholas Skala Student Activist Scholarship Fund. Before you decide that you are receiving too many requests today, do just one thing. Click on the following link, look at Nick’s portrait, and then just try to say no. I couldn’t. I hope you’ll join me.

https://pnhp.salsalabs.org…

Peace.

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By Robert Pear
The New York Times, November 24, 2018

The Trump administration has labored zealously to cut federal regulations, but its latest move has still astonished some experts on health care: It has asked for recommendations to relax rules that prohibit kickbacks and other payments intended to influence care for people on Medicare or Medicaid.

The goal is to open pathways for doctors and hospitals to work together to improve care and save money. The challenge will be to accomplish that without also increasing the risk of fraud.

With its request for advice, the administration has touched off a lobbying frenzy. Health care providers of all types are urging officials to waive or roll back the requirements of federal fraud and abuse laws so they can join forces and coordinate care, sharing cost reductions and profits in ways that would not otherwise be allowed.

Federal health officials are reviewing the proposals for what they call a “regulatory sprint to coordinated care” even as the Justice Department and other law enforcement agencies crack down on health care fraud, continually exposing schemes to bilk government health programs.

“The administration is inviting companies in the health care industry to write a ‘get out of jail free card’ for themselves, which they can use if they are investigated or prosecuted,” said James J. Pepper, a lawyer outside Philadelphia who has represented many whistle-blowers in the industry.

Federal laws make it a crime to offer or pay any “remuneration” in return for the referral of Medicare or Medicaid patients, and they limit doctors’ ability to refer patients to medical businesses in which the doctors have a financial interest, a practice known as self-referral.

These laws “impose undue burdens on physicians and serve as obstacles to coordinated care,” said Dr. James L. Madara, the chief executive of the American Medical Association. The laws, he said, were enacted decades ago “in a fee-for-service world that paid for services on a piecemeal basis.”

Melinda R. Hatton, senior vice president and general counsel of the American Hospital Association, said the laws stifle “many innocuous or beneficial arrangements” that could provide patients with better care at lower cost.

Hospitals often say they want to reward doctors who meet certain goals for improving the health of patients, reducing the length of hospital stays and preventing readmissions. But federal courts have held that the anti-kickback statute can be violated if even one purpose of the remuneration is to induce referrals or generate business for the hospital.

The premise of the kickback and self-referral laws is that health care providers should make medical decisions based on the needs of patients, not on the financial interests of doctors or other providers.

Doctors, hospitals and drug companies are urging the Trump administration to provide broad legal protection — a “safe harbor” — for arrangements that promote coordinated, “value-based care.” In soliciting advice, the Trump administration said it wanted to hear about the possible need for “a new exception to the physician self-referral law” and “exceptions to the definition of remuneration.”

“Good providers can work within the existing rules,” said Joel M. Androphy, a Houston lawyer who has handled many health care fraud cases. “The only people I ever hear complaining are people who got caught cheating or are trying to take advantage of the system. It would be disgraceful to change the rules to appease the violators.”

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

This article demonstrates some of the undesirable consequences of blindly continuing down the pathway of value-based health care through practice arrangements such as accountable care organizations. The system should be structured to serve the health care interests of patients first but these models are serving primarily the financial interests of physicians and hospitals. They are endorsed by the AMA and the American Hospital Association which seems to explain why these organizations are on the wrong side of the the debate over Single Payer Medicare for All.

The laws, rules and regulations that are being addressed by the proposed rules that would relax enforcement exist because the health industry did engage in activities that placed the financial interests of the providers above the health care interests of patients – activities that were often unethical and immoral. It is ironic that the business models being pursued today are claimed to increase value when, in fact, they bring back old behaviors that have been considered to be illegal, and for good reason. Maybe we’ve abandoned some of the old language – fee-splitting, kickbacks, ghost surgery, etc. – but the alternative payment models are bringing back arrangements that represent similar compromises in medical ethics.

Houston lawyer Joel Androphy says, “Good providers can work within the existing rules. The only people I ever hear complaining are people who got caught cheating or are trying to take advantage of the system. It would be disgraceful to change the rules to appease the violators.”

The effort of the Trump administration to relax the rules of ethics to take care of the providers is wrong, though there certainly is need to back off on their efforts to expand the dysfunctional value-based models that they are advancing.

We need a change, but a change that better serves the interests of patients – like, for instance, a Single Payer Medicare for All program. That would work better for the providers as well, except maybe for the very few who are primarily driven by greed. Besides, if we remove the opportunities for greed, then greed disappears (except for the relatively rare, hardcore, mafioso-type Medicare crooks).

Single Payer Medicare for All – where the rules serve the interests of patients first.

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