By Steffie Woolhandler and David Himmelstein
Health Affairs Blog, November 19, 2018

Single-payer reform is in the news — and in the U.S. House and Senate. One hundred twenty-three Congresspeople have signed on as co-sponsors of H.R. 676, the single-payer legislation in House of Representatives, and 16 Senators have formally endorsed S.1804, the Senate version. (Disclosure: H.R. 676 was closely modeled on the Physicians for a National Health Program reform proposal published in JAMA, for which we served as lead authors).

While both bills would cover all Americans under a single, tax-funded insurance program, they prescribe different provider payment strategies. The Senate version largely adopts Medicare’s current payment mechanisms; the House bill’s is modeled on Canada’s single-payer program, also called “Medicare,” which pays hospitals global budgets (much as a fire department is paid in the U.S.) and sharply constrains opportunities for investor-owned care.

These differences haven’t attracted much attention from politicians or the press, and few patients are aware of, or deeply concerned about them. That’s not surprising, since both bills address the lay public’s most pressing payment-related concern: they would drastically shrink (S.1804) or completely eliminate (H.R. 676) out-of-pocket payments for needed care.

But these divergent payment strategies would create very different financial incentives for providers, shaping the culture of medicine and the financial viability of a single-payer reform. The Senate version would, like Medicare, pay hospitals and other institutional providers on a per-patient basis, intermixing payments for current operating expenses with funding for future capital investments and profits. As at present, hospitals’ success, and even survival, would depend on generating profits (“surpluses” in non-profit facilities). Hospitals with a favorable bottom line could invest and add new buildings and programs, while unprofitable ones couldn’t modernize or expand, risking a downward spiral toward takeover or closure.

It’s this profit imperative that drives hospitals’ financial gaming, e.g. upcoding, and concentration on the most lucrative services, such as elective cardiac and orthopedic services, rather than money losers like mental health. This payment mechanism (and S.1804 as a whole) also leaves the door open to investor-owned providers.

In contrast, the House bill would abolish per-patient billing by hospitals and other institutions, and its global budget payments would cover only operating costs; hospitals would be prohibited from retaining surpluses, and capital investments would be funded through separate government grants. The bill would also explicitly proscribe payments to investor-owned facilities, and it calls for their conversion to non-profit status financed by issuing bonds.

Implications For The Financial Viability Of Reform

Expanding and improving coverage, as both S.1804 and H.R. 676 would do, is expected to increase care utilization and hence clinical costs. Yet most analysts foresee savings on billing and administration (as well as on prescription drugs prices) that would offset these increases. Both bills would replace the current welter of private plans—with average overhead of about 12 percent of premiums—with a single public insurer whose overhead would likely be similar to the traditional Medicare program’s 2 percent, or the 1.6 percent in Canadian Medicare (National Health Expenditure Trends, 1975 to 2017: Data Tables — Series A).

But insurance overhead accounts for only 44 percent of the administrative savings that could be realized under a single-payer program; the rest comes from streamlining providers’ administrative work. For instance, U.S. hospitals’ administrative costs average 25.3 percent of their total revenues, versus only 12 percent in single-payer systems like Canada’s and Scotland’s that pay global operating budgets and minimize rewards for financial gaming.

Medicare’s payment approach requires hospitals to bill for and justify each hospitalization, a requirement that persists in value-based payment schemes like ACOs and would continue under S.1804. Hence, hospitals would have to maintain much of their current wasteful billing, documentation, and internal cost-tracking systems. Retaining the profit imperative would also continue to reward hospitals for financial gaming and tailoring services to profitability, driving up both administrative costs and wasteful spending on low-value care.

Instead of bundled payment arrangements tied to individual patients, the House version would substitute an institution-wide bundled payment, i.e., a global budget covering all operating costs. As noted above, that approach has streamlined hospital administration in other nations, which have been more effective than the United States at restraining overall costs. In contrast, ACOs have increased providers’ administrative costs by about $200 per patient annually, and have generated trivial or no savings after accounting for Medicare’s “shared savings” bonus payments. Similarly, Medicare’s (and other payers’) pay-for-performance initiatives impose substantial administrative costs on providers, with no evidence that they’ve improved patients’ outcomes in any setting.

In sum, the financial viability of a single-payer reform turns on cutting administrative costs and minimizing incentives for financial gaming. Maintaining Medicare’s current payment strategies, as under S.1804, would be substantially costlier than adopting the non-profit global-budgeting strategy used in several other nations.

Implications For Medical Culture

Differences in payment strategies also have implications for the work lives of doctors and other clinical personnel. Medicare’s turn to ACOs effectively forces providers to become insurers who bear the risk of their patients’ medical expenses, even those incurred in other venues. This strategy virtually banished small independent providers, triggering a wave of mergers and acquisitions. Community hospitals have been gobbled up, and a rapidly growing share of doctors have become employees.

The profit imperative imposed on hospitals and physician practices by Medicare’s payment incentives filters down to doctors. It manifests as morale-sapping productivity pressures; redundant documentation requirements; time wasted on mandatory upcoding classes; and the sense that clinical priorities have become subservient to financial ones. The length of doctors’ notes in EPIC’s electronic health record—larded with clinically useless templated and copied material, and four times as long in the U.S. as in other nations—gives one indication of how payment rules translate into burnout.

The Senate’s version risks maintaining these ACO-driven incentives, and even risks the reemergence of private insurance under the guise of vertically integrated, risk-bearing corporate ACOs.

The Future Of Investor-Owned Care

The House single-payer bill envisions a buyout of the investor-owned facilities needed to provide care under the single-payer system, while the Senate version would leave them in current hands.

Proponents of the House approach acknowledge that many non-profit health care organizations have drifted far from their charitable roots. However, they cite evidence that for-profit providers (including hospitals, dialysis centers, nursing homes, home care agencies, and hospices) provide inferior care at inflated prices (see, for instance here, here, here, here and here – use URL below to access live hyperlinks) and are more likely to bend care to profitability (see here, here, here and here). For-profit hospitals spend less on nurses and other clinical aspects of care, but more on administration and financial management; for-profit chains have often been cited for questionable business practices and have been repeatedly implicated in large scale fraud (see here, here, here and here).

According to CMS, for-profit nursing homes are cited for quality deficiencies 28 percent more often than non-profits, and for deficiencies that place residents in immediate jeopardy 53 percent more frequently. Investor-owned home care agencies cost Medicare $752 more per patient than non-profit agencies, while providing worse care.

Yet even some who would prefer to exclude investor-owned facilities from a single-payer system worry about the cost of a buyout. In conversations with Congressional aides, some have suggested that these costs could amount to $1 trillion or more, although none could cite a source for that figure. While it’s not clear exactly how to value the assets of investor-owned medical facilities, estimates of their current capital assets and of their stock market valuations provide some guidance.

In the detailed cost reports filed with Medicare covering fiscal year 2016 (the most recent year for which virtually all reports are available), all for-profit hospitals taken together reported total capital assets of $97.845 billion at the start of the year, and additional purchases totaling $7.453 billion (Himmelstein & Woolhandler, unpublished analysis of hospital cost reports). So the total capital stock of all for-profit hospitals – including not just acute care hospitals, but most other inpatient facilities besides stand-alone nursing homes – totaled $105.298 billion. (The comparable figure for non-profits is $718.628 billion).

Since most investor-owned providers also carry debt, it’s not surprising that the capital asset figures are considerably higher than the stock market value of the firms that own the facilities. As indicated in Exhibit 1 (use URL below to access exhibit), the market valuation of the five publicly-traded firms that account for the vast majority of for-profit hospitals totals $50.071 billion. While data on the market value of the (smaller) privately held for-profit hospital chains is not available, the value of the larger chains, and past sale prices for three of the privately-held firms, suggests that they’d add only several billion to the total.

Similarly, as Exhibit 1 shows, the total value of shares in publicly traded nursing home firms, rehab, dialysis, and home care and hospice providers is relatively modest: less than $50 billion. And these valuations (which fluctuate from day-to-day) include aspects of the businesses that would not be included in a buyout, e.g. the value of real estate devoted to senior living communities, or the roughly 15 percent of DaVita’s business that’s unrelated to dialysis and the 20 percent of Fresenius’ revenues attributable to sales of products such as dialysis supplies.

Overall, the fair market value of investor-owned facilities covered by a buyout, whether assessed by capital stock or stock prices, seems unlikely to exceed $150 billion. Purchasing these assets using Treasury Bill financing over 15 years at the current interest rate of 3 percent would cost about $12.75 billion annually, equivalent to about 1 percent of annual hospital costs. Moreover, even in the short term, some or all of these costs would be offset by savings on profits, which totaled more than $6 billion in 2017 for just three of these firms (HCA, DaVita and Fresenius).

Bottom line: A buyout of investor-owned facilities is affordable. Indeed, it might well lower costs.

Looking Forward

In the short run, the divergence between the House and Senate versions of single-payer reform is of little consequence. No bill will be enacted under the current administration. Yet with support for single payer blossoming among Democratic leaders and the public, the prospect of legislative action is increasing, and with it the push for convergence. Indeed, Pramila Jayapal, the leader of the House Single-Payer Caucus, has indicated her intent to move the two bills closer together.

In aligning the bills, House members should, in our view, adopt some aspects of the Senate’s bill, notably its repeal of the Hyde Amendment that forbids using federal funds for abortion, as well as its greater specificity. But Senators should adopt the House bill’s payment strategies and commitment to non-profit ownership of health care providers.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

This Health Affairs Blog post by PNHP cofounders Steffie Woolhandler and David Himmelstein explains the differences between the House and Senate versions of Single-Payer Medicare for All legislation, and why it is important that they be aligned in a manner that gets the policy right.

Because of the importance of the topic, the article is presented in its entirety, but the electronic version accessible at the Health Affairs website also provides important hyperlinks plus an exhibit itemizing market value of investor-owned health care providers. You may want to read the article as posted on the Health Affairs website (URL above).

Besides covering some important single-payer principles, this article is particularly helpful in that it explains how a buyout of investor-owned facilities is affordable and, in the long run, would actually lower costs. This should alleviate the concerns of those who say that we cannot afford to convert to a non-profit health delivery system that eliminates passive investors.

The process of aligning the bills and converting them into legislative language is already underway and is expected to continue into the next session of Congress, which is almost upon us. So today’s message could not be more timely.

Those members of Congress who were elected after campaigning in support of Medicare for All need to understand that voters were supporting Single-Payer Medicare for All and not simply supporting the addition of a public option to our existing fragmented, dysfunctional, overpriced, and underperforming system, even if the public option carried a Medicare label.

But it is absolutely imperative that we communicate in a dignified and respectful style; the passion for our cause must be used to fuel a very positive message of truly attainable health care for all. The principles presented in this blog will provide the message that we need to convey.

This article should be shared widely to be used in our advocacy work.

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

By Harris Meyer
Modern Healthcare, November 15, 2018

Nearly 4,000 Arkansans lost their Medicaid expansion coverage in October because they failed to comply with the state’s new work requirement, joining 8,462 other low-income adults who lost benefits in the previous two months.

State officials reported Thursday that 3,815 of the 69,041 people subject to the so-called community engagement requirement in October were noncompliant for three months and were dropped from Medicaid. They will lose coverage for the rest of 2018 and can only reapply in January.

The total number of people cut off of coverage in October in the state’s Medicaid expansion program, dubbed Arkansas Works, was 15,081.

Of that number, 25% were axed due to noncompliance with the state’s requirement that they spend at least 80 hours a month working, volunteering, going to school or receiving job training, while 28% were dropped because they failed to supply the requested information.

The state said 6,002 additional people have been noncompliant for two months and are at risk of losing their coverage at the end of November.

Only about 1,525 of the 69,041 people subject to the work requirement in October reported meeting the 80-hour-per-month work requirement.

Total enrollment in Arkansas Works now stands at 245,553, down 12% from 279,602 when the work requirement started in May.

Arkansas Gov. Asa Hutchinson said in September that the program’s goal is to boost labor participation and increase work training and assistance to able-bodied people who want to work. The Republican cited state data showing that about 1,000 people gained job training or employment as a result of the program.

But experts and provider groups have expressed alarm about the coverage losses and the viability of the state’s complex work and reporting requirements. Beneficiaries can only report through an online portal.

The Arkansas Hospital Association has said it would like to see the requirement halted. Providers fear the new system will disrupt care for people with chronic conditions and drive up uncompensated-care costs.

In June, (U.S. District Judge James) Boasberg invalidated the CMS’ approval of a similar requirement waiver in Kentucky on the grounds that the agency did not adequately consider its impact on coverage. Following that ruling, the CMS held a new public comment period on the Kentucky waiver and is expected to re-approve it in some form.

Two other Republican-led states, Indiana and New Hampshire, also received CMS approval this year for a five-year demonstration waiver to establish a community engagement requirement. Their programs haven’t started yet.

Ten other states have requests pending to establish similar Section 1115 demonstrations.

In addition, there are discussions in Idaho, Nebraska and Utah, three states where voters just approved Medicaid expansion, about including a work requirement. Similar discussions are taking place in Montana, where voters just shot down a tobacco tax to fund a renewal of Medicaid expansion, and in Alaska, where an anti-expansion Republican was just elected governor.

The Trump administration in January encouraged states to seek work requirement waivers.

In Arkansas, beneficiaries must report that they were either meeting the community engagement requirement or that they qualified for an exemption, such as for a disability. They can only report through an online portal run by the state Department of Human Services. There is no option for reporting by phone, mail or in person.

Enrollees may be hard to reach by phone due to unstable housing or other factors, and a large percentage lack email or internet access. In addition, the online reporting process is complicated and confusing, even to advocates and providers that have tried to help beneficiaries.

“The most likely reason for noncompliance is that (Medicaid expansion enrollees) simply do not know about the new requirements or else do not know about or understand the online portal they need to navigate in order to successfully comply,” said Bruno Showers, senior policy analyst at Arkansas Advocates for Children and Families.

https://www.modernhealthcare.com…

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Comment:

By Don McCanne, M.D.

Two common problems for which there is a legitimate role of government in intervention include impaired access to health care for low-income individuals, and difficulties with finding and keeping adequate employment.

What is difficult to understand is why bizarre ideological concepts are allowed to displace need. In this instance, failure in one endeavor – lack of success in finding employment – is used to penalize the other – taking away health care merely because the patient lacks employment.

People by the thousands are losing health care because of this nutty idea. Instead of stepping in and correcting the problem, our current government ideologues are expanding this punishment of depriving people of health care.

The two problems are separate and require different solutions. We won’t discuss here the complex problem of ensuring optimal rates of employment, but we certainly can and should comment on the health care issue.

Everyone who needs health care should have it. We have an excellent understanding of the policies that would ensure health care for everyone. Simply enacting and implementing Single Payer Medicare for All would do it.

It’s not that we should reject ideology in our policy decisions. Rather it is that we should make efforts to get the ideology right. Ensuring health care for everyone is clearly the right thing to do – an ideological concept representing a moral imperative. Using the deprivation of health care as a punishment for failure of other unrelated policies represents an ideological perversion.

We can get this right. Enact Single Payer Medicare for All, and then separately continue to address our issues with chronic and recurrent unemployment. All we voters need to do is select government stewards who understand and support the ideology of our moral imperatives.

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

By Peter Sullivan
The Hill, November 15, 2018

Progressive Democrats are pushing for a vote on a controversial health-care bill after the party takes control of the House early next year.

But the left’s push for “Medicare for all” legislation would likely divide Democrats and pose a headache for House Minority Leader Nancy Pelosi (D-Calif.), who is poised to become Speaker in the next Congress.

Rep. Pramila Jayapal (D-Wash.), who is co-chair of the Medicare for All Caucus in the House, told supporters on an organizing call Tuesday night that simply expressing support for the idea is not enough.

“When we have that majority, we need to make sure that we put it to use,” she said.

Yet, many other House Democrats, including members of the leadership, are not on board with the idea of government-run universal health insurance.

Supporters say they are going to push for a vote and organize grass-roots efforts to pressure Democratic holdouts to sign on to the legislation. However, any floor vote would probably fail, with all Republicans and some Democrats rejecting the measure.

Republicans used Medicare for all — otherwise known as single-payer — as a leading area of attack on Democrats during the 2018 midterm elections. They touted a recent cost estimate by the Mercatus Center at George Mason University, which put the bill’s price tag at $32 trillion over 10 years.

Rep. Raúl Grijalva (D-Ariz.), the co-chairman of the Congressional Progressive Caucus, acknowledged that centrist members did not want a vote on Medicare for all, but countered, “There’s going to be votes that we need to take.”

“Regardless of the political ideology, everybody understands the expectations that we’re under, and you have to satisfy a lot of expectations,” Grijalva said. “Medicare for all is one of them.”

Rep. Ron Kind (Wis.), a centrist Democrat, countered that he did not want a vote on Medicare for all, pointing to what is realistic given that a Republican-controlled Senate would certainly never pass such a bill.

“Even Leader Pelosi and our leadership isn’t pushing that right now, so I think we need to be pragmatic in our legislative ambitions around here with a divided Congress and with Trump down at the White House,” Kind said.

A spokesman for Pelosi referred back to the California Democrat’s previous statements on Medicare for All when asked if Pelosi was open to having a vote.

Pelosi said in June that ideas like Medicare for all would “have to be evaluated in terms of the access that they give, the affordability of it and how we would pay for it.”

“But again, it’s all on the table,” she added.

Left-leaning groups are energized about the idea and aren’t taking no for an answer.

On a call put together by National Nurses United on Tuesday night, organizers from progressive groups told supporters how they would use grass-roots pressure to target House Democratic holdouts with phone calls and visits to their offices. They said they would particularly target 13 Democrats on the key House Ways and Means and House Energy and Commerce committees who have not co-sponsored the legislation.

National Nurses United is organizing “barnstorms” of intense grass-roots activity to pressure Democrats on Medicare for all from Feb. 9-13.

Sen. Bernie Sanders (I-Vt.), the leading champion of the idea who may run for president again in 2020, said on the call that proponents needed “massive grass-roots support” in order to pass the measure.

But Rep. Frank Pallone Jr. (D-N.J.), the likely chairman of the Energy and Commerce Committee next year, indicated Wednesday he is not interested in holding hearings or a vote on the bill and pointed to smaller steps to shore up the Affordable Care Act.

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

The current Medicare for all legislation, H.R. 676, has 123 Democratic co-sponsors, roughly two-thirds of the current House Democratic Caucus. But that is still far short of the number needed to pass the legislation. Neither Pallone nor the likely chairman of the Ways and Means Committee, Rep. Richard Neal (D-Mass.), is a co-sponsor of single-payer.

Jayapal said she is working with colleagues on an updated version of that bill and hopes to have agreement on it “over the next month” to be ready to introduce in the next session, which begins in January.

Organizers on Tuesday night’s call cited as an example of their work that they had already been showering the office of Rep. Joe Kennedy III (D-Mass.) with calls pressuring him to support the legislation.

Kennedy told The Hill on Wednesday that he is open to co-sponsoring an updated version of the bill if it addresses some problems he has with the current text, which would bring a rising Democratic star on board.

“I am more than open to the idea of single-payer,” Kennedy said. He said “unquestionably single-payer is a part of” the discussion going forward, but added: “I think the first step is trying to make sure we maintain the progress that we’ve had with the Affordable Care Act.”

Rep. John Larson (D-Conn.), a former member of Democratic leadership, said he thinks allowing people 50 and over to buy into Medicare is a more “intelligent and incremental” way to address the issue, but did not push back on the idea of a vote on Medicare for all.

“Congress should be about the vitality of ideas,” he said. “That’s an idea that should be discussed.”

https://thehill.com…

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Comment:

By Don McCanne, M.D.

The push for Single Payer Medicare for All is gaining enough traction such that the House of Representatives will likely hold hearings on it in the next session of Congress, and there may even be an actual vote held on the proposed legislation. It is unlikely that the Senate would advance the bill to the President’s desk, but this development is nevertheless very significant because it shows how popular the concept has become.

Education, advocacy, and grassroots efforts are working. Organizations such as National Nurses United and Physicians for a National Health Program, along with several others, have been particularly active in education and advocacy efforts. Grassroots support drove many politicians to endorse Medicare for All in the midterm election.

The people are leading, and the politicians are following. Keep it up! Single payer Medicare for All!

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

By Thomas W. Feeley, M.D. and Namita Seth Mohta, M.D.
NEJM Catalyst, November 8, 2018

In a survey of the NEJM Catalyst Insights Council in July 2018, sponsored by Optum, 42% of respondents say they think value-based reimbursement models will be the primary revenue model for U.S. health care. Indeed, this transition is already happening. Respondents report that a quarter of reimbursement at their organizations is based on value, on average. While three-quarters of their revenue remains fee-for-service, we see a remarkable change to a reimbursement system that was static for decades.

In particular, survey respondents’ organizations are pursuing two value-based strategies: accountable care organizations, which often use capitated payments; and bundled payments, which provide single payments for multiple services addressing a single condition.

Nearly half (46%) of respondents — who are clinical leaders, clinicians, and executives at U.S.-based organizations that deliver health care — say value-based contracts significantly improve the quality of care, and another 42% say value-based contracts significantly lower the cost of care. While this data suggests considerable support for value-based reimbursement, it is worth mentioning that a significant number (36%) of respondents say they are uncertain that this will ever become the primary revenue model for U.S. health care, indicating that for many, the jury is still out.

This finding deserves some informed speculation. Some respondents may want to adhere to the fee-for-service system. Others may want to see more evidence that value-based reimbursement actually improves outcomes and controls costs. Others may be unfamiliar with what value-based reimbursement actually represents. All of these concerns we have heard repeatedly over the past several years, and they are reflected in verbatim comments from survey respondents.

Clinicians, in particular, have reservations about value-based reimbursement. Fewer clinicians (37%) and clinical leaders (39%) than executives (51%) say they think value-based reimbursement will be the primary revenue model of the future. Fewer clinicians (38%) than executives (55%) and clinical leaders (47%) believe that value-based contracts significantly improve the quality of care, and fewer clinicians (36%) than executives (50%) and clinical leaders (42%) think value-based contracts significantly lower the cost of care.

As with several other questions in this survey, a significant number of respondents are undecided. More than one-third (37%) say they neither agree nor disagree that value-based contracts significantly improve the quality of care, and 41% neither agree nor disagree that value-based contracts significantly lower the cost of care.

To us, this survey suggests that many in health care see value-based reimbursement as a real solution to the nation’s current health care crisis. Until payers and providers become better aligned, however, there will be challenges in scaling and accelerating this approach. The survey participants say what is needed is a better understanding of value and better ways of assessing value. Collectively, we must measure outcomes that matter to patients seamlessly in the workflow, through advances in information technology, and then reward those outcomes in a value-based reimbursement system.

Thomas W. Feeley is a Senior Fellow at Harvard Business School and former Head of the Institute for Cancer Care Innovation at the University of Texas MD Anderson Cancer Center.

Namita Seth Mohta, MD, is the Clinical Editor for NEJM Catalyst. She practices internal medicine at the Brigham and Women’s Hospital and is faculty at The Center for Healthcare Delivery Sciences and at Harvard Medical School.

Analysis of the NEJM Catalyst Insights Council Survey on the New Marketplace: Transitioning Payment Models: Fee-for-Service to Value-Based Care, sponsored by Optum. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.

https://catalyst.nejm.org…

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Comment:

By Don McCanne, M.D.

This resource represents the views of leaders in the health care industry. It shows, once again, that value-based health care is a business concept rather than a patient care concept. Wrong priority.

We are off and running with value-based care primarily because it is being controlled by the people who move money around rather than the people who ensure the health of their patients.

We have serious problems in health care. Too many are left out. Too many face excessive financial barriers to care. Too many are deprived of their choices of health care professionals and institutions. The value-based models will do nothing to correct these deficiencies. What will? Single Payer Medicare for All. Let’s shift our priorities and efforts to a model that really will work.

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

By Tricia Neuman, Karen Pollitz, and Jennifer Tolbert
KFF, October 2018

As policymakers debate next steps for expanding health insurance coverage and lowering health costs, some have introduced legislation that would broaden the role of public programs, such as Medicare and Medicaid. During the 115th Congress, eight such proposals were introduced, ranging from bills that would create a new national health insurance program for all U.S. residents, replacing virtually all other sources of public and private insurance (Medicare-for-All), to more incremental approaches that would create a new public plan option, as a supplement to private sources of coverage and public programs.

These eight legislative proposals differ in ways that have important implications for consumers, health care providers and payers, including employers, states, the federal government, and taxpayers. Key policy differences relate to eligibility, the size and scope of the public plan, covered benefits and cost sharing, premiums, subsidies for premium and cost sharing, cost containment strategies, and the likely interactions with current public programs and private sources of coverage. They also vary in their level of detail; some bills, according to their sponsors, are intended to serve as blueprints for reform, and are expected to include greater specificity over time. Given the timing of the legislative calendar, these bills are unlikely to advance in the current Congressional session; however, they illustrate the range of options that will likely serve as prototypes for legislation that may be introduced in the next session of Congress.

Greatly simplified, these public plan proposals fall into four general categories:

• Two proposals would create Medicare-For-All, a single national health insurance program for all U.S. residents (Senator Sanders, S. 1804; Rep. Ellison, H.R. 676)1;
• Three proposals would create a new public plan option, based on Medicare, that would be offered to individuals and some or all employers through the ACA marketplace (The Choice Act by Rep. Schakowsky, H.R. 635, and Sen. Whitehouse, S. 194); The Medicare-X Choice Act by Sen. Bennett, S. 1970, and Rep. Higgins, H.R.4094; and the Choose Medicare Act by Sen. Merkley, S. 2708 and Rep. Richmond, H.R. 6117)
• Two proposals would create a Medicare buy-in option for older individuals not yet eligible for the current Medicare program (Sen. Stabenow, S. 1742; Rep. Higgins, H.R. 3748); and
• One proposal would create a Medicaid buy-in option that states can elect to offer to individuals through the ACA marketplace. (Sen Schatz, S. 2001 and Rep. Luján, H.R. 4129).

This policy brief summarizes key features of these proposals, highlights similarities and differences, and discusses key questions, trade-offs and potential implications.

Key Policy Considerations

1. HOW WOULD THE PROPOSALS PROVIDE AND EXPAND COVERAGE?
2. HOW WOULD THE PROPOSALS AFFECT THE AFFORDABILITY OF COVERAGE FOR CONSUMERS?
3. HOW WOULD THE PROPOSALS AFFECT MARKETPLACE COVERAGE?
4. HOW WOULD THE PROPOSALS AFFECT PRIVATE EMPLOYER-SPONSORED HEALTH COVERAGE?
5. WOULD THE NEW PUBLIC PLAN OPTIONS BE THE SAME AS THE CURRENT MEDICARE PROGRAM?
6. HOW WOULD THE PROPOSALS AFFECT THE CURRENT MEDICARE PROGRAM?
7. HOW WOULD THE PROPOSALS AFFECT THE CURRENT MEDICAID AND CHIP PROGRAMS?
8. HOW WOULD THE PROPOSALS ADDRESS THE NEEDS OF SPECIFIC POPULATIONS?
9. HOW WOULD THE PROPOSALS AFFECT PAYMENTS TO PROVIDERS?
10. WHAT COST CONTAINMENT FEATURES ARE IN THE PROPOSALS?
11. WHAT ARE THE COSTS AND POTENTIAL TRADE-OFFS?
12. HOW WOULD THE PROPOSALS BE FINANCED?

From the Discussion

With health care reemerging as an issue for voters in the mid-term elections, the debate over the role of public programs in our health care system appears to be intensifying. Current proposals offer a range of approaches from those that would transform the existing system by creating a new national, Medicare-for-All plan to more incremental approaches that would offer a new public plan option alongside existing private coverage and public programs. With many details yet to be provided, these proposals raise a number of questions, the answers to which will have important implications for consumers, health care professionals, and health care payers, including employers, states, and the federal government.

http://files.kff.org…

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Comment:

By Don McCanne, M.D.

This 16 page KFF issue brief summarizes various legislative proposals that would expand public coverage of health care. Because they vary in their impact, the authors have suggested questions that should be asked in evaluating each proposal. Single Payer Medicare for All supporters can certainly come up with several other important questions.

Some in the legislative and policy communities would consider these proposals to be on a level paying field, and that choices would be based on various policy trade-offs that might be preferred by a majority of legislators and policy wonks. Although that process could bring us to an optimal system, it very well might not. It risks neglecting fundamental goals that should be a moral imperative such as universality, equity, accessibility, comprehensiveness, efficiency and affordability.

The proposed and other pertinent questions should be asked not only regarding the Medicare for All, public option and buy-in proposals, but they should also be asked about the state versus federal proposals, especially Single Payer Medicare for All. Under any circumstances would it ever be right to leave out certain socioeconomic sectors in states other than yours?

By asking the right questions, we can identify the policy pathway to health care nirvana. That would be either a national health service or Single Payer Medicare for All. The latter would not only be more feasible, it would also align more closely with perceived American cultural values, even if the former might actually be a superior model.

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

By Matt Pearce
Los Angeles Times, November 7, 2018

Liberal-backed ballot measures — especially those involving criminal justice reform or healthcare — had greater success than Democratic candidates.

Party identification is one of the most powerful forces in politics, with many people voting strictly on party lines when it comes to choosing their politicians.

But ballot measures, while often pushing policies favored by one party more than another, don’t come with “D” or “R” labels. Voters can make their choices without feeling like they’re casting their ballots for one party or another.

Most Americans “aren’t particularly ideological,” said Lilliana Mason, a government professor at the University of Maryland and author of a recent book, “Uncivil Agreement,” about identity in politics.

Though Americans are polarized around “who you are, what your identity is,” polling shows that “the public holds fairly liberal positions” on a lot of issues, Mason said.

State-level Medicaid expansion under Obamacare, a major Democratic-supported policy, also saw several victories in deep-red states.

Republican candidate Brad Little trounced Democrat Paulette Jordan 60% to 38% to become governor of Idaho, but voters there approved a Medicare expansion measure 60.5% to 39.5%.

It was a similar story in Nebraska, where voters expanded Medicaid while handily reelecting incumbent Republican Sen. Deb Fischer, another expansion skeptic.

In Utah, Republican Mitt Romney vaulted into the Senate as voters there approved Medicaid expansion and legalized medical marijuana. Romney opposed both measures, saying the issues should instead be addressed by elected officials.

http://www.latimes.com…

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Comment:

By Don McCanne, M.D.

As if we didn’t need another lesson, the midterm election demonstrates again a very important point. Essentially everyone should be able to agree on health care reform (who could ever be opposed to better health for everyone?), and thus we should be able to bypass partisan politics and join together in fixing our system. The midterm election showed that voters can separate policy from partisanship.

A recent American Barometer poll (HillTV/HarrisX) showed that 52 percent of registered Republicans support Medicare for all (“Would you support or oppose providing Medicare to every American?”). That is in spite of the fact that the Republican politicians spent years trying to repeal the Affordable Care Act. Policy and partisanship are not welded together.

Initially the process that led to the Affordable Care Act was bipartisan, even if some memories suppress that fact. It was only because of a political decision made by Senate Republican leader Mitch McConnell to use this process to discredit President Obama that the Republicans in the committees shifted to an adversarial position. On the Democratic side they had already decided to abandon single payer in an effort to meet the Republicans on common ground (in spite of the popularity of Medicare for all).

A clear majority of the people want Single Payer Medicare for All, but the opposition remains primarily in the ranks of the politicians. The midterms show that Republican voters can vote for their candidates while still supporting policies that have widespread public support.

Advocates for Single Payer Medicare for All should expand their target for their educational endeavors beyond the the progressives and include conservatives as well. It will be the political base in each party that sends the messages to the politicians. Essentially everyone, except the extreme fringe, wants health care for all. All politicians need to understand that.

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By John Tozzi
Bloomberg, November 7, 2018

Obamacare repeal is officially dead. On to the battle over Medicare for All.

Tuesday’s midterm victories by Democrats mean that Republicans no longer have a path to make major changes to the Affordable Care Act. It also sets up a debate between Democrats’ liberal and moderate wings over whether to embrace a broad expansion of insurance to all Americans as they prepare to challenge President Donald Trump for the presidency in 2020.

Tuesday’s midterm victories by Democrats mean that Republicans no longer have a path to make major changes to the Affordable Care Act. It also sets up a debate between Democrats’ liberal and moderate wings over whether to embrace a broad expansion of insurance to all Americans as they prepare to challenge President Donald Trump for the presidency in 2020.

Once considered an outlier position, Medicare for All has gained substantial support among Democrats thanks to midterm primary victories by progressives who embraced it.

In its broadest terms, the proposal would expand benefits in Medicare — which covers more than 50 million elderly or disabled Americans — and offer it to working age people. It would be a radical change to U.S. health care, potentially dismantling much of an existing system where people get health benefits through work. It would also shift trillions of dollars that the country currently spends on private insurance.

“Medicare for All has really been a slogan that has not been well-defined, and it was weaponized by the Republican party as some kind of an attempt to socialize the medical system,” said Dan Mendelson, founder of the consulting group Avalere Health.

“It’s really going to be important for anyone running for president to define what they mean by Medicare for All,” he said.

https://www.bloomberg.com…

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Quick: What’s The Difference Between Medicare-For-All and Single-Payer?

By Samantha Young
Kaiser Health News, November 5, 2018

Across the country, catchphrases such as “Medicare-for-all,” “single-payer,” “public option” and “universal health care” are sweeping state and federal political races as Democrats tap into voter anger about GOP efforts to kill the Affordable Care Act and erode protections for people with preexisting conditions.

Voters have become casualties as candidates toss around these catchphrases — sometimes vaguely and inaccurately. The sound bites often come across as “quick answers without a lot of detail,” said Gerard Anderson, a professor of public health at the Johns Hopkins University Bloomberg School Public Health.

“It’s quite understandable people don’t understand the terms,” Anderson added.

For example, U.S. Sen. Bernie Sanders (I-Vt.) advocates a single-payer national health care program that he calls Medicare-for-all, an idea that caught fire during his 2016 presidential bid.

But Sanders’ labels are misleading, health experts agree, because Medicare isn’t actually a single-payer system. Medicare allows private insurance companies to manage care in the program, which means the government is not the only payer of claims.

What Sanders wants is a federally run program charged with providing health coverage to everyone. Private insurance companies wouldn’t participate.

In other words: single-payer, with the federal government at the helm.

https://khn.org…

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Comment:

By Don McCanne, M.D.

The concept of Medicare for all has grown in popularity to the extent that many of the pundits have stated it was a significant driving force in the midterm election. But the media reports suggest that there is confusion as to just what Medicare for all means.

“Medicare for all” for many years has referred rigidly to a single payer national health program – an improved and expanded version of Medicare that includes everyone. Because of the popularity of the term, many politicians latched onto it, suggesting that the ultimate goal was to make health care coverage universal but without defining what that coverage would be, while, in the meantime, they suggest perhaps Medicare could be offered as another option in the health insurance marketplace. They then use the Medicare for all label to refer to this strategy. Of course, when it has already been defined as a single payer system, this is a clear misuse of the Medicare for all label.

Now this mislabeling is getting worse, further confusing the general public. The very reliable Kaiser Health News says that Bernie Sanders’ use of Medicare for All is misleading because his is not a single payer system since Medicare allows the option of selecting private Medicare Advantage plans, even though the intent of single payer is to eliminate private plans. The Bloomberg article says that, in its broadest terms, Medicare for all would be offered to working age people – not exactly a broad definition.

Little does it matter that the improved version of Medicare that is called Medicare for all would be a true single payer system. Not only have the incrementalists lifted the Medicare for all label, they now seem to want to deny its use for the single payer model that not only was the original model for that label but is also the model for which the label is actually descriptive – Medicare for all.

We need to keep the Medicare for all label to be used to describe the real thing, perhaps making it clear by calling it “Single Payer Medicare for All,” as mentioned in in prior commentary. And what should we call those models such as the Medicare public option that leaves much of the dysfunctional system in place? In this age of Trump rhetoric, perhaps we should label those alternate proposals “Fake Medicare for Some.”

(Thanks to John Walsh for the suggestion of the “Fake” label.)

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Health care: Embrace single payer but maybe settle for less

By Elizabeth Aguilera
CALmatters, November 6, 2018

As the incoming Newsom administration prepares to unveil its legislative priorities, the single-payer health care concept he has touted will generate a lot of talk. But Capitol skeptics say that despite his promises to make it happen, action will be much more difficult—especially given the idea’s federal obstacles and huge costs.

Newsom may be more likely to initially pursue a less ambitious strategy: getting more of the uninsured covered under current government programs.

Except that is not what he promised the California Nurses Association, the powerful union that then endorsed and enthusiastically campaigned for him. The union says it’s not going to take no for an answer, and plans to insist on meetings with the governor-elect about how to move forward as soon as he takes office.

“Given the statements that Newsom made at our convention a year ago, we believe he is fundamentally committed to changing the health care system,” said Stephanie Roberson, director of government relations for the union. “He said that in a room full of nurses. His sentiments were very clear.”

Extending health care to all Californians has been, hands down, Newsom’s signature health issue.

In a January gubernatorial debate, he said: “I’m also very enthusiastic about taking a system that’s fragmented, that’s disjointed, that’s complicated and wasteful, and building a new system. Not on top of it, but replacing the existing system with a single payer financed system of universal quality health care.”

Newsom, the one-time mayor of San Francisco, pledged to create a statewide universal health care program of the sort he backed when he was leading that city. The Healthy San Francisco program, primarily funded from city coffers, provides basic insurance to residents who lack access to health insurance regardless of legal status.

Although it is not a single-payer system, the governor-elect has often cited it to illustrate his commitment to coverage.

The model would not work across the state but it has the right goals and values, said Anthony Wright, executive director of Health Access California, which advocates for consumers.

“He’s talked about wanting to take concrete tangible steps toward to the goal of affordable health care for all,” said Wright. “He’s talked about the vision of Medicare for all and universal coverage. He’s also been wide-eyed about the barriers to that goal.”

Those challenges will likely keep Newsom from pushing for single-payer out of the gate, said Gerald Kominski, senior fellow at the UCLA Center for Health Policy Research. “He understands the barriers are difficult to overcome,” said Kominski. “I suspect he’ll support ways to reduce the remaining uninsured further.”

As lieutenant governor, Newsom praised a bill that aimed to set up universal health care, but failed. It would have barred private insurers, and set up a state system funded by taxes and required for all residents. It was a tough sell.

Roberson of the nurses union said a new bill in the works will be a fine-tuned version of that bill. “What it’s going to take is political will, to sit in a room and not emerge until we find a way to reach that goal,” she said.

https://calmatters.org…

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California Dreamin’? With Newsom’s Win, Single-Payer Unlikely To Follow Anytime Soon

By Samantha Young
California Healthline, November 6, 2018

Californians on Tuesday elected a governor who campaigned for a complete overhaul of how people get their health coverage — but they shouldn’t hold their breath.

Rather, as Gov.-elect Gavin Newsom and the Democratic-controlled legislature take steps to provide more people with health insurance, they’ll likely approach it piecemeal over several years.

Newsom himself is already tempering expectations about California’s move to a single-payer system, saying it will take more than the will of one person to realize.

“I’m not going to hesitate to be bold on this issue, and I also want to set expectations,” Newsom told reporters last week at a campaign stop in Sacramento. “It’s a multiyear process.”

Undaunted, the California Nurses Association said it intends to bring another single-payer bill before the legislature next year and has launched a national campaign to pass single-payer in other states and convince Congress of its merits.

Lawmakers earlier this year directed a council to study the feasibility of a publicly funded health insurance plan, and its findings aren’t due until 2021 — giving the new governor and lawmakers time to punt on the issue.

http://californiahealthline.org…

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Comment:

By Don McCanne, M.D.

Single payer advocate Gavin Newsom has been elected governor of California, and it looks like he will have a supermajority of Democrats in the state legislature. Sounds like the ideal time to move forward with the first state-level single payer system to serve as an example for the nation, much as Saskatchewan did in Canada. Sounds like the ideal time, but is it?

In a personal conversation I had with Lt. Gov. Newsom a few years ago, he indicated to me his strong support for single payer as being the most efficient and effective model of reform, but he also indicated that there were many barriers that had to be negotiated and thus it might not happen on the state level in one piece of legislation, especially since federal cooperation would be mandatory (and that would not be forthcoming right now).

Single payer supporters understandably become nervous when Newsom emphatically endorses single payer but then expresses reservations, indicating, “it’s a multiyear process.” They seem apprehensive that he may be backing off on his promise to support single payer reform. But actually his position has been consistent all along. He wants single payer, but you cannot throw pragmatism to the wind. You can only do what you can do.

Nobody should be pessimistic. In fact, this is the time for optimism. Support for Single Payer Medicare for All has grown throughout the nation. California is in a position to take a leadership role in advancing the cause.

Right now California can move forward with whatever is possible on a state level while at the same time supporting work on a national level over the next two years so that in 2020 we will be ready with definitive federal legislation for a newly elected Congress and administration that is dedicated to enacting and implementing Single Payer Medicare for All. The homework has to be done in advance. We cannot let state hurdles and Fake Medicare for Some interfere with our progress. We’re perfectly situated for a two year plan, and the time to begin instituting it is yesterday.

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By Atul Gawande
The New Yorker, November 12, 2018

My hospital had, over the years, computerized many records and processes, but the new system would give us one platform for doing almost everything health professionals needed—recording and communicating our medical observations, sending prescriptions to a patient’s pharmacy, ordering tests and scans, viewing results, scheduling surgery, sending insurance bills. With Epic, paper lab-order slips, vital-signs charts, and hospital-ward records would disappear. We’d be greener, faster, better.

But three years later I’ve come to feel that a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me. I’m not the only one. A 2016 study found that physicians spent about two hours doing computer work for every hour spent face to face with a patient—whatever the brand of medical software. In the examination room, physicians devoted half of their patient time facing the screen to do electronic tasks. And these tasks were spilling over after hours. The University of Wisconsin found that the average workday for its family physicians had grown to eleven and a half hours. The result has been epidemic levels of burnout among clinicians. Forty per cent screen positive for depression, and seven per cent report suicidal thinking—almost double the rate of the general working population.

Something’s gone terribly wrong. Doctors are among the most technology-avid people in society; computerization has simplified tasks in many industries. Yet somehow we’ve reached a point where people in the medical profession actively, viscerally, volubly hate their computers.

Human beings do not only rebel. We also create. We force at least a certain amount of mutation, even when systems resist. Consider that, in recent years, one of the fastest-growing occupations in health care has been medical-scribe work, a field that hardly existed before electronic medical records. Medical scribes are trained assistants who work alongside physicians to take computer-related tasks off their hands. This fix is, admittedly, a little ridiculous. We replaced paper with computers because paper was inefficient. Now computers have become inefficient, so we’re hiring more humans. And it sort of works.

The story of modern medicine is the story of our human struggle with complexity. Technology will, without question, continually increase our ability to make diagnoses, to peer more deeply inside the body and the brain, to offer more treatments. It will help us document it all—but not necessarily to make sense of it all. Technology inevitably produces more noise and new uncertainties.

https://www.newyorker.com…

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Comment:

By Don McCanne, M.D.

Almost no one should be surprised by Atul Gawande’s observations on the physicians’ role in the use of computerized medical records. The trade-offs have been almost unbearable. He discusses the solution of using medical scribes, yet “research has found error rates between twenty-four and fifty per cent in recording key data.”

Although he says that the use of scribes “sort of works,” that really isn’t a satisfactory solution. Does anyone think that Gawande will do much better as he crafts the Bezos/Buffett/Dimon-sponsored solution to the problems with our health care system? At least it seems clear that we should not take a wait-and-see approach before we decide to move forward with Single Payer Medicare for All. We should do that right now.

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