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Does Anyone Really Know What ‘Medicare for All’ Means?

Does Anyone Really Know What ‘Medicare for All’ Means?

More and more politicians are calling for single-payer health care. Is it just talk?

By Elisabeth Rosenthal and Shefali Luthra
New York Times, October 19, 2018

After decades in the political wilderness, “Medicare for all” and single-payer health care are suddenly popular. The words appear in political advertisements and are cheered at campaign rallies — even in deep-red states. They are promoted by a growing number of high-profile Democratic candidates, like Alexandria Ocasio-Cortez in New York and Representative Beto O’Rourke in Texas.

Republicans are concerned enough that this month President Trump wrote a scathing op-ed essay that portrayed Medicare for all as a threat to older people and to American freedom.

It is not that. But what exactly these proposals mean to many of the people who say they support them remains unclear.

As a renegade candidate for the 2016 Democratic nomination for president, Bernie Sanders opened the door to such drastic reform. Now, with Republicans showing little aptitude for fixing an expensive, dysfunctional health system, more voters, doctors and politicians are walking through it.

More than 120 members of Congress have signed on as co-sponsors of a bill called the Expanded and Improved Medicare for All Act, up from 62 in 2016. And at least 70 have joined Capitol Hill’s new Medicare for All Caucus.

But some worry the terms “Medicare for all” and “single payer” are at risk of becoming empty campaign slogans. In precise terms, Medicare for all means bringing all Americans under the government’s insurance program now reserved for people 65 and over, while single-payer health care would have the government pay everyone’s medical bills. But few are speaking precisely.

Celinda Lake, a Democratic pollster, said, “People read into ‘Medicare for all’ what they want to read into it.”

For every candidate with a clear proposal in mind, another uses the phrases as a proxy for voter frustration. The risk, some critics say, is that “Medicare for all” could become a Democratic version of the Republican “repeal and replace” slogan — a vote-getter that does not translate to political action because there is neither agreement about what it means nor a viable plan.

“If you’re on the left, you have to have something on health care to say at town halls,” said David Blumenthal, president of the Commonwealth Fund. “So you say this and move on. That’s part of the motivation.”

Dr. Carol Paris, the president of Physicians for a National Health Program, an advocacy group, said she has fielded a number of calls from candidates asking for tutorials on Medicare for all.

“I’m heartened, but not persuaded” that all the high-profile talk will result in any action, she said. She worries about what she called “faux ‘Medicare for all’ plans” that don’t live up to the mantra.

Polling highlights health care as a top voter concern, and pressure is building for politicians to take meaningful action that could redress the pain caused by personal health care costs that continue to rise faster than inflation.

Maybe that action would be negotiating lower drug prices or fixing flaws in the insurance system that allow for surprise medical bills and high out-of-pocket costs. Republican candidates mostly continue to bad-mouth “Obamacare” as the root of all problems in American health care (of course, it’s not), and some still push to repeal it. They tend to offer only vague assurances that, for example, they will guarantee that people with pre-existing conditions can find affordable insurance — proposals that do not withstand expert scrutiny.

But more and more voters seem to think the country needs more radical change.

In polling this year, 51 percent of Americans and 74 percent of Democrats said they support a single-payer plan. Surveys suggest growing enthusiasm among doctors, too, with more than half in favor.

Yet experts suggest voter support may not withstand warnings of tax increases or changes to employer-sponsored insurance. A 2017 poll from the Kaiser Family Foundation found that support for Medicare for all dropped when respondents were told that their taxes might increase or that the government might get “too much control over health care” — a common Republican talking point.

Despite initial enthusiasm, Vermont’s governor let a state single-payer plan die in part because it was calculated that it would require an 11.5 percent payroll tax on businesses and a state income tax of up to 9.5 percent.

The broader goal — affordable, universal health care — could be achieved by a range of strategies. For models, we can look to nations that have generally achieved better health outcomes, for less money, than the United States.

Canada and Britain come particularly close to true single-payer. Their governments pay medical bills with money raised through taxes and have monopolistic negotiating power over prices. But after that, the systems differ.

In Canada, which is Mr. Sanders’s inspiration, the government provides health insurance for most medical needs, with no out-of-pocket costs. People can, and often do, buy a second, private plan for any unmet health needs, such as prescription drugs.

Britain goes a step farther. Its government owns hospitals and employs many specialists via the National Health Service. A small private system exists, catering mainly to wealthier people seeking faster access to elective procedures.

Other countries achieve universal health care (or nearly so), but without single-payer. France and Germany have kept an insurance system intact but heavily regulate health care, including by setting the prices for medical procedures and drugs, and requiring all citizens to purchase coverage.

These more incremental options have not captured the American imagination to the same extent as Medicare for all. But adopting such a system would require the biggest shift, with significant implications for taxes, patient choice, doctors’ salaries and hospital revenue.

Enthusiastic politicians sometimes gloss over those consequences. For example, Liz Watson, a Democrat running in Indiana’s Ninth Congressional District, suggested the impact on doctors’ income was not much of a concern, because they would see a “huge recovery” on expenses since they would no longer need to navigate the bureaucracy of insurance paperwork. But analysts across the board agree single-payer would cut revenue for doctors — many say by about 12 percent on average.

And many voters seem confused by the fundamentals. In polling by the Kaiser Family Foundation, about half of Americans said they believed they would be able to keep their current insurance under a single-payer plan, which is not the case.

Optimism without specifics carries risk, as Barack Obama learned after promising that people wouldn’t lose their doctors under the Affordable Care Act. That promise haunted the Obama administration — it was singled out as PolitiFact’s “Lie of the Year” in 2013 and is still mocked by members of the Trump White House.

There’s also the thorny issue of how Medicare for all would affect the thousands of jobs at private insurers. “We have an insurance industry in Omaha, and people say, ‘I worry about those jobs,’” said Kara Eastman, a Democrat running on Medicare for all in Nebraska’s Second District. She suggested people could be retrained, saying there would have to be “repurposing of positions.”

Critics of Medicare for all, on the other hand, tend to exaggerate the costs of single-payer: “Denmark’s top tax bracket is nearly 60 percent!” (True, although that’s largely not because of health care.) “Doctors’ incomes will drop 40 percent!” (True, specialists in private practice would probably see pay cuts, but primary care doctors could well see an increase.)

Canadians generally pay higher taxes than Americans do — specifically a goods and services tax, and higher taxes on the wealthy. In Germany, working people pay 7.5 percent of income as a contribution toward comprehensive insurance.

But many Americans pay far more than that when you count premiums, deductibles, co-payments and out-of-network charges. Estimates of the tax increases required to support a Medicare-for-all or single-payer system are all over the map, depending on how the plan is structured, the prices paid to providers and drug makers, and the generosity of benefits.

As a politician famously noted, “Nobody knew health care could be so complicated.”

Some candidates do have clear proposals in mind. Ms. Ocasio-Cortez, for example, running for the House from New York’s 14th District, is firm: a single, government-run health plan that covers everyone with no co-payments or deductibles and perhaps allows Americans to buy supplemental private coverage. It’s the Canadian approach, textbook single-payer.

But many who back Medicare for all are vague or open to incremental approaches, like a “public option” that maintains the current insurance structure while allowing people to buy into Medicare.

Mr. O’Rourke casts Medicare for all as a starting point for discussion. But he said that what matters most is “high-quality, guaranteed universal health care.” Getting there, he added, “will inevitably require some compromise” — like a public option. Notably, he has not signed on as a co-sponsor of the Medicare for all bill because that plan does not allow for-profit providers to participate.

Jared Golden, a Democratic House candidate from Maine’s Second District, says in his campaign materials that he favors “something like Medicare for all,” but he clarified that at least initially, he would argue to lower the Medicare eligibility age, a change that wonks often call “Medicare for more.”

And the Wisconsin Democrat Randy Bryce, who is running to replace Speaker Paul Ryan in the House, said he would support a public option or lowering the eligibility age for Medicare. “I don’t want to say that there’s only one way to go about it,” Mr. Bryce said.

But many other candidates — both for Congress and for governorships — who are talking “Medicare for all” on the campaign trail either did not acknowledge or declined multiple requests to be interviewed on the subject. They include Andrew Gillum, who is running for governor in Florida; Gina Ortiz Jones of the Texas 23rd; the California candidate for governor Gavin Newsom; the Massachusetts Seventh candidate Ayanna Pressley; and the Pennsylvania First District candidate Scott Wallace.

Ms. Lake, the pollster, suggested that policy details simply aren’t as relevant in a midterm year and that for now we shouldn’t expect a candidate’s support for Medicare for all to be anything more than a way to signal his or her values. But she suggested that will change in the run-up to 2020, adding, “When we head into the presidential election, people will probably be pickier and want more details.”

That gives politicians and voters a few years to decide what they mean and what they want when they say they support Medicare for all or single-payer health care. For now, it’s hard to read too much into promises.

Dr. Paris, who lives in Nashville, said she was surprised and excited to hear that her representative, Jim Cooper, a Blue Dog Democrat, had signed up as a co-sponsor of the Medicare for all bill.

“I told him, ‘I’m dumbfounded,’” she recalled.

His answer? “Don’t get too excited.”

https://www.nytimes.com…

Medicare Advantage plans profit by wholesale denial of legitimate claims

Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials

U.S. Department of Health and Human Services, Office of Inspector General, September 2018

Why OIG Did This Review

A central concern about the capitated payment model used in Medicare Advantage is the potential incentive for MAOs to inappropriately deny access to services and payment in an attempt to increase their profits. An MAO that inappropriately denies authorization of services for beneficiaries, or payments to healthcare providers, may contribute to physical or financial harm and also misuses Medicare Program dollars that CMS paid for beneficiary healthcare.

What OIG Found

When beneficiaries and providers appealed preauthorization and payment denials, Medicare Advantage Organizations (MAOs) overturned 75 percent of their own denials during 2014–16, overturning approximately 216,000 denials each year. During the same period, independent reviewers at higher levels of the appeals process overturned additional denials in favor of beneficiaries and providers. The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided. This is especially concerning because beneficiaries and providers rarely used the appeals process, which is designed to ensure access to care and payment. During 2014-16, beneficiaries and providers appealed only 1 percent of denials to the first level of appeal.

Centers for Medicare & Medicaid Services (CMS) audits highlight widespread and persistent MAO performance problems related to denials of care and payment. For example, in 2015, CMS cited 56 percent of audited contracts for making inappropriate denials. CMS also cited 45 percent of contracts for sending denial letters with incomplete or incorrect information, which may inhibit beneficiaries’ and providers’ ability to file a successful appeal. In response to these audit findings, CMS took enforcement actions against MAOs, including issuing penalties and imposing sanctions. Because CMS continues to see the same types of violations in its audits of different MAOs every year, however, more action is needed to address these critical issues.

https://oig.hhs.gov…

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Comment:

By Don McCanne, M.D.

The findings of this review by CMS’s Inspector General are shocking. Of the claim rejections by the private Medicare Advantage Organizations that were appealed, most of them were overturned, indicating that the claims were certainly legitimate. But likely due to the tremendous administrative burden on the providers of health care, 99 percent of the claim rejections were never appealed. For these organizations to keep funds entrusted to them that were designated to pay for health care services that were actually delivered is worse than thievery because it is on such a massive scale. This is racketeering at its worst.

In her response to this report, CMS Administrator Seema Verma concurs with the recommendations for corrective actions, but then offers no new remedial measures. It is likely that they are not forthcoming. In an effort to privatize Medicare she has greatly increased the payment rates for the plans well beyond legislative intent. She has relaxed the star rating requirements allowing more plans to receive bonuses. She has recently relaxed the regulations on benefits to encourage more Medicaid beneficiaries to enroll in the private plans. And yet she states, “We are not steering any Medicare beneficiary anywhere” (Pear, NYT, 10/13/18).

At the same time, Verma has refused to recommend much needed reforms in the traditional Medicare program. In fact, she is fighting to force physicians to take downside risk in the traditional program (i.e., bear losses), likely with the intent of driving physicians out of the traditional program and into the private Medicare Advantage plans. Verma makes the outrageous claim that Medicare for All “would destroy Medicare for the seniors” (AHIP 10/16/18), when it would actually increase their benefits. Yet she is doing all she can herself to destroy Medicare while building up the private plans so that they can eventually take over.

Enough with the privateers and the racketeers. Let’s take back our Medicare, improve it, and expand it to cover everyone. But we do need public stewards in charge who actually believe in government of, by, and for the people.

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Medicare for all is a good option, despite what GOP says

By Elmore F. Rigamer, M.D.
New Orleans Times-Picayune, Letters, October 18, 2018

Don’t believe the fear tactics about Medicare for all.

A record number of Americans now reject our fractured, profit-based health system in favor of improved Medicare for all. In response, Republicans are frightening seniors by telling them they will lose Medicare benefits under a single-payer program like House Bill H.R. 676. Quite the contrary, Medicare for all would improve Medicare’s benefits by adding in previously uncovered services such as dental, hearing, vision, and long-term care, while eliminating cumbersome out-of-pocket fees.

Fear is a smart tactic when the truth is not on your side — it activates the part of the brain that makes us notice threats, while inhibiting the executive part of the brain that helps us think rationally, analyze facts and make smart decisions.

So, don’t believe the Medicare-for-all fear mongering. The real boogeymen are the health insurance and pharmaceutical industries, who have the most to lose if their profits are redirected to direct patient care. It’s no wonder so many members of Congress want to protect the interest of insurance and pharma — these two industries spent $371 million on lobbying in 2017 alone! Now that’s a scary fact.

https://www.nola.com…

When you’re really sick, you may find your insurance is not so great after all

1,495 Americans Describe the Financial Reality of Being Really Sick: ‘Do you pay the hospital bill or do you pay the utility bill?’ Don’t count on your health insurance for serious illnesses, a new survey warns.

By Margot Sanger-Katz
The New York Times, October 17, 2018

The whole point of health insurance is protection from financial ruin in case of catastrophic, costly health problems. But a recent survey of people facing such problems shows that it often fails in that basic function.

The survey, of some of the country’s most seriously ill people, found that even with health insurance, more than a third of the respondents had spent all or most of their savings while sick. They are often faced with deductibles and co-payments; treatments their insurance won’t cover; and financial challenges — like lost work — that health insurance alone can’t address.

The New York Times, the Commonwealth Fund and the Harvard  T.H. Chan School of Public Health used the survey to examine the sliver of the American population who use the health care system the most. To be included in the results, a respondent had to  have been hospitalized twice in the last two years, and to have seen at least three doctors.

Their experiences may serve as an early warning system for problems that all of us may face: Because the estimated 40 million people in this population visit doctors, hospitals, nursing homes and pharmacies the most, they are the likeliest to see the weak points in the health care system.

One of these is financial insecurity. Among people with health insurance, more than 20 percent had trouble paying for basic necessities. More than a quarter had bills in collection, and 13 percent had borrowed money as a result of their illness.

https://www.nytimes.com…

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Being Seriously Ill in America Today

The Commonwealth Fund, The New York Times, Harvard T.H. Chan School of Public Health, October 2018

From the Conclusions

These poll results present a unique look at the experiences of the most seriously ill patients in America today. They point to significant conclusions.

First, although about nine in ten seriously ill patients (91%) have health insurance coverage, the survey shows that while most people are financially protected, a substantial minority are not. About one-third (34%) report serious problems paying their hospital bills, and about three in ten (29%) report serious problems paying for their prescription drugs.

Among seriously ill patients who have health insurance coverage, these numbers about financial problems are still high. Thirty-one percent report serious problems paying their hospital bills, and 27% say they have problems paying for their prescription drugs.

These unpaid bills have a significant impact. Thirty-seven percent report that they used up all or most of their savings as a result of the cost of their medical condition, and 23% report being unable to pay for basic necessities like food, heat, or housing. For many of these individuals the problem is not that they have no health insurance coverage, but that their coverage is inadequate to deal with a serious illness.

This has implications for the national debate about whether or not governments should require higher levels of basic health insurance coverage for individuals. It also has implications when looking at the scope of public programs, such as Medicare. It is very unlikely that these seriously ill people imagined this high amount of health care expenditures in the years ahead at the time they bought their health insurance coverage or were aware of the level of coverage that Medicare would or would not give them if they were seriously ill.

https://cdn1.sph.harvard.edu…

Other resources on this topic, “Health Care in America: The Experience of People with Serious Illness,” are available at the following link:
https://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

Some say that we need health insurance only for major illnesses and injuries, that we can take care of routine care out of our savings whether or not the funds are transmitted through a health savings account. We know that isn’t true since routine costs have been shown repeatedly to impair access to essential health care services and frequently result in financial hardship for individuals and families. But what about the larger expenses? Does insurance provide adequate protection against catastrophic expenses?

“Among seriously ill patients who have health insurance coverage… Thirty-one percent report serious problems paying their hospital bills, and 27% say they have problems paying for their prescription drugs.” Further, “These unpaid bills have a significant impact. Thirty-seven percent report that they used up all or most of their savings as a result of the cost of their medical condition, and 23% report being unable to pay for basic necessities like food, heat, or housing.”

Obviously insurance is not providing adequate protection for all too many Americans. Even for those over 65 with Medicare, though protection is better it is still not adequate – thirty percent still used up most or all of their savings. That is one of the main reasons why we insist that we need an improved version of Medicare to serve as a financing infrastructure for a single payer national health program.

We can’t say too often that when people use the label, “Medicare for All,” to advocate for a public option or Medicare buy-in, we must challenge them on the inadequacy of such a proposal. Not only is more of the same kind of Medicare inadequate, most of the rest of the financing system that is resulting in the financial hardship reported in this study would remain in place.

The health care financing system needs to be changed. Let’s fix Medicare and then expand it to include absolutely everyone. We’ll still need other changes, but removing the financial barriers to care is a great start.

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Gov. candidate willfully misrepresents single payer

By Brian Yablon, M.D. and Beret Fitzgerald
Minneapolis Star Tribune, Letters, October 17, 2018

In a recent gubernatorial debate (“Arguing the Rx for health care,” Oct. 11), Republican candidate Jeff Johnson claimed that under a single-payer plan, “we all lose our insurance and are forced onto one government plan.”

This characterization willfully misrepresents what single-payer means. In actuality, single-payer means that everyone would have a robust set of comprehensive benefits without the headaches and games of our wasteful multipayer system. Hospitals, clinics and physicians would still operate independently. There would be no more “networks” to restrict access to your preferred provider and no more worries that you would forfeit coverage if you lost your job.

As for Johnson’s fearmongering that public insurance would financially threaten rural hospitals, he should instead be worried about what’s happening right now. Nearly 75 percent of Minnesota’s hospitals are designated critical-access hospitals, located more than 35 miles from another facility. Last year, almost half were at risk of closing. Rural hospitals are disproportionately burdened by the cost of billing in our outrageously complex health insurance system. A single-payer system would eliminate this burden, empower hospitals to negotiate global budgets based on operating costs, and incentivize providers to practice in underserved areas.

Our current system is convoluted, inequitable and dysfunctional for urban and rural Minnesotans alike. A single-payer system, by contrast, would guarantee everyone access to comprehensive health care, save money and be publicly accountable. We should be demanding no less from our elected officials at the state and federal levels.

Dr. Yablon and Ms. Fitzgerald are volunteer board members of Physicians for a National Health Program-Minnesota.

http://www.startribune.com…

Guess who is the new director of Medicaid and CHIP

Controversial former aide to Maine’s LePage to run Medicaid

By Dan Diamond and Brianna Ehley
POLITICO, October 15, 2018

The Trump administration has tapped Mary Mayhew — the architect of Maine’s aggressive conservative reforms to the social safety net — to oversee the national Medicaid program. She has been an ally of outgoing Maine Gov. Paul LePage, a Republican who has fought as hard as any governor against expanding Medicaid under Obamacare.

CMS announced the move internally Monday, the day Mayhew began as the agency’s deputy administrator and director of Medicaid and the Children’s Health Insurance Program.

Mayhew served as Maine’s health commissioner for six years under LePage, leading efforts to tighten the state’s Medicaid eligibility standards, add work requirements to the food stamp program and implement other conservative reforms. She supported LePage as he rejected efforts to expand the state’s Medicaid program — repeatedly vetoing legislation and then resisting after nearly 60 percent of Maine voters approved expansion on a ballot measure in 2017. LePage is spending his final months in office fighting a court order to expand the program.

Mayhew stepped down in May 2017 and ran to succeed LePage as governor, losing in the June Republican primary. As part of her campaign, Mayhew touted how safety-net programs had shrunk under her watch, pointing to a 70 percent decrease in enrollment in the Temporary Assistance for Needy Families program — one of the sharpest declines in the nation — and a 24 percent decrease in Medicaid enrollment.

Advocates have warned that Maine’s safety-net suffered under Mayhew’s leadership, noting that measures of hunger and poverty rose even while she oversaw cuts to programs designed to feed and support low-income residents.

https://www.politico.com…

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Comment:

By Don McCanne, M.D.

The Trump administration has appointed Mary Mayhew as director of Medicaid and the Children’s Health Insurance Program (CHIP). She previously worked with Maine Governor Paul LePage to slash safety net programs in that state, taking great pride in the fact that they reduced Medicaid enrollment by 24 percent.

Really? President Trump, Secretary Azar and Administrator Verma brought in a slash and burn expert to supervise the health programs for low-income individuals and families? This is happening right now in the good old United States of America? What kind of a nation have we become that we tolerate this?

Shall we call for a hundred million man march on Washington? If we did, I’m afraid that it would be quite lonely out there.

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Frakt on Medicare for All as the answer to sky-high administrative costs

Is Medicare for All the Answer to Sky-High Administrative Costs?

By Austin Frakt
The New York Times, October 15, 2018

Calls for a Medicare for All system are growing louder. Many Democrats have embraced it, while President Trump said last week that it would raise health care costs drastically.

Democrats say that giving people the option to partake in Medicare — no matter their age — will actually cut costs.

American administrative costs for health care are the highest in the world, and they argue that one advantage of Medicare for All is that it would save money because Medicare’s administrative costs are below those of private insurers.

Does that argument hold up?

Don’t forget about Medicare’s private plans

Medicare’s administrative costs were $8.1 billion last year, or 1.1 percent of total spending, close to the proportion it has been in recent years.

But some have argued that the actual cost is higher because of services performed for Medicare by other parts of the government that aren’t accounted for: The Social Security Administration collects premiums, the Internal Revenue Service collects taxes for the program, the F.B.I. provides fraud prevention services, and at least seven other federal agencies and departments also do work that benefits Medicare.

The claim that these administrative costs are overlooked is false. As annual reporting of Medicare’s finances plainly states, they are accounted for.

But there is something missing from the $8.1 billion Medicare administrative cost figure, as Kip Sullivan explains in a 2013 paper published in the Journal of Health Politics, Policy and Law. Although it accurately accounts for the federal government’s administrative costs, it does not include those borne by private plans that also offer Medicare benefits.

In addition to the traditional (public) Medicare plan, Medicare is also available from private plans through the Medicare Advantage program. Today, one-third of people using Medicare are in such plans, up from about one-fifth a decade ago. Moreover, all Medicare drug benefits are administered through private plans.

National Health Expenditure data shows both the government’s administrative costs for Medicare and those of Medicare’s private plans. Putting them together for the most recent year available (2016), they reach $47 billion, or 7 percent of total Medicare spending — well above the administrative costs borne directly by the Medicare program.

Medicare’s private drug benefit plans incur administrative costs that are about 11 percent of their spending. All of this additional, private administrative cost is paid for by taxpayers and, through their premiums, people who use Medicare.

Medicare’s direct administrative costs are not only low, but they also have been falling over the years, as a percent of total program spending. Yet the program’s total administrative costs — including those of the private plans — have been rising.

“This reflects a shift toward more enrollment in private plans,” Mr. Sullivan said. “The growth of those plans has raised, not lowered, overall Medicare administrative costs.”

The high costs of private insurer plans

Making an accurate estimate of the administrative costs of Medicare for All would depend, in part, on whether it would be more like an expansion of traditional Medicare (with its 1.1 percent administrative cost rate) or of all of Medicare, including its private plans (with a combined 7 percent administrative cost rate).

Yet both figures are well below private insurers’ administrative costs, which run about 13 percent of spending (this also includes profit), according to America’s Health Insurance Plans, an advocacy organization for the industry.

Some critics have argued that Medicare’s administrative cost rate appears artificially low because Medicare enrollees’ health spending is so high. Average Medicare spending per beneficiary is just over $12,000 per year; for an average worker in a private plan, it’s about $6,000. If you simply divide administrative costs by total spending, you will get a lower number for Medicare for this reason alone.

This is true, but the government’s administrative costs for Medicare are still below those of private plans. The government’s administrative costs are about $132 per person compared with over $700 for private plans. One reason Medicare’s are so much lower is that it reaps economies of scale. It also benefits from not needing to do much marketing, and it doesn’t earn profits.

A final critique of Medicare’s administrative costs is that they’re inefficiently low because the program doesn’t spend enough on anti-fraud efforts.

This is hard to prove or disprove. The government engages in a number of Medicare anti-fraud activities that more than pay for themselves. Perhaps another dollar spent tracking fraud would yield more than a dollar in return.

Still, even if Medicare did every bit as much in this area as the private sector, it would not raise its administrative costs by much.

“While private health plans have active anti-fraud, waste and abuse efforts, their total spending on this is very low,” said Andrew Naugle, a health care consultant with Milliman who studies health plan administrative costs. “For most plans, it’s not even in the top 10 categories of administrative spending.”

Features that may be worth the cost

Although Medicare for All might shed some administrative costs, it could also shed some other features, including some that many people appreciate.

“We should keep in mind that traditional Medicare and private plans are completely different products, and thus their associated administrative cost loads are very different,” Mr. Naugle said.

Traditional Medicare is primarily focused on processing payments to providers, while private plans — including those offered by Medicare Advantage, employers and Affordable Care Act marketplace plans — engage in care management, which could help coordinate care for people with chronic conditions. Private plans also establish networks of physicians, which could help steer enrollees to higher-quality providers.

These activities cost money and are things traditional Medicare doesn’t do, at least not directly. It has, however, put in new programs to give health care providers incentives to better coordinate care.

Another point in favor of private plans is that they’re more responsive to consumer demand. For this reason, private plans have provided some benefits that Medicare hasn’t — or provided them long before Medicare did.

For example, drug coverage was commonplace in private plans well before Medicare put in a universal prescription drug benefit in 2006. Another is that traditional Medicare still doesn’t have an out-of-pocket limit, whereas that’s standard for private plans.

But let’s get back to the main question we posed at the top: Are Democrats right that Medicare’s administrative costs are below those of private insurers? The answer is yes. But that’s in part because private plans do things that Medicare doesn’t. Whether those things are worth higher administrative costs is a value judgment on which reasonable people can disagree.

https://www.nytimes.com…

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Published Comment:

By Don McCanne, M.D.

The 1.1 percent administrative cost of traditional Medicare increases to 6 percent when only one-third of the Medicare beneficiaries are enrolled in private Medicare Advantage plans. The waste of the private plans is diluted by the efficiency of the traditional program.

More importantly, the administrative excesses permeate our entire health care delivery system because of the highly fragmented, dysfunctional financing system which also places a great administrative burden on the providers of health care. When people ask where we are going to get the funds tp pay for Medicare for All, they should be reminded that hundreds of billions of dollars are actually recoverable by merely changing to an efficient Medicare for All public financing. That would still leave hundreds of billions for essential administrative services.

Regarding whether or not the private Medicare Advantage plans are providing value for their administrative excesses, the answer is clearly no. Their intrusive care management has been directed more at upcoding to increase profits rather than providing much in the way of truly beneficial services.

It would be much more efficient to roll the extra benefits of Medicare Advantage, retiree plans, and Medigap into the traditional program, creating an improved Medicare for All. The administrative savings along with negotiated pricing is the key to providing affordable health care services to absolutely everyone.

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What Trump gets wrong about Medicare-for-all

By Steffie Woolhandler, M.D., M.P.H. and David U. Himmelstein, M.D.
CNN, October 13, 2018

President Trump’s critique of “Medicare-for-all” reform assaults the truth. Contrary to his claims, the single-payer bills in the House and Senate would upgrade coverage and broaden choice for seniors, along with the rest of Americans. And Medicare-for-all would slow the growth of medical costs, assuring Medicare’s long-term financial health.

Medicare currently leaves many seniors facing unaffordable medical bills. According to estimates from the Commonwealth Fund, the average enrollee spends $3,024 out of their own pockets on medical bills each year, and medical costs eat up more than 20% of total income for one in four seniors.

To escape some of those costs, many seniors are fleeing to private Medicare Advantage plans that restrict their enrollees to narrow networks of doctors, and often exclude cancer centers and other top-tier hospitals. But the trade-off might not be worth the savings, since the average person enrolled in a Medicare Advantage plan is still saddled with $2,472 in uncovered medical bills.

Medicare-for-all would plug these coverage holes, eliminating virtually all copayments, deductibles and uncovered services. It would also free seniors to choose any hospital and any doctor, and spare doctors from the managed care paperwork and restrictions on referrals imposed by Medicare Advantage plans, freeing up more time to spend with patients.

The President’s claim that Medicare-for-all would break the bank rests on a study by the Mercatus Center, which receives funding from the conservative Koch brothers. But Trump leaves out the fact that even the Mercatus study concluded that a single-payer reform would actually reduce medical spending by $2 trillion over 10 years; the federal government’s health spending would rise, but spending by employers, state and local government, and families would fall by an even larger amount.

The bottom line of the Mercatus study (which probably underestimates single payers’ savings), and many others is that single-payer reform would lower costs for the vast majority — including seniors — and avert the funding crisis that looms over Medicare.

Medicare-for-all can upgrade coverage while lowering costs by cutting out the insurance middlemen who currently drain hundreds of billions annually from our health care system but add no value. This year alone, private health insurers’ overhead — the money they collect in premiums that goes for marketing, accounting, executives’ bonuses, profits and more, instead of care — will total $256.3 billion, 12% of their premiums. That’s fivefold higher than the traditional Medicare program’s 2% overhead, according to 2017 data.

And Medicare-for-all would shrink billing and paperwork costs for doctors and hospitals, which currently contend with the arcane billing, coverage and documentation requirements of hundreds of different insurance plans. In countries with single-payer programs like Canada (Canada’s program is called Medicare) and Scotland, hospitals spend half as much as US hospitals, percentagewise, on administration. And according to research published in 2011, the average doctor in the United States was spending $89,975 each year dealing with insurance paperwork, $60,770 more than Canadian doctors spent under that nation’s Medicare-for-all system.

Overall, a single-payer reform could save more than $500 billion annually on insurance overhead and providers’ billing costs. In addition, our research shows that a Medicare-for-all program could use its market clout to bargain down drug prices to the levels in Canada and Europe, saving another $113 billion. The savings on bureaucracy and drug prices are more than enough to cover the nearly 29 million Americans uninsured in 2017, and improve the coverage for seniors and the tens of millions of others with unaffordable copayments and deductibles.

In his effort to tar Medicare-for-all as a socialist plot, the President invokes the example of Venezuela. But he ignores the successes of single-payer programs in capitalist countries like Canada, Australia, Scotland and much of Europe. The national health insurance programs in those nations cover everyone, cost half as much (per person) as our system, and get better results; US life expectancy, which used to lead the world, has stagnated and now lags years behind that of Canada and most of Europe. For what we’re now spending, we could have a Rolls- Royce version of Canada’s system.

The President’s fear-mongering about waiting lists, bankrupt doctors and hospitals, and socialism mirrors rhetoric in the campaign to block Medicare in the mid-1960s. Back then, The Wall Street Journal warned about “patient pileups,” and the American Medical Association mounted a campaign featuring Ronald Reagan that smeared Medicare as creeping socialism that would rob Americans’ freedom.

But today, America’s doctors are rallying to Medicare-for-all. Polls show that many doctors, and most Americans, favor such reform, and thousands have endorsed Physicians for a National Health Program’s single-payer proposals. A 2018 poll from the Kaiser Family Foundation found six in 10 favor a national health care plan.

Ironically, the President claims the mantle of Medicare’s protector, even as his chief economic adviser has announced plans for “entitlement reform” — Washington-speak for cutting Medicare, Medicaid and Social Security. Meanwhile, Republicans continue to press for the repeal of the ACA’s coverage expansions, and its pre-existing condition protections. While the sham replacement they offer would guarantee people with a pre-existing condition the right to buy coverage, insurers could refuse to pay bills for the condition.

President Trump’s Medicare-for-all attack rests on fake facts and baseless smears. The insurance companies and drug firms whose profits would shrink under single payer will no doubt welcome his words. But the truth is that Medicare-for-all isn’t just the best way to fix our broken health care system — it’s the only way.

Drs. Steffie Woolhandler and David U. Himmelstein are both distinguished professors at The City University of New York’s Hunter College, primary-care doctors in the South Bronx, and lecturers in medicine at Harvard Medical School.

https://www.cnn.com…

Medicare-for-All versus public plan buy-in proposals

Medicare-for-All and Public Plan Buy-In Proposals: Overview and Key Issues

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);

* 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.

Issue Brief (16 pages):
http://files.kff.org…

Side-by-Side Comparison of Medicare-for-All and Public Plan Proposals (12 pages):
http://files.kff.org…

Interactive for comparing proposals:
https://www.kff.org…

***

Comment:

By Don McCanne, M.D.

The enthusiasm for Medicare for All continues to increase so much so that it has now become part of our national parlance. Until recently, the meaning of the term has been quite specific, referring to a single payer national health program based on an improved version of our traditional Medicare program that would include everyone and which would be publicly-financed and publicly-administered.

Now advocates of various models of incremental reform want to get in on the action, and they are doing so usually by using the Medicare label. So we not only have two Medicare for All bills, but we also have the labels of Medicare public option (Choice, Medicare-X Choice, Choose Medicare), Medicare Buy-in (Medicare at 55, Medicare Buy-in and Health Care Stabilization), and even a Medicaid buy-in option. Needless to say, this has caused confusion which particularly has been a problem with distinguishing true single payer from merely adding a public option to our current inefficient, fragmented financing system.

This report, authored by the policy experts at KFF, is timely and welcome since it describes the eight leading legislative proposals and discusses some of the key issues that distinguish them. The authors do set apart Medicare for All as a single, federal, government-administered program that would provide coverage to all U.S. residents, replacing virtually all other sources of private health coverage (employment-sponsored plans and insurance offered inside and outside ACA marketplaces) and most public programs, including Medicare, Medicaid and CHIP. All of these other programs – public option, Medicare buy-in, and state Medicaid buy-in – keep intact our administratively inefficient, expensive, fragmented, dysfunctional health care financing system while merely adding administratively complex options.

The difference is night and day. There should be no confusion between an improved Medicare for All that would fix our health care financing problems, and the other proposals that merely add to the complexity and waste while failing to adequately address the inequities and deficiencies inherent in our current system.

This is why the Issue Brief and Side-by-Side comparison produced by KFF are so pertinent. They can be used to educate others on the stark differences between the two approaches to reform – single payer versus adding an option – not to mention that they can be used to sharpen your communication skills as you attempt to educate others on these crucial differences.

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

Mr. Trump, If You Love Medicare, Improve It and Expand It to All

Can the U.S. afford to expand Medicare to all? The real question is, can we afford not to?

By Carol Paris, M.D.
Common Dreams, October 11, 2018

Well, now I’ve heard everything: Donald Trump wants to keep “the government” away from Medicare and protect seniors from attempts to improve it.
 
Huh?
 
Mr. President, take it from me—a newly-minted senior citizen and a doctor—you need to sit down and read the bill that single-payer supporters consider the gold standard for universal coverage: H.R. 676, the Expanded and Improved Medicare for All Act. Don’t worry, it’s a much easier read than the average commercial health insurance policy.
 
Here’s the deal: H.R. 676 would vastly upgrade Medicare for seniors by covering all medically necessary care, including dental, vision, hearing, mental health, and long-term care—none of which are currently covered. We learned very early on in medical school that, yes, the eyes, ears, mouth, and brain are all part of the human body and all those parts need care.

H.R. 676 would also provide tremendous financial relief for seniors by eliminating Part B and D premiums and doing away with all copays and deductibles. Doctors know copays and deductibles only discourage patients from seeking care, and nobody should have to choose between buying groceries and paying for doctor visits.
 
Today, Medicare beneficiaries’ average out-of-pocket health care spending was 41 percent of average Social Security income and 36 percent of those in traditional Medicare spent at least 20 percent of their income on out-of-pocket health care costs in 2013. H.R. 676 would provide the financial freedom that many seniors (and everyone else for that matter) need and deserve.
 
The seniors I talk to aren’t fooled by restrictive Medicare Advantage plans, either. They just want one, simple plan that gives them full choice of hospitals and doctors. Commercially administered Medicare Advantage plans don’t offer a full range of choices. Why? Because it would cut into their obscene, taxpayer-funded profits.
 
The argument that expanding Medicare’s coverage to younger Americans will somehow hurt seniors is preposterous. Mr. Trump, I know that you’re old enough to remember when Medicare was first signed into law in 1964. When 19 million seniors enrolled in Medicare in the first year, there was no significant increase in the total number of doctor visits in the U.S., no evidence of reduced clinical capacity, no waiting lists, and no “rationing” of care.
 
The same happy story repeated itself when we provided coverage to millions of children through the Children’s Health Insurance Program (CHIP) and low-income adults through Medicaid.
 
Our public health programs—especially Medicare—are an American success story, and an ideal foundation for a system that ensures high-quality care for everyone. The reason for that success is Medicare’s remarkable administrative efficiency: Traditional Medicare’s overhead is just over 3 percent, compared to private plans, including Medicare Advantage plans, whose overhead averages 30 percent.
 
Can the U.S. afford to expand Medicare to all?  The real question is, can we afford not to? Moving to a streamlined, national single-payer program like H.R. 676 would save an estimated $617 billion annually by slashing the administrative waste of private health insurance and the paperwork imposed on hospitals and doctors ($504 billion), and by bargaining down drug prices ($113 billion). That would free up enough money for universal coverage without any net increase in U.S. health spending.
 
You try to frighten us with a $32 trillion price tag but fail to mention that if we maintain the status quo, we are on target to spend $50 trillion on health care over the next 10 years. 
 
This desperate fear-mongering about Medicare for all is no surprise, given the surge in support for the idea, which is now favored by a majority of Americans (including a majority of Republicans!) and a majority of doctors like me.
 
If you love Medicare, fight to make it better and expand it to every one of your constituents.

Dr. Carol Paris is a psychiatrist and president of Physicians for a National Health Program (PNHP).

https://www.commondreams.org…

There are solid options in health care reform

By George Bohmfalk, M.D.
The Aspen (Colo.) Times, October 11, 2018
(Part 6 of 6. Read parts 1, 2, 3, 4 and 5.)

Many people are hesitant to adopt a government-run, universal, single-payer health insurance in one fell swoop. They ask about incremental reform, and retaining a role for private insurance companies. They wonder why this can’t be tested in individual states, like legalization of marijuana and same-sex marriage, before taking it on nationwide.

Are these valid options?

The financial keys to universal health care are the administrative savings inherent in a single-payer system and a single risk pool. If we were to offer a public-option system and retain employer-provided and private insurance, billions of dollars will still be squandered on administration in those private systems. The primary goal of for-profit insurers is profit, rather than paying out health benefits. They are skilled at attracting younger, healthier enrollees while directing older and sicker applicants to public programs.

It’s likely that, with an arrangement of such distorted competition, the public system would become overweighted with high-cost enrollees and be destined to fail. If everyone is in the same boat, there will be plenty of funding to provide excellent care to all, and political pressure to guarantee it.

Some countries, such as Germany, France and Japan, do involve private insurance companies in their systems, but these are highly regulated, nonprofit companies that administer the universal programs in those countries in lieu of a government agency like Medicare. Administrative overheads are lower in countries that use a government agency, like Canada, South Korea and Taiwan.

Sen. Bernie Sanders’ Medicare for All Act (S.1804) proposes a transition over a period of several years. While this may seem like a reasonable phase-in process, it’s completely unnecessary and would be doubly detrimental. Such a drawn-out transition would allow years of expensive administrative waste to continue. Millions of Americans would be deprived of needed care and exposed to unaffordable medical costs in the interim. There’s just no need to waste several years and billions of dollars on a phase-in, as Taiwan demonstrated just over 20 years ago with their smooth immediate transition.

What about letting individual states test universal health insurance?

In order for individual states to enact a single-payer system, they must obtain Congressional waivers to redirect federal funds, such as Medicare and Medicaid, to state agencies. These waivers are extremely difficult to obtain, particularly from a Congress disinclined to support any more federal involvement in health care.

Failed efforts in many states, including Vermont, New York, California and Colorado, have demonstrated not any weaknesses of a single-payer system, but only the near impossibility of enacting one in a single state, for this and many other reasons. This is an issue that can only be done nationwide.

Several proposals have been offered for halfway steps to universal health care, some of which disguise themselves in Medicare for All phrasing, such as the Center for American Progress’ (CAP) Medicare “Extra” for All plan. Colorado’s Sen. Michael Bennet and Virginia’s Tim Kaine offered Medicare Part X, and several proposals call themselves Medicare Part E.

While all of those might provide some relief to some Americans, they all fall far short of providing universal, complete coverage. There is simply no reason, other than fear, not to take the commonsense approach and move in a single stroke to a well-designed single-payer system that would benefit everyone, as described in H.R. 676.

As you read about alternative proposals to Improved Medicare for All, determine whether they accomplish three critical aspects. Do they:

Guarantee universal coverage to all Americans?

Protect against unaffordable deductibles and copayments that delay care?

Eliminate hundreds of billions of dollars in wasteful administrative overhead?

Any proposals that fail to accomplish these three goals are inadequate.

Some say the political will to fully improve and expand Medicare simply isn’t there, so we need to compromise on an achievable policy. Our choice is between a good policy, which has been proved to work in every other industrialized nation, or halfway measures that may chip at the edges but leave us as the world’s most expensive health care system and with the worst results. We must insist on the best policy, and change the politics. It’s just the common sense, correct thing to do.

Dr. George Bohmfalk practiced neurosurgery in Texas before retiring to spend half of each year in the Roaring Fork Valley. He is active in Physicians for a National Health Program, a physician-driven group advocating for a single-payer health care system.

https://www.aspentimes.com…

Out-of-network risk is increasing in the individual market

To Infinity and Beyond: Exposure to Out-of-Network Bills Is High and Rising in the Individual and Small Group Markets

Robert Wood Johnson Foundation, October 4, 2018

The threat to consumers posed by bills from out-of-network (OON) health care providers is an issue that has been gaining prominence lately, with coverage from the media and growing policymaker interest.

With the growing use of managed care plan designs and narrow networks, OON coverage is becoming increasingly rare. This tendency is more pronounced in the fully insured market. In the individual market in particular, there has been a steep decline in the percent of plans that offer OON coverage, from 58 percent in 2015 to 29 percent in 2018. The decline in the small group market has been far less sharp, and probably tracks more closely to what is happening in larger employer plans. Part of the difference in the two segments reflects patterns in carrier participation in the individual market. National commercial carriers, which are more likely to offer broader network plans, exited the individual market in droves in 2016 and 2017, leaving a market that is dominated by Blues and Medicaid-managed care organizations (MMCO). MMCO plans almost always offer closed-network plans, and even many Blues plans have shifted to narrow network offerings in the individual market.

High Deductibles

The share of plans with OON benefits has declined, and so has the comprehensiveness of those OON benefits that are offered. In about 95 percent of individual and small group plans with OON benefits, the deductible must be met before there is any cost-sharing. OON deductibles are generally high, particularly in the individual market, where the median OON deductible is approximately $12,000. In about 30 percent of individual market plans with OON coverage, the deductible is greater than $20,000. The small group market is quite different, with a median deductible of about $6,000 and virtually no deductibles higher than $20,000.

Infinite Maximum Out-of-Pocket

After the deductible is met, cost-sharing usually takes the form of 50 percent co-insurance. This generally continues until the maximum out-of-pocket (MOOP) limit is reached. For ACA plans, the MOOP for in-network coverage is capped at $7,350 for individuals, and at about $14,700 for families. Yet for OON benefits, there is no such limit. In fact, about one-third of individual marketplace plans have no dollar amount for the MOOP, meaning that cost-sharing can continue basically forever once the deductible is reached. For plans that do have dollar limits, they are high. The median for the individual market is close to $19,000. In the small group markets this is much less common, as only 8 percent of plans with OON benefits have no MOOP limit. Median out-of-pocket maximums for plans with dollar limits are about $15,000 in the small group market. 

OON bills are a source of concern to consumers, and a recent study showed that approximately 20 percent of hospital visits among patients with large group coverage resulted in an OON bill. In the case of medical emergencies, the ACA requires that OON care is reimbursed at in-network rates, although depending on state law, providers may still “balance bill” patients. Consumers with plans in the individual and small group markets have a high level of exposure to these charges. Narrow networks increase the likelihood that providers are out of network. Many plans in the small group market and most plans in the individual market do not have any OON coverage at all, and for those that do, the coverage tends to be very minimal, leaving consumers with a lot to lose in the event of an unpleasant surprise.

https://www.rwjf.org…

***

Comment:

By Don McCanne, M.D.

One of the most important reasons for enactment of the Affordable Care Act was the inadequacy of plans offered in the individual insurance market. Though some of the deficiencies were corrected, such as ensuring availability of coverage for individuals with pre-existing medical conditions, it is not the nature of the insurance industry to forgo opportunities to improve the business model of their insurance products. This report on what has happened in the individual insurance market since the implementation of ACA should raise alarms.

With an emphasis on controlling access to care by establishing narrower networks of health care providers, the insurers have reduced coverage provided for care obtained outside of the networks. As recently as 2015, 58 percent of individual plans offered coverage for care obtained outside of networks. This year that has declined to only 29 percent. If there is out-of-network coverage the average deductible is about $12,000 and for about 30 percent of the plans it is over $20,000. Since out-of-network care is often unavoidable, the potential financial exposure can be very great in spite of the effort of some states to regulate such exposure.

The Affordable Care Act did place limits on the maximum out-of-pocket costs to which enrollees in exchange plans would be exposed, but this maximum may not apply to care obtained out-of-network. Some individual plans do have a maximum on out-of-network out-of-pocket costs though the average maximum is about $19,000. The majority of individual plans do not have an out-of-pocket maximum and thus cost sharing can continue forever. Thus this coverage would be inadequate for a majority of individuals who had to obtain a significant portion of their care out-of-network.

It is not in the nature of the private insurers to find ways to remove financial barriers to care for patients. Quite the opposite. To meet their own business goals, they increase barriers. After the implementation of ACA we have seen an increase in the use of narrow networks and higher deductibles. If we find ways to reduce the negative impact of these policies on patients, the insurance industry, as masters of innovation, will find more ways to avoid paying for health care. In a way it is our fault because we have allowed our elected representatives to keep these people in charge.

Suppose we had a well designed, single payer national health program – an improved Medicare that covered everyone. Networks designed to limit access would not exist. High deductibles designed to erect financial barriers to care would not exist. Unlimited out-of-pocket spending would not be a problem since costs for essential health care services would be fully covered. Public programs are designed to serve patients whereas private programs are designed to serve business interests.

Again, insurer innovation since full implementation of ACA has been detrimental, as this report shows, and further detrimental innovation is inevitable as long as we leave the private insurance industry in charge. Instead of continuing with our relatively feeble efforts to try to level the playing field, let’s establish our own level field supervised by our own public stewards.

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