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Enhancing the benefits of traditional Medicare

Enhancing the benefits of traditional Medicare

Medicare Benefit Redesign: Enhancing Affordability for Beneficiaries While Promoting Choice and Competition

By Cathy Schoen, Karen Davis, Christine Buttorff, and Amber Willink
The Commonwealth Fund, October 24, 2018

Abstract

Issue: Out-of-pocket expenses are capped for enrollees in Medicare Advantage (MA) plans but not for beneficiaries in traditional Medicare, which also requires a high deductible for hospital care. The need for supplemental Medigap coverage adds to traditional Medicare’s complexity and administrative costs. Shortfalls in financial protection also make it difficult to offer traditional Medicare as a choice for people under age 65, as some have proposed.

Goals: Describe alternative benefit designs that would limit out-of-pocket costs for traditional Medicare’s core services, assess their cost, and illustrate financing mechanisms.

Methods: Analysis of a $3,500 ceiling on annual out-of-pocket expenses for Parts A and B benefits and options for replacing Part A hospital cost-sharing with a $350 or $100 copayment per admission.

Key Findings: Estimates of the costs of the reforms are $36–$44 per beneficiary per month, assuming no behavioral or supplemental coverage changes. This could be financed by a $9–$11 increase in premiums combined with a 0.3-to-0.4-percentage-point increase in the Medicare payroll tax (split between employer and employees). Medicaid costs would decrease, while employers, retirees, and Medigap enrollees would see reduced premiums.

Conclusion: The reforms would improve affordability and put traditional Medicare on a more equal footing with MA plans. They would also make it easier to open traditional Medicare to people under age 65.

From the Conclusion of the Full Report

Implementing a ceiling on liability for traditional Medicare’s benefits would provide greater financial protection to people covered by Medicare only, while also reducing the costs of supplemental coverage for other beneficiaries — making all better off. If financed by a mix of premiums and payroll taxes, the savings from these reforms could be substantial. Because we did not offset the costs of an out-of-pocket limit with increased cost-sharing for other services, such an approach could gain beneficiaries’ support and make it possible for many to rely on Medicare alone for their health care coverage needs.

Improving Medicare’s core benefit design also could make it easier to offer Medicare as a coverage option to people under age 65 who are not eligible for the program. The marketplace for individual coverage nationwide is currently plagued by risk selection, premium instability, and the withdrawal of private insurers. Many markets also lack affordable plan choices: prices paid by private plans to hospitals and physicians for care continue to increase at rates much faster than Medicare, driving up premiums.

One option for ensuring more affordable plan choices to people under age 65 would be to offer an improved traditional Medicare plan in the private insurance market. Such a plan also could be offered in the small-group market. Medicare has the strong advantages of low administrative costs and broad provider networks. Improving traditional Medicare thus could help stabilize the insurance market for those seeking individual coverage or small-employer groups who are not yet eligible for Medicare. This could be especially attractive to older adults who are preparing for coverage under Medicare when they retire.

A viable Medicare option in the individual and small-business markets with predictable and affordable benefits would put pressure on private plans to generate value for the coverage they offer. A further step would be to require Medicare Advantage insurers to offer plans in individual marketplaces where they have substantial networks, bringing both their provider networks and ability to pay providers at near-Medicare rates. The enhanced leverage in negotiating provider payment rates, given the alternative of using Medicare provider payment rates for in-network and out-of-network providers, would help counter rising health care prices and costs.

A better Medicare benefit package, therefore, is an investment in more affordable coverage as well as lower health care costs across insurance markets. Not only would it ensure that beneficiaries can access the care they need, it also would simplify coverage choices and remove waste from the health system.

https://www.commonwealthfund.org…

Issue Brief (PDF):
https://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

The Abstract defines the issue covered in this report: “Out-of-pocket expenses are capped for enrollees in Medicare Advantage (MA) plans but not for beneficiaries in traditional Medicare, which also requires a high deductible for hospital care. The need for supplemental Medigap coverage adds to traditional Medicare’s complexity and administrative costs.”

Simply stated, the marketing appeal of the private Medicare Advantage plans (MA) is that Congress and HHS have used our tax funds to pay the private MA plans enough extra so that they can cap the out-of-pocket costs and sharply reduce or eliminate the cost sharing – deductibles and coinsurance. If Congress truly believed in fairness and competition, then for the traditional Medicare program they would reduce the cost sharing requirements and place a cap on out-of-pocket spending. Why should we pay taxes for extra benefits for those in the MA plans, benefits that we are deprived of?

The differences are great enough such that those enrolled in traditional Medicare must obtain a Medigap plan, especially because of the potential for catastrophic losses (unless they have other additional coverage such as dual Medicaid coverage or a retiree plan). When we already have egregiously excessive administrative costs and complexity, why should we increase our administrative waste by adding another superfluous private plan – Medigap. Besides, if traditional Medicare had the same support as the private MA plans, then there would be no reason to have to put up with the narrow networks and extra administrative waste of the private plans.

For those who would like to see the addition of the choices of lowering the age for Medicare eligibility, or buying into Medicare, then it is almost imperative that a cap be established and cost sharing adjustments be made, otherwise the out-of-pocket costs would create too great of a financial burden for the new Medicare enrollees.

Incrementalists should be doing all they can to improve the traditional Medicare program if they truly believe in a Medicare buy-in or in lowering the age of Medicare eligibility. Those who wave the banner of Medicare for All but actually support incremental steps should be front and center in support of the proposals here.

That said, those of us who understand that incremental approaches are inadequate because they unnecessarily prolong suffering and financial hardship for those whose reforms are postponed until some unspecified future date, should continue to fight for uncompromising reform. An improved Medicare should eliminate all cost sharing and, instead, be fully funded through equitable tax policies. The other policies of the PNHP model of single payer reform also should be enacted and implemented as soon as possible.

It has been over fifty years since completing the first incremental step of enactment of Medicare with the intent of expanding it soon thereafter. Half a century! What moral basis is there for continuing on the incremental pathway when people are facing bankruptcy or suffering physically or even dying, when all we have to do is immediately take that last giant step to health care nirvana – enacting and implementing a well designed, single payer, improved Medicare for All?

For you incrementalists, Cathy Schoen and her colleagues are shining the light on the moral pathway to reform. But please excuse us when we pass you on the way there as we move forward immediately toward the full package of reform. We don’t want to stop you in case we stumble temporarily, but likewise we hope you’ll join us when you see that we are well on our way there. In fact, why delay? Join us now. We’ll get there faster.

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Why a National Health System Is Needed to Slow the Opioid Crisis

By Michael Corcoran
Truthout, October 25, 2018

It is widely expected that by Election Day Donald Trump will sign the Support for Patients and Communities Act or opiate bill (H.R.6), that was finalized by Congress on October 3. There will surely be fanfare when the bipartisan bill — passed 99-1 in the Senate — is signed into law. The opioid crisis kills 115 people a day and has touched Americans everywhere. The Mayo Clinic calls it the “most important and most serious public health crisis” today. “We’ve stepped up to the plate,” boasted Sen. Shelley Moore Capito (R-West Virginia), seemingly pleased she could tell her voters that Congress took action.

The reality, however, is that the bill is woefully insufficient given the scale of the problem, according to a strong consensus of public health advocates. There are valuable provisions, but it is largely, as Rep. Peter Welch (D-Vermont) lamented, “a very energetic effort to pretend we’re doing something significant.”

The bill largely focuses on “supply side” enforcement. This includes an effort to stop fentanyl, the potent opiate that has caused a sharp spike in overdoses, through law enforcement and interdiction. It also encourages the development of non-opioid pain medications and launches a competitive grant-based pilot project for people transitioning to independent living.

The legislation also raises the cap on how many patients a doctor can prescribe an important treatment. Most doctors who are trained to prescribe buprenorphine (Suboxone) are limited to 100 patients, but under the new law, they could have 275. Medicare will also now cover methadone. In the past, methadone was not covered because it isn’t usually dispensed in a retail pharmacy, a requirement for Medicare Part D.

Many of these reforms are welcome, advocates say, but the bill does not do enough to expand treatment for people who need help now.

“The bottom line is, we need people to be alive if we want to help them,” said Nancy Nielsen, senior associate dean of health policy at the University of Buffalo, in an interview with Truthout.

Why Medication-Assisted Treatment Matters

Methadone and buprenorphine are considered the most effective treatments for chronic opiate abuse disorder. The medications are “partial opiate agonists,” meaning they do, like any opiate, bind to opiate receptors. The medication does not, however, provide euphoric effects for opiate-tolerant individuals. It also binds so strongly to receptors that it serves to block or minimize the effect of full opiates like heroin or oxycodone.

There is widespread consensus among public health experts that these medications are the most effective treatment for chronic opiate abuse. Evidence supporting the use of the medications are found in clinical guidelines and reports from the Substance Abuse and Mental Health Services Administration, the National Institute on Drug Abuse, and the Centers for Disease Control and Prevention, among others. Methadone and buprenorphine are especially important during an overdose epidemic since they can lower mortality rates by between 66 percent and 80 percent, as reporter Zach Siegel outlined at Slate. “We know how to treat opioid addiction,” he said, “but our antiquated conceptions of addicts prevent us from doing so.”

Advocates insist that making these medications available should be central in response to the crisis, and the new opiate bill falls far short of what is needed.

“We have treatment that works. The priority should be making it so anyone who wants help can go see a doctor or an ER and get on medication-assisted treatment,” said Bruce Trigg of the Harm Reduction Coalition. “We know of ways to help make this happen but Congress is not thinking big, not wanting to spend money.” The opiate bill has not been scored by the Congressional Budget Office, but the Senate version contained about $8 billion in new spending.

In a sense, this disappointment was inevitable. This is the United States: health care is a commodity, patients are “consumers.” It would be inconsistent to solve the grave opioid crisis by providing widespread coverage for vulnerable populations. A public, government-led expansion of care is a nonstarter for most of the GOP. There are an increasing number of Democrats embracing these policies, especially in the House. But the 115th Congress is still a very conservative body controlled by politicians who have been hell-bent on taking health care away from Americans.

After all, if enough members of Congress cared about moral, humane health policy, the US would probably already have a universal, national health system that was designed to put patient needs first. The US doesn’t have a health care “system” so much as a jumbled mess that makes a coherent national response to the opioid crisis essentially impossible. This is something advocates of a single-payer system point out.

“Single-payer makes health care about the patients. Our health system currently has nothing to do with patients. It is all about profit,” Trigg said.

Indeed, this crisis is very much rooted in greed. Pharmaceutical companies have been lobbying to make sure they are taken care of in the final bill. This profit motive is a major reason why the drug industry helped start (and is still profiting from) the epidemic. Under a single-payer Medicare for All system, which is supported by 70 percent of the country, the incentives would be different.

“In theory, you could have a single-payer system that negotiates drug costs but continues to allow pharma to market directly to patients [and] pay off and deceive physicians,” said Benjamin Day, director of Healthcare-NOW, in an interview with Truthout. “But, there’s a reason you don’t actually see that anywhere in the world — once you have a single-payer system, any policies that actually make people sicker you have to pay for down the road, so such systems naturally create incentives for preventive care and policies.”

In fact, the opiate crisis is a very “American problem,” as the BBC notes. In Europe, where health care is a right under international treaties, the opiate problem is not nearly as bad. The US has around 4 percent of the world’s population but about 27 percent of the world’s drug overdose deaths, according to the United Nations Office on Drugs and Crime. Notably, the US is also one of only two countries that allow prescription drugs to be advertised on television.

DrugChart2018

You will find more infographics at Statista.

Canada has a serious opiate problem, but not as extreme as in the United States. Interestingly, in Canada socialists have been trying to help, in part, by creating (sometimes unsanctioned) injection sites and building solidarity. Both countries have relatively weak welfare states and high inequality. (Canada’s health care system is understandably praised by Americans, but Canadian advocates note that the Canadian system is the only universal health care system without drug coverage.)

Federal Government Lags Behind

Overhauling how we finance health care is not the only change that must be made to confront the opioid crisis. There are many valuable tactics being used by county and state officials that help. But the tools are largely being ignored at the federal level and are largely absent in the new bill, Trigg said.

Some hospitals, for instance, will now offer patients medication-assisted treatment if they go into an emergency room for an opiate-related issue, such as an overdose or a withdrawal. Patients who come in with an overdose are also of a great deal of importance since about 7 percent of overdose survivors die within a year.

“We have these people who need help in the door, for whatever reason, and for years we have been tossing them to the street,” Trigg said. “It just doesn’t make any sense. They go out and within a year many of these people are dead.”

Nielsen notes that she is involved in a program in Buffalo that offers similar services. “Someone comes into the emergency room — might have been an overdose or an abscess or any number of things — and if they want help we have 13 hospitals that will give them a prescription that day,” Nielsen said. The program provides training to help doctors get waivers as well.

Some jails and state prisons have been increasingly offering various forms of medication-assisted treatment, though, of course, not nearly enough of them. Rhode Island is currently the only state prison system to offer all three of the major medications (buprenorphine, methadone and naltrexone) to prisoners, Trigg said. He noted that the federal prison system, in particular, offers very few opportunities for medication-assisted treatment (as Mike Ludwig has ongoingly reported for Truthout). Medical neglect is especially rampant in the world of corrections and law enforcement, and a lack of access to medication-assisted treatment is no exception.

“It is a wasted opportunity. You have all these vulnerable populations in these jails. Most of them probably don’t deserve to be there, but while they are there we should at least offer them treatment,” Trigg said.

The United States jails more people per capita than any other country on the planet, and 65 percent of prisoners fit the criteria for substance abuse disorder. Yet only 11 percent are given treatment (and those treatment options are often very limited). Outside of prisons, only 22 percent of people who qualify for the clinical definition of substance abuse disorder treatment receive treatment. Though not all of that is due to lack of treatment options, the most common reason for not getting treatment is cost (cited by 39 percent), according to a survey from the National Survey on Drug Use. A 2017 study published in the Annals of Family Medicine found that about 60 percent of rural counties in the United States (where much of the epidemic is located) don’t have a single physician who has a DEA [Drug Enforcement Administration] waiver to prescribe buprenorphine.

People on probation or parole may be denied treatment (or forced to taper off medication) by their probation officers, a practice which may violate discrimination laws aimed at protecting those with mental illness, according to the Legal Action Center. Congress has done nothing to eliminate these obstacles.

Constant Barriers Push People Away From Treatment

Eliza Tartell is a single mother of one who lives in Cape Cod and knows these kinds of barriers all too well. The area she lives in has been hit especially hard by the ongoing overdose crisis. It was called a “shoreline of addiction” by the Guardian as recently as May and the subject of a documentary as well. Tartell has been living with opioid abuse disorder and PTSD for much of her life, and she wants help.

Despite being insured and living in Massachusetts, a state that has more access to evidence-based treatment than most, Tartell tells Truthout she has continually been denied and/or dismissed when trying to get buprenorphine treatment for a variety of reasons. One time she was not given treatment due to a pregnancy (denying medication-assisted treatment based on pregnancy conflicts with protocols made by the American Society of Addiction Medicine).

“I’ve been sent away so many times because the doctor has too many patients,” said Tartell in an interview with Truthout. “I [have] had to commute hours and hours for weekly treatments that were nearly impossible…. I have been denied care because of my psych meds.”

Most recently, she dealt with two closures of outpatient suboxone programs at Arbour, the largest for-profit mental health provider in the state, within one year. She tried to transition into a different facility in Cape Cod, but they closed their outpatient program as well. Another provider refused to help her because of the medications she takes for anxiety and PTSD. After these denials, Tartell was left feeling panicked and overwhelmed with fear and frustration.

“My options were relapse or hospitalization, and I have a kid I need to take care of.” she said.

Out of reasonable options, she says, Tartell was forced to go off her medication and is attempting to stay off opiates without medication-assisted treatment. This is risky. “Retention in methadone and buprenorphine treatment is associated with substantial reductions in the risk for all cause and overdose mortality in people dependent on opioids,” concluded a study in the BMJ from 2017.

Doctors’ hesitancy to treat people on benzodiazepines (anxiety medication) may well be guided by a 2016 FDA warning that urged caution when mixing these drugs and medication-assisted treatment. But they have since updated that warning as evidence showed refusing treatment to these patients is significantly more dangerous than co-treating patients with both medications (which increases risk of respiratory depression but not in a statistically significant way, according to the FDA’s follow-up advisory). “The dangers associated with failing to treat an opioid use disorder can outweigh the risks of co-prescribing MAT [medication-assisted treatment] and benzodiazepines,” the FDA concludes.

In fact, only 322 deaths were reported to involve buprenorphine in 2014, despite the sinister media coverage of the drug, including The New York Times’s infamous “Treatment With a Dark Side,” article in 2013.

“My biggest regret as a doctor was, when I started prescribing buprenorphine 10 or 12 years ago I used to tell people with anxiety medication in their system to clean their system out and come back,” Trigg said. “But some of those people will never come back once you show them the door. And some of them will die.”

In some parts of the country, lower-income people face a massive barrier to ongoing medication-assisted treatment: 11 states have lifetime caps after which Medicaid stops paying for medication-assisted treatment after one or two years. In some states prior authorization may enable the treatment to continue — another barrier.

Given the nature of the treatment, time limits are a critical problem. The FDA’s guidelines instruct that “patients may require treatment indefinitely and should continue treatment for as long as they benefit and as long as the use of [medication-assisted treatment] contributes to their intended treatment goals.”

Sadly, the bill that Congress has passed, and which Trump is expected to sign soon, does very little to help Tartell and others in her situation. Even the best parts of the bill have limited utility, Trigg notes.

“It is great to allow doctors to see more patients and prescribe them medication,” he said. “But that doesn’t help if doctors are not getting trained, getting the waivers and taking these patients. And a lot of doctors don’t want these patients. The care can be costly, high-maintenance and more time-consuming.”

The Affordable Care Act mandates mental health and addiction as Minimum Essential Benefits, but it gives each state wide latitude to determine what coverage means. Some states cover medication-assisted treatment, others do not. Some states have lifetime caps or dosage limits and others do not. Some states cover inpatient detox, but not counseling. Other states do the reverse.

“The system is just so complicated. There are federal rules and restrictions and some states add their own, more strict regulations,” Trigg said, noting that medication should be easily accessible to all who need it.

If the US implemented an integrated, universal health care system, someone like Tartell would be in much better shape. When her treatment center closed, it was a decision made for financial reasons to serve the interests of board members of Arbour’s parent company who were located hundreds of miles away in central Pennsylvania. If patients were a priority over profits, this is not how business would be done, and Tartell would be less likely to keep running into (very sudden) closures.

Of course, even with a single-payer system that put patients first, there are still barriers created by stigma — from providers, from the community, and even from some aspects of the recovery community. So, a push toward national health care reform must also include efforts to educate providers, families and communities about ending stigma.

Lessons in Clinical Neglect and Human Folly

The medical term “iatrogenesis” describes a scenario in which injury or illness occurs because of medical care. It is from the Greek, meaning “brought forth by the healer.”

“It is a great word to describe the crisis,” Trigg said. “Drug companies, providers, physicians, policymakers — there is a lot of blame to go around.”

Indeed, the term can be used accurately to describe many historical efforts at practicing medicine. Until the 19th century, there was near-global consensus in favor of Humorism — a practice that involved bleeding patients to maintain the right balance of, “blood, phlegm, yellow bile and black bile.” This nonsense was the mainstream treatment for 2,000 years and not discarded entirely until the mid-19th century. It led to widespread bloodletting as treatment for countless ailments.

Humorism died in the 19th century as the scientific revolution occurred. But the fact that this pseudoscience survived two millennia should humble us all. Humanity is capable of wide-scale clinical negligence. In many ways, the US approach to the opiate crisis is more negligent because, unlike the doctors who practiced bloodletting in the 15th century, we have a solid grasp of the science of opiate abuse disorder and how to treat it. But the greed inherent in the market-based health care system of our capitalist society has many policymakers and providers ignoring evidence.

The federal government’s weak response to the opioid crisis is a sad contemporary example of this folly. More than that, it reflects one of the US’s true national tragedies: its lack of a national health system that prioritizes patients above all else. So long as greed is at the heart of American medicine, the country will face more tragedies like this opiate epidemic.

https://truthout.org…

Council of Economic Advisers brings out the socialist scarecrow

What Could Kill Booming U.S. Economy? ‘Socialists,’ White House Warns

By Binyamin Appelbaum and Jim Tankersley
The New York Times, October 23, 2018

Karl Marx. Vladimir Lenin. Mao Zedong. Elizabeth Warren?

The White House Council of Economic Advisers on Tuesday published a 72-page report criticizing what it described as the socialist ideas of leading Democratic Party politicians, and seeking to link President Trump’s political rivals with figures reviled by most Americans.

The document departs from the council’s long tradition of delivering sober, albeit partisan, studies on current questions confronting economic policymakers, such as the value of tax cuts or the effects of increased corporate concentration. Instead, the report seeks to tar Democrats by linking them with the failed economic policies of communist governments in China, the Soviet Union and other countries.

The word “socialism” appears 144 times — on average, twice a page.

In case the point was lost on anyone, the message was driven home by a follow-up release from the White House press office with the headline “Congressional Democrats Want to Take Money From Hardworking Americans to Fund Failed Socialist Policies.”

“There are proposals on the table, like the ‘Medicare for All’ proposal, that are very consistent with the design of socialism,” Kevin Hassett, the chairman of the council, told reporters during a conference call to discuss the report on Tuesday.

https://www.nytimes.com…

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The Opportunity Costs of Socialism

The Council of Economic Advisers, October 2018

From the Introduction

The Nordic and European versions of socialized medicine have been viewed as so desirable by modern U.S. socialists that they have proposed nationalizing payments for healthcare — which makes up more than a sixth of the U.S. economy — through the recent “Medicare for All” proposal. This proposal would create a monopoly government health insurer to provide healthcare for “free” (i.e., without cost sharing) and to centrally set all prices paid to suppliers such as doctors and hospitals. We find that if this policy were financed out of current Federal spending without borrowing or tax increases, then more than half the entire existing Federal budget would need to be cut. If it were financed through higher taxes, GDP would fall by 9 percent, or about $7,000 per person in 2022. Evidence on the productivity and effectiveness of single-payer systems suggests that “Medicare for All” would reduce longevity and health, particularly among the elderly, even though it would only slightly increase the fraction of the population with health insurance.

(For details on Medicare for All, use the link to access the section, “Socialized Medicine: The Case of Medicare for All,” pages 39-53.)

Report – The Opportunity Costs of Socialism:
https://www.whitehouse.gov…

Council of Economic Advisors – Staff:
https://www.whitehouse.gov…

***

Comment:

By Don McCanne, M.D.

No authorship is claimed for this document other than that it is a product of President Trump’s Council of Economic Advisers (CEA). It does seem to represent the conservative ideology of some of the prominent members and staff of the CEA. Specifically, it attacks as socialism the Medicare for All proposal that has become quite popular. It seems to be timed to suppress the vote for the candidates in the forthcoming midterm election who support the Medicare for All concept.

You should be prepared to hear from some of our conservative or libertarian politicians the highly biased rhetoric contained in this document.

They claim that the taxes required to finance Medicare for All would cause the GDP to drop by 9 percent. But under the PNHP model of an improved Medicare for All, the total spending would be about the same as it is now, and the volume of services also would be about the same since any additional care required for unmet needs would displace care that is of little benefit, simply because of the capacity limits of the system. The claim that diverting resources to health care suppresses the economy is without merit since health care is a robust sector of our economy. There should be no negative impact on the GDP.

They label Medicare for all as a monopoly when most economists consider it to be a monopsony – serving as a buying agent benefiting patients.

The report also claims that there is an opportunity cost (inability to use funds elsewhere) of paying the taxes required to fund Medicare for All. But the collective amount that we will be paying in taxes is no more than we are already paying in public and private funds, so there is no additional opportunity cost. If there were no taxpayer funded program and we instead were paying directly for health care, there would still be the same opportunity cost of not being able to spend those funds elsewhere.

In the full report, they make some preposterous statements designed to dismiss the benefit of recovering the hundreds of billions of dollars in our current administrative waste. By denying that, they are also, in effect, denying that we would be receiving greater value in our health care spending since that waste would be redirected to beneficial health care services.

Probably the most outrageous claim of all is that they say that Medicare for All would reduce longevity and health, particularly among the elderly. But our seniors would be receiving more and better services under a more efficient financing system. How could they claim that that would impair health and shorten life?

How many times do we have to say it? Can’t we just do away with the divisive politics and get down to the policy issues that would benefit all of us – like affordable health care for everyone? It’s really very simple, not to mention that it would place us on the moral high ground.

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Today’s Republicans overlook conservative case for universal health care

They hesitate to state their views even though it's an idea consistent with conservative principles – respect for tradition, Judeo-Christian values, sanctity of life and individual freedoms.

By Daniel C. Bryant, M.D.
Portland (Maine) Press Herald, October 24, 2018

A May Maine Voices column that I co-authored discussed a poll of Maine gubernatorial and Cumberland County legislative candidates’ health care policies. No Republicans had responded. In a Sept. 17 letter, Barry Salter, M.D., wrote that Republican gubernatorial candidate Shawn Moody had not attended the Maine Medical Association annual meeting, while the other candidates had. On his website, Mr. Moody devotes to health care less than 20 percent of the space the other candidates do.

Why do Republicans seem so reluctant to state their views on such a vital issue, especially when an idea consistent with conservative principles – respect for tradition, Judeo-Christian values, business, sanctity of life, individual freedoms – is out there: government-funded, privately provided universal health care (Medicare for all)?

Prominent conservatives have accepted government responsibility for health care since at least the 1880s, when Chancellor Otto von Bismarck established universal health insurance in Germany as a way to stimulate the economy and resist socialism.

In 1944, economist Friedrich von Hayek, one of House Speaker Paul Ryan’s heroes, wrote that there is not “any reason why the state should not assist individuals in providing for those common hazards of life against which, because of their uncertainty, few individuals can make adequate provision. … There is no incompatibility in principle between the state providing greater security in this way and the preservation of individual freedom.” Winston Churchill included in the 1945 Conservative Party General Election Manifesto: “We propose to create a comprehensive health service covering the whole range of medical treatment from the general practitioner to the specialist.”

Ronald Reagan wrote in 1979, “I have always felt that medical care should be available to those who cannot otherwise afford it,” and proceeded to expand Medicare. A 1989 Heritage Foundation report stated that “all citizens should be guaranteed universal access to affordable health care,” and a goal of the 2016 Republican platform was “to ensure that all Americans have improved access to affordable, high-quality health care.”

That platform also emphasized “our country’s Judeo-Christian heritage.” The Bible gives healing of the sick top priority, from “I (God) will take sickness away from the midst of thee,” to Jesus’ granting his disciples power “to heal all manner of sickness,” to the “Go and do likewise” instruction of the Good Samaritan parable. Given Scripture’s importance to Republicans, they have good reason, if not the moral imperative, to act on it any way they can.

Warren Buffett argues for a government-funded, privately provided system because of the drain (“tapeworm“) that health insurance puts on American business, and his (Republican) business partner Charlie Munger told Yahoo Finance that he’s for it because of the waste and profiteering he sees in our present system.

MCS Industries CEO Richard Master and other members of the Business Initiative for Health Policy believe that “it is crucial to build a political movement behind Medicare for All, with candidates who are willing to take on the insurance and pharmaceutical industries’ oversized political influence.” In other words, business leaders advocate for a system in which health care no longer distorts competitiveness.

“Lack of health insurance is associated with as many as 44,789 deaths per year in the United States,” a 2009 study found. To support government-guaranteed universal health care, then, is to affirm the sanctity of life.

Such a system would free workers from a drag on raises as well as from the dependence on workplace health benefits that discourages workers from taking more rewarding jobs or becoming entrepreneurs themselves. It would free some of the uninsured, who are limited by illness, to enter the workforce. It would free patients from restrictive networks, and their providers from complex billing and restrictions on treatment plans. Freedom, in fact, is what this system, like conservatism itself, is all about.

Let’s hope that in the future, Republican candidates will be more forthcoming about their health care positions. Support of a government-funded, privately provided universal health care system would certainly be consistent with many conservative principles.

https://www.pressherald.com…

Half of registered Republicans now support providing Medicare to every American

Majority of Republicans supports 'Medicare for all,' poll finds

By Julia Manchester
The Hill, October 22, 2018

More than half of Republicans in a new American Barometer poll say they support “Medicare for all,” also known as a single-payer health-care system.

The survey, conducted by Hill.TV and the HarrisX polling company, found that 52 percent of Republicans polled said they supported the option, while 48 percent said they opposed it.

Twenty-five percent said they “strongly” supported “Medicare for all,” while 27 percent said they “somewhat” supported it.

Twenty-two percent said they “somewhat” opposed the idea, while 26 percent said they “strongly” opposed it.

The poll comes as Democrats aim to make health care, along with “Medicare for all,” a central campaign issue.

Reid Wilson, campaign reporter for The Hill, told Hill.TV’s Joe Concha that Republicans have yet to find their messaging on the issue.

“Republicans are only beginning to think about how to message this. So this is not baked in at all. This is a debate that plays out over the long term,” he added.

The American Barometer was conducted on October 19-20 among 1,000 registered voters. The sampling margin of error is 3.1 percentage points.

https://thehill.com…

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Comment:

By Don McCanne, M.D.

The question asked? Would you support or oppose providing Medicare to every American? This is not an ambiguous question.

According to this poll, half of registered Republicans now support Medicare for all (52% with a sampling error of 3.1%). Well over four-fifths of Democrats (86%) and two-thirds of Independents (68%) also are in support.

The support of the Democrats is understandable, but we can only speculate as to what has resulted in the sharp increase in support from Republicans, especially considering the intensity of political polarization in this nation. It is likely that Republican and Independent voters are quite dissatisfied with the status quo in health care financing, and that they have grown weary of the Republican politicians who have continued to call for the repeal of Obamacare, but when it came time to perform with a replacement program, they came up empty handed. The turning point may well prove to be when Sen. John McCain expressed the will of the American people by turning thumbs down on the empty charade of reform without substance.

Although the voters are aligning themselves in support of Medicare for all, the politicians are not, though the Republicans have latched onto supporting coverage of pre-existing conditions to show the voters that their hearts are in the right place, even if they have not developed any effective policies to implement it should Obamacare be repealed.

People lead, politicians follow. Hopefully the Republican voters will cause their candidates to develop some introspection and seriously consider the greater value that a Medicare for all would bring us – just common business sense – not to mention that the program would be truly universal, equitable, and affordable for all.

The congressional Republicans would have to neutralize the McConnell curse – if the the Democrats are for it, we’re against it – the insane attitude that partisan politics must take precedence over sound policy. It would be easiest if Sen. McConnell could simply experience a revelation. If the Republican voters are loud enough, that just could happen.

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Transforming Section 1332 waivers into ‘State Relief and Empowerment Waivers’

Trump Administration announces State Relief and Empowerment Waivers to give states the flexibility to lower premiums and increase choices for their health insurance markets

The Centers for Medicare & Medicaid Services (CMS), October 22, 2018

Today, the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of the Treasury (collectively, the Departments) issued new guidance so states can move their insurance markets away from the one-size-fits-all rules and regulations imposed by the Affordable Care Act (ACA) and increase choice and competition within their insurance markets. The new guidance grants states more flexibility to design alternatives to the ACA and to give Americans more options to get health coverage that better meets their needs. Under this new policy, states will be able to pursue waivers to improve their insurance markets, increase affordable coverage options for their residents, and ensure that people with pre-existing conditions are protected. These waivers are called State Relief and Empowerment Waivers to reflect this new direction and opportunity.

“The Trump Administration inherited a health insurance market with skyrocketing premiums and dwindling choices,” said CMS Administrator Seema Verma. “This is a new day – this is a new approach to empower states to provide relief. States know much better than the federal government how their markets work. With today’s announcement, we are making sure that they have the ability to adopt innovative strategies to reduce costs for Americans, while providing higher quality options.” 

https://www.cms.gov…

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State Relief and Empowerment Waivers

Federal Register, Scheduled to be published October 24, 2018

Agencies: Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services; Department of the Treasury

Action: Guidance

Summary: This guidance relates to section 1332 of the Patient Protection and Affordable Care Act (PPACA) and its implementing regulations. Section 1332 provides the Secretary of Health and Human Services and the Secretary of the Treasury (collectively, the Secretaries) with the discretion to approve a state’s proposal to waive specific provisions of the PPACA (a State Innovation Waiver, now also referred to as a State Relief and Empowerment Waiver), provided the section 1332 state plan meets certain requirements. The Department of Health and Human Services and the Department of the Treasury (collectively, the Departments) finalized implementing regulations on February 27, 2012. This updated guidance provides supplementary information about the requirements that must be met for the approval of a State Innovation Waiver, the Secretaries’ application review procedures, the calculation of pass-through funding, certain analytical requirements, and operational considerations. This guidance supersedes the guidance related to section 1332 of the PPACA that was previously published on December 16, 2015. Changes include increasing flexibility with respect to the manner in which a section 1332 state plan may meet section 1332 standards in order to be eligible to be approved by the Secretaries, clarifying the adjustments the Secretaries may make to maintain federal deficit neutrality, and allowing for states to use existing legislative authority to authorize section 1332 waivers in certain scenarios. The Departments are committed to empowering states to innovate in ways that will strengthen their health insurance markets, expand choices of coverage, target public resources to those most in need, and meet the unique circumstances of each state. This guidance aims to lower barriers to innovation for states seeking to reform their health insurance markets.

From I. Overview

This guidance intends to expand state flexibility, empowering states to address problems with their individual insurance markets and increase coverage options for their residents, while at the same time encouraging states to adopt innovative strategies to reduce future overall health care spending. Section 1332 of the PPACA permits a state to apply for a State Innovation Waiver (referred to as a section 1332 waiver or a State Relief and Empowerment Waiver) to pursue innovative strategies for providing their residents with access to higher value, more affordable health coverage. The overarching goal of section 1332 waivers is to give all Americans the opportunity to gain high value and affordable health coverage regardless of income, geography, age, gender, or health status while empowering states to develop health coverage strategies that best meet the needs of their residents. Section 1332 waivers provide states an opportunity to promote a stable health insurance market that offers more choice and affordability to state residents, in part through expanded competition. These waivers could potentially be used to allow states to build on additional opportunities for more flexible and affordable coverage that the Administration opened through expanded options for Association Health Plans (AHP) and short-term, limited-duration insurance (STLDI).

The Secretaries will consider favorably section 1332 waiver applications that advance some or all of these five principles as elements of a section 1332 waiver application. The principles are:

* Provide increased access to affordable private market coverage. Making private health insurance coverage more accessible and affordable should be a priority for a section 1332 waiver. A section 1332 state plan should foster health coverage through competitive private coverage, including AHPs and STLDI plans, over public programs. Additionally, the Departments will look favorably upon section 1332 applications under which states increase issuer participation in state insurance markets and promote competition.

* Encourage sustainable spending growth. Section 1332 waivers should promote more cost-effective health coverage and be fair to the federal taxpayer by restraining growth in federal spending commitments. For example, states should consider eliminating or reducing state-level regulation that limits market choice and competition in order to reduce prices for consumers and reduce costs to the federal government, as part of their section 1332 waiver applications.

* Foster state innovation. States are better positioned than the federal government to assess and respond to the needs of their citizens with innovative solutions. We encourage states to craft solutions that meet the needs of their consumers and markets and innovate to the maximum extent possible under the law.

* Support and empower those in need. Americans should have access to affordable, high value health insurance. Some Americans, particularly those with low incomes or high expected health care costs, may require financial assistance. Policies in section 1332 waiver applications should support state residents in need in the purchase of private coverage with financial assistance that meets their specific health care situations.

* Promote consumer-driven healthcare. Section 1332 waivers should empower Americans to make informed choices about their health coverage and health care with incentives that encourage consumers to seek value. Instead of only offering a one-size-fits-all plan proposal, a section 1332 state plan should focus on providing people with the resources and information they need to afford and purchase the private insurance coverage that best meets their needs.

From II. Changes to 2015 Guidance

A major disadvantage of the 2015 interpretation was that it deterred states from providing innovative coverage that, while potentially less comprehensive than coverage established under the PPACA, could have been better suited to consumer needs and potentially more affordable and attractive to a broad range of its residents. For example, even if coverage similar to that made available under the PPACA remained available in a state, an offer of more attractive, but less comprehensive plans would have reduced the number of residents who elected PPACA-like coverage, and would likely have caused the state waiver plan to fail the comprehensiveness guardrail. To avoid this effect of the 2015 guidance, this guidance focuses on the availability of comprehensive and affordable coverage. This shift in focus ensures that state residents who wish to retain coverage similar to that provided under the PPACA can continue to do so, while permitting a state plan to also provide access to other options that may be better suited to consumer needs and more attractive to many individuals.

The coverage guardrail requires that coverage be provided to at least a comparable number of residents as would occur absent the waiver. However, the text of the coverage guardrail provision of the statute is silent as to the type of coverage that is required. Accordingly, to enable state flexibility and to promote choice of a wide range of coverage to ensure that consumers can enroll in coverage that is right for them, this guidance permits states to provide access to less comprehensive or less affordable coverage as an additional option for their residents to choose. This guidance on the coverage guardrail continues to consider the number of state residents who are actually receiving coverage. As long as a comparable number of residents are projected to be covered as would have been covered absent the waiver, the coverage guardrail will be met.

From III. Statutory Guardrail Requirements

A. Comprehensiveness and Affordability

The Departments may consider these guardrails met if access to coverage that is as affordable and comprehensive as coverage forecasted to have been available in the absence of the waiver is projected to be available to a comparable number of people under the waiver. The Departments will not require projections demonstrating that this coverage will actually be purchased by a comparable number of state residents; in other words, these guardrails will be met if the state plan has made other coverage options available that state residents may prefer, so long as access to affordable, comprehensive coverage is also available.

B. Number of State Residents Covered (Coverage)

A section 1332 state plan will be considered to comply with this coverage guardrail if, for each year the waiver is in effect, the state can demonstrate that a comparable number of state residents eligible for coverage under title I of PPACA will have health care coverage under the section 1332 state plan as would have had coverage absent the waiver. For purposes of meeting this guardrail, in line with the Administration’s priority favoring private coverage, including AHPs and STLDI plans, the Departments will consider all forms of private coverage in addition to public coverage, including employer-based coverage, individual market coverage, and other forms of private health coverage.

C. Deficit Neutrality

Under the deficit neutrality requirement, the projected federal spending net of federal revenues under the section 1332 waiver must be equal to or lower than projected federal spending net of federal revenues in the absence of the section 1332 waiver.

https://s3.amazonaws.com…

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Comment:

By Don McCanne, M.D.

Section 1332 of the Affordable Care Act authorizes the states to apply for waivers to modify health plans offered through their insurance exchanges as long as they still meet certain specifications that fulfill the intent of the legislation. Now the Trump administration wishes to reduce federal regulatory oversight of the exchange plans with the ideological goal of allowing states to “increase choice and competition within their insurance markets.”

They plan to do that by using the “Guidance” released today. Wading through their regulatory jargon, their intent is made clear by this statement: “… in line with the Administration’s priority favoring private coverage, including AHPs (Association Health Plans) and STLDI plans (short-term, limited-duration insurance), the Departments will consider all forms of private coverage in addition to public coverage, including employer-based coverage, individual market coverage, and other forms of private health coverage.”

The perilous deficiencies of AHPs and STLDI plans have provoked concerns, but the administration apparently has been tone deaf to these concerns. They state that it remains their priority to favor private coverage, including these deficient insurance products.

According to the Guidance, “the Departments have determined that the analysis of comprehensiveness and affordability of coverage under a waiver should focus on the nature of coverage that is made available to state residents (access to coverage), rather than on the coverage that residents actually purchase” and “this guidance permits states to provide access to less comprehensive or less affordable coverage as an additional option for their residents to choose.” As they repeatedly state, it’s all about access (to insurance products, not health care).

Also, “the Departments will consider the longer-term impacts of a state’s proposal, and may approve a waiver even where a state expects a temporary reduction in coverage but can demonstrate that the reduction is reasonable under the circumstances, and that the innovations will produce longer-term increases in the number of state residents who have coverage such that, in the aggregate, the coverage guardrail will be met or exceeded over the course of the waiver term.” They will approve waivers that reduce the number of insured, in exchange for a promise (a la Trump) that they’ll cover them later.

Deficit neutrality is met even if federal spending net of federal revenues is lower than projected federal spending net of federal revenues in the absence of the section 1332 waiver, but, of course, not if it is higher. Obviously, this administration’s goal is to reduce federal spending.

This would all go away if we would enact and implement an improved Medicare for All. But Seema Verma says, “Medicare for All would become Medicare for None.” We desperately need government health care stewards with a much better vision than that.

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Trump op-ed designed to sway midterm votes

By Anh Le and Fred S. Mayer, R.Ph., Pharm.D., M.P.H.
Marin (Calif.) Independent Journal, October 21, 2018

President Trump’s recent op-ed in USA Today regarding “Medicare for All” is a failed attempt to scare seniors before the midterm elections.

Trump ignores the intelligence and wisdom of older Americans to discern the truth, and to know when an op-ed purporting to protect their interests is a mere snow job.

The president claims that “Democrats will eviscerate Medicare.” Is this falsehood just another pre-election scare tactic? How ironic, considering that the president’s own budget director slashed Medicare’s budget, and House Speaker Paul Ryan has tried to gut both Medicare and Social Security.

The president says that he will protect seniors, and falsely claims that Democrats’ “Medicare for All” would not cover “pre-existing conditions.” Yet the president’s and Republicans’ efforts to repeal the Affordable Care Act, President Barack Obama’s landmark legislation which addressed pre-existing conditions, were defeated, thanks to Democrats’ push-back and Sen. John McCain’s vote. It is the president and Republicans who want to eliminate the coverage of pre-existing conditions for Americans.

Medicare for All, or universal heath care for all Americans, will benefit and serve all Americans, regardless of age. The present health care system is exorbitantly costly and wasteful. Medicare for All would insure all Americans, at a much lower cost than currently spent per capita, and produce better health outcomes.

Sen. Bernie Sanders’ call for Medicare for All continues to gain increasing acceptance by the American people, Congress, medical doctors and public health experts.

Trump should not misuse seniors to advance partisan and propaganda purposes.

https://www.marinij.com…

What does ‘Medicare for All’ mean?

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

By Elisabeth Rosenthal and Shefali Luthra
The 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.

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.

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.

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.

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.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

“Medicare for All” means fixing Medicare and then expanding it to include everyone. It is a straightforward concept that has gained widespread support in the United States. Because of its popularity, many politicians on the left have latched onto the “Medicare for All” label to use in their campaigning while remaining quite vague on the fact that they really support the post-Obamacare status quo for most of us, with the addition of a public option or Medicare buy-in. Those on the right have noticed that this chicanery has gained traction and so, led by President Trump, they are condemning “Medicare for All” using whatever pejorative terms suit their campaigns.

Soon the midterm campaigns will be over. At that time we need to pressure those who said they support Medicare for All to live up to their campaign promise and cosponsor bona fide Improved Medicare for All legislation. For those who claim to be opposed to Medicare for All but also said that they now support a guarantee of health care for individuals with pre-existing disorders, we need to convince them that a single payer national health program is the most efficient and equitable method of achieving that goal. Maybe we’ll even let them call it Trumpcare if that gets the job done.

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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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