PNHP

Medicare for all too costly? Not so fast.

Medicare for all too costly? Not so fast.

By Louis Balizet, M.D.
The Pueblo (Colo.) Chieftain, September 4, 2018

Canadians live on average three years more than we do (82 versus 79 years). They pay, per capita, 50 percent less than we do for health care ($4,613 vs. $9,507). How do they do this? It’s fairly simple – their health care system (called ”Medicare”) covers everybody, is publicly funded by an assortment of taxes and delivers medical care largely by private providers. This arrangement produces efficiencies that allow all Canadians to access medical care without fear of financial ruin.

Driven by our persistent health care inequities and relentless cost increases, and faced with the embarrassing comparison with our neighbors to the north, more and more American politicians are backing bills that would convert our health care “system” to one that resembles the Canadian model. Two non-identical bills have been introduced into the current Congress to achieve “Medicare for all”: House Resolution 676, sponsored by Representative Keith Ellison of Minnesota (the stronger of the two, and which most closely duplicates the Canadian system), and Senate Bill 1804, proposed by Senator Bernie Sanders of Vermont.

It is the latter that has attracted ferocious attack by defenders of the status quo – by Ben Shapiro in The Pueblo Chieftain column of Aug. 5, and, more recently, in television ads that target Jared Polis (a co-sponsor of H.R. 676). Both assert that Medicare for all would be prohibitively expensive.

Both draw heavily on an analysis of Sanders’ bill by the Mercatus Center, a right-wing think tank founded by, funded by and run by the Koch brothers. This analysis, which contends that Medicare for all would increase federal spending by $32 trillion over 10 years, is influenced by the center’s anti-government, anti-tax agenda. (Previous Mercatus Center productions denounced restrictions on polluters, questioned climate change and opposed the Consumer Finance Protection Bureau.)

The center low-balls (by $3 trillion) the administrative savings that would accrue from replacing insurance companies’ 13-plus percent overhead with Canada Medicare’s 2 percent overhead. In ignores the estimated $5 trillion saved by providers (hospitals, doctors, pharmacies) no longer having to fund gargantuan billing, coding and collection systems. It miscalculates the savings that would result from the national government negotiating the price of drugs (as all single-payer countries do) rather than allowing drug companies to charge whatever the market will bear (as we do) – a $ 1.5 billion to $2 trillion error.

It assumes a massive surge in utilization under Medicare for all. But the “surge” when Medicare was introduced in 1966 was negligible, and it was minimal when Obamacare opened up in 2014. The Mercatus Center analysis does not recognize the savings by businesses and state and local governments that would no longer have to joust annually with insurance companies over health insurance for employees.

What the Mercatus Center study, and one with a similar conclusion from the Urban Institute, fail to recognize is that while federal taxes would certainly go up (just not by $3.2 trillion a year), money spent on insurance premiums would virtually disappear. The net result for most Americans would be that money would be directed to health care decreases. And for all Americans, getting sick would no longer mean courting financial disaster.

There will be dueling analyses of the cost of Medicare for all in the months and years to come. Relatively few of us are inclined to, or able to, sort through the numbers. But we can all recognize what is real – that citizens of 20-plus countries with national health insurance live longer than we do and pay far less for health care than we do. This is irrefutable and uncontested, even by the Mercatus Center. Why can’t we do the same as these countries? The answer: We can.

https://www.chieftain.com…

Alex Azar opposes setting drug prices by government fiat, while people die

Insulin's High Cost Leads To Lethal Rationing

By Bram Sable-Smith
NPR, September 1, 2018

Diabetic ketoacidosis is a terrible way to die. It’s what happens when you don’t have enough insulin. Your blood sugar gets so high that your blood becomes highly acidic, your cells dehydrate, and your body stops functioning.

Diabetic ketoacidosis is how Nicole Smith-Holt lost her son. Three days before his payday. Because he couldn’t afford his insulin.

“It shouldn’t have happened,” Smith-Holt says looking at her son’s death certificate on her dining room table in Richfield, Minn. “That cause of death of diabetic ketoacidosis should have never happened.”

The price of insulin in the U.S. has more than doubled since 2012. That has put the life-saving hormone out of reach for some people with diabetes, like Smith-Holt’s son Alec Raeshawn Smith. It has left others scrambling for solutions to afford the one thing they need to live. I’m one of those scrambling.

My first vial of insulin cost $24.56 in 2011, after insurance. Seven years later, I pay more than $80. That’s nothing compared with what Alec was up against when he turned 26 and aged off his mother’s insurance plan.

Smith-Holt says she and Alec started reviewing his options in February 2017, three months before his birthday on May 20. Alec’s pharmacist told him his diabetes supplies would cost $1,300 a month without insurance — most of that for insulin. His options with insurance weren’t much better.

Alec’s yearly salary as a restaurant manager was about $35,000. Too high to qualify for Medicaid and, Smith-Holt says, too high to qualify for subsidies in Minnesota’s health insurance marketplace. The plan they found had a $450 premium each month and an annual deductible of $7,600.

“At first, he didn’t realize what a deductible was,” Smith-Holt says. She says Alec figured he could pick up a part-time job to help cover the $450 per month.

Then Smith-Holt explained it.

“You have to pay the $7,600 out of pocket before your insurance is even going to kick in,” she remembers telling him. Alec decided going uninsured would be more manageable. Although there might have been cheaper alternatives for his insulin supply that Alec could have worked out with his doctor, he never made it that far.

He died less than one month after going off of his mother’s insurance. His family thinks he was rationing his insulin — using less than he needed — to try to make it last until he could afford to buy more. He died alone in his apartment three days before payday. The insulin pen he used to give himself shots was empty.

A miracle discovery

Insulin is an unlikely symbol of America’s problem with rising prescription costs.

Before the early 1920s, Type 1 diabetes was a death sentence for patients. Then, researchers at the University of Toronto — notably Frederick Banting, Charles Best and J.J.R. Macleod — discovered a method of extracting and purifying insulin that could be used to treat the condition. Banting and Macleod were awarded a Nobel Prize for the discovery in 1923.

For patients, it was nothing short of a miracle. The patent for the discovery was sold to the University of Toronto for only $1 so that live-saving insulin would be available to everyone who needed it.

Today, however, the list price for a single vial of insulin is more than $250. Most patients use two to four vials per month (I personally use two). Without insurance or other forms of medical assistance, those prices can get out of hand quickly, as they did for Alec.

Depending on whom you ask, you’ll get a different response for why insulin prices have risen so high. Some blame middlemen — such as pharmacy benefit managers, like Express Scripts and CVS Health — for negotiating lower prices with pharmaceutical companies without passing savings on to customers. Others say patents on incremental changes to insulin have kept cheaper generic versions out of the market.

For Nicole Holt-Smith, as well as a growing number of online activists who tweet under the hashtag #insulin4all, much of the blame should fall on the three main manufacturers of insulin today: Sanofi of France, Novo Nordisk of Denmark and Eli Lilly and Co. in the U.S.

https://www.npr.org…

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Remarks on Drug Pricing Blueprint

By HHS Secretary Alex M. Azar II
HHS.gov, May 14, 2018

You’ve probably heard before that Medicare could save tons of money by negotiating directly for drugs. This just isn’t true, and you don’t have to take my word for it.

The only way that direct negotiation saves money is by doing something this administration does not believe in: denying access to certain medicines for all Medicare beneficiaries, or setting prices for drugs by government fiat.

We don’t believe either of these proposals would put American patients first. They would move us toward the kind of socialized medicine systems that have such a notorious reputation for poor quality and access.

https://www.hhs.gov…

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Comment:

By Don McCanne, M.D.

There could not be a more glaring example of our policy failures in the design of our health care financing system. The tragic, premature death of 26 year old Alec Raeshawn Smith would have never happened with a well designed, single payer, improved Medicare for All. You can read through his story and pick out each of the policy defects that should be completely unacceptable in the most expensive health care financing system in the world.

There are now a plethora of reports about the outrageous pricing of our pharmaceutical products, including many tragic stories about the gouging of diabetic patients for their life-saving insulin. Yet we have as HHS Secretary, Alex Azar, the former president of the U.S. subsidiary of Eli Lilly – a major producer of insulin – under whose reign Lilly’s prices skyrocketed.

So what does Alex Azar have to say about the outrageous pricing of these products? He says, “this administration does not believe in… setting prices for drugs by government fiat.” He says, this “would move us toward the kind of socialized medicine systems that have such a notorious reputation for poor quality and access.”

With that kind of uncaring, cruel attitude, it seems that it is time to nationalize our health care financing system. We already have the tools to do that in a civil manner: replace our current politicians with ones that will enact an improved Medicare for All.

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Abraham Lincoln on labor

By President Abraham Lincoln
First Annual Message, December 3, 1861

It continues to develop that the insurrection is largely, if not exclusively, a war upon the first principle of popular government–the rights of the people. Conclusive evidence of this is found in the most grave and maturely considered public documents, as well as in the general tone of the insurgents. In those documents we find the abridgment of the existing right of suffrage and the denial to the people of all right to participate in the selection of public officers except the legislative boldly advocated, with labored arguments to prove that large control of the people in government is the source of all political evil. Monarchy itself is sometimes hinted at as a possible refuge from the power of the people.

In my present position I could scarcely be justified were I to omit raising a warning voice against this approach of returning despotism.

It is not needed nor fitting here that a general argument should be made in favor of popular institutions, but there is one point, with its connections, not so hackneyed as most others, to which I ask a brief attention. It is the effort to place capital on an equal footing with, if not above, labor in the structure of government. It is assumed that labor is available only in connection with capital; that nobody labors unless somebody else, owning capital, somehow by the use of it induces him to labor. This assumed, it is next considered whether it is best that capital shall hire laborers, and thus induce them to work by their own consent, or buy them and drive them to it without their consent. Having proceeded so far, it is naturally concluded that all laborers are either hired laborers or what we call slaves. And further, it is assumed that whoever is once a hired laborer is fixed in that condition for life.

Now there is no such relation between capital and labor as assumed, nor is there any such thing as a free man being fixed for life in the condition of a hired laborer. Both these assumptions are false, and all inferences from them are groundless.

Labor is prior to and independent of capital. Capital is only the fruit of labor, and could never have existed if labor had not first existed. Labor is the superior of capital, and deserves much the higher consideration. Capital has its rights, which are as worthy of protection as any other rights. Nor is it denied that there is, and probably always will be, a relation between labor and capital producing mutual benefits. The error is in assuming that the whole labor of community exists within that relation. A few men own capital, and that few avoid labor themselves, and with their capital hire or buy another few to labor for them. A large majority belong to neither class–neither work for others nor have others working for them. In most of the Southern States a majority of the whole people of all colors are neither slaves nor masters, while in the Northern a large majority are neither hirers nor hired. Men, with their families–wives, sons, and daughters–work for themselves on their farms, in their houses, and in their shops, taking the whole product to themselves, and asking no favors of capital on the one hand nor of hired laborers or slaves on the other. It is not forgotten that a considerable number of persons mingle their own labor with capital; that is, they labor with their own hands and also buy or hire others to labor for them; but this is only a mixed and not a distinct class. No principle stated is disturbed by the existence of this mixed class.

Again, as has already been said, there is not of necessity any such thing as the free hired laborer being fixed to that condition for life. Many independent men everywhere in these States a few years back in their lives were hired laborers. The prudent, penniless beginner in the world labors for wages awhile, saves a surplus with which to buy tools or land for himself, then labors on his own account another while, and at length hires another new beginner to help him. This is the just and generous and prosperous system which opens the way to all, gives hope to all, and consequent energy and progress and improvement of condition to all. No men living are more worthy to be trusted than those who toil up from poverty; none less inclined to take or touch aught which they have not honestly earned. Let them beware of surrendering a political power which they already possess, and which if surrendered will surely be used to close the door of advancement against such as they and to fix new disabilities and burdens upon them till all of liberty shall be lost.

http://www.presidency.ucsb.edu…

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Comment:

By Don McCanne, M.D.

There is a reason why we celebrate Labor Day rather than Capitalism Day. Although there was no Labor Day in 1861, President Lincoln’s astute and prescient words remind us why it is natural for our nation to celebrate labor.

And, yes, this message is very directly related to the issue of health care justice for all, even if unspoken.

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Off the Table. The Case for H.R. 676.

Hear U.S. and Canadian rank and file workers, leading officials from the U.S.W. and U.E., and doctors from Physicians for a National Health Program explain how Canadian-style Medicare could cover everyone in the U.S. without co-pays, deductibles, or premiums.

Featuring PNHP national coordinator Dr. Claudia Fegan and PNHP past president Dr. Andrew Coates. Produced by John Rice Films for Unions for Single Payer Health Care.

KFF: Public opinion on single payer, national health plan, and expanding Medicare

Public Opinion on Single-Payer, National Health Plans, and Expanding Access to Medicare Coverage

Kaiser Family Foundation

For many years, Kaiser Family Foundation has been tracking public opinion on the idea of national health plan. Since the 2016 presidential primary and Bernie Sanders’ rallying cry for “Medicare-for-all,” our polls have shown a modest increase in support for the idea of a national health plan (Figure 1), and broad support for proposals that expand Medicare (Figure 2). Overall, about six in ten adults favor a national health plan or Medicare-for-all plan (Figure 3). There is robust support among Democrats, and even somewhat among Republicans, for expansions of the Medicare program through a Medicare buy-in (Figure 6) or an “optional” Medicare-for-all proposal (Figure 7). Yet, it is unclear how much staying power this support has once people become aware of the details of any plan. Public support quickly erodes when people hear further explanation about potential tax increases or increased government control (Figure 8) and recent polling also shows many people falsely assume they would be able to keep their current health insurance under a single-payer plan (Figure 10), suggesting another potential area for decreased support.

While health care appears to be playing a role in the 2018 midterm campaigns (Figure 11) and single-payer has been a hot-button issue in some Democratic primaries, it is unclear that it will play a major role in the general election, with few voters saying a candidate’s position on a national health plan is an important factor in their vote (Figure 12). So while the general idea of a national health plan (whether accomplished through an expansion of Medicare or some other way) may enjoy fairly broad support in the abstract and it can be used as a rallying cry to motivate the liberal base of the Democratic party, it is unlikely to be a determining issue for most 2018 midterm voters.

12 Power Point slides which can be downloaded:
https://www.kff.org…

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Comment:

By Don McCanne, M.D.

Kaiser Family Foundation has summarized in twelve Power Point slides the public opinion on single payer, national health plans, and expanding access to Medicare coverage. Over the last two decades support for “a national health plan in which all Americans would get their insurance from a single government plan” has gradually grown from 40 percent to 53 percent.

Support increases when those initially opposed are told that such a plan would “reduce health insurance administrative costs,” “ensure that all Americans have health insurance as a basic right,” or “reduce the role of all private health insurance companies in health care.”

Support diminishes when those initially in support are told that such a plan would “give the government too much control over health care,” “require many Americans to pay more in taxes,” or “eliminate or replace the Affordable Care Act.”

However the polling suggests that there is considerable support for more incremental approaches. When asked, “Do you favor or oppose letting some people under the age of 65 buy insurance through the Medicare program?”, 63 percent are in favor and 33 percent are opposed. When asked if they would favor “A national Medicare-for-all plan open to anyone who wants it but people whom currently have other coverage could keep what they have,” support is 75 percent as opposed to 59 percent who favor “A national health plan, or Medicare-for-all, in which all Americans would get their insurance from a single government plan.”

Thus it seems that support for a multi-payer system that expands the role of Medicare is greater than support for a single payer version of Medicare for all. This, of course, plays into the hands of those who support expanding the use of private Medicare Advantage plans – a concept that currently is being sold under the false label of “Medicare for All.”

A Medicare Advantage option for all has almost nothing in common with a bona fide single payer improved Medicare for all. The former perpetuates all of the injustices, waste, and excess costs of our current fragmented, dysfunctional method of financing health care, whereas the latter finally brings to us an efficient, effective, equitable method of removing financial barriers to care for absolutely everyone with a system that each of us could afford.

It is going to be very difficult to get this crucial message across when “let those who want to buy into Medicare do it” becomes the reflex response. The polling suggests that it may already be a meme.

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A.M. Best: ‘U.S. Government-Related Health Insurance Business Continues to Grow’

Best’s Market Segment Report: U.S. Government-Related Health Insurance Business Continues to Grow Despite Risks

A.M. Best, August 13, 2018

The U.S. health insurance industry’s premium composition is increasingly shifting toward government-sponsored business, which exposes carriers to additional risks as the business is generally low-margin and results in a greater reliance on state and federal funding, according to a new A.M. Best report.

The Best’s Market Segment Report, “Government-Related Health Insurance Business Continues to Grow Despite Risks,” states that the health industry is generating an increasingly large share of premium from Medicare Advantage, Medicaid and individual commercial businesses. Medicaid reported the largest increase in net premiums written growth, to $224.0 billion in 2017 from $43.1 billion in 2007, owing to Medicaid expansion under the Affordable Care Act (ACA), and to more states turning to managed care to run traditional, pre-expansion Medicaid programs. Medicaid’s share of total industry NPW (Net Premiums Written) in that timeframe rose to 27.1% from 10.2%, although much of that growth occurred in 2014-2015. Medicare Advantage also has been a major source of premium growth for health insurers, with NPW increasing to $202.7 billion in 2017, representing 24.5% of overall industry premium, from $69.9 billion in 2007. Like Medicaid, growth in this business has flattened over the past few years.

According to the report, changes in the nature and financing of the individual market under the ACA have effectively turned this portion of the commercial market into government-sponsored business. At the same time, group commercial premium since 2014 has experienced lower growth because of relatively stable medical cost trends, the absence of material membership expansion and the transition to self-funded arrangements. As a result, many commercial carriers have a greater exposure to government-financed business without having increased their participation in Medicaid or Medicare Advantage lines. Increased exposure to the individual exchange business and its financial losses led to a decline in underwriting margins in the commercial segment from 2014 to 2016, but the market recovered in 2017, leading to historically high results for the overall commercial segment.

With health care remaining a controversial political issue, the regulatory regime is likely to remain volatile over the near to medium term, especially as it relates to the individual exchange segment.

As industry consolidation continues and as companies build massive operational infrastructures to service these programs, a quick exit, if need be, may be more difficult. However, the larger carriers, as well as some of the midsize ones, have been successful in adjusting to regulatory changes and revising business models to accommodate different population needs under the government programs.

https://news.ambest.com…

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Comment:

By Don McCanne, M.D.

This sterile report from A.M. Best suggests that there are uncertainties for the health insurance industry in its participation in government programs, but the important message is that their government-related health insurance business is growing as they prove capable of accommodating to regulatory volatility.

The clear trend is further privatization of the government health insurance programs. With the strong public support for Medicare for All, the insurance industry realizes that there is a great opportunity to expand their markets though the public option of a private Medicare Advantage for All. If you listen carefully to the political candidates supporting Medicare for All, many of them slip in “through a public option,” simply meaning a private insurance option with a Medicare label. That’s what Medicare Advantage is.

Listen up. As we attempt to insert ourselves into the process again (we failed during the Clinton and the Obama administrations), we are going to be met with, “We got it; now get out of our way.” The incremental step of Medicare Advantage for All will ensure a solid rock foundation shoring up the medical-industrial complex, likely for decades to come.

We’re very good at inertia, and it is going to kill any semblance of a single payer, publicly-administered Medicare for all, as we perceive it. Are you just going to sit there? Are all of us just going to sit here?

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NHIS insurance statistics; don’t pop the champagne corks

Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January–March 2018

By Robin A. Cohen, Ph.D., Michael E. Martinez, M.P.H., M.H.S.A., and Emily P. Zammitti, M.P.H.
U.S. Department of Health and Human Services, National Center for Health Statistics, August 2018

Highlights

* In the first 3 months of 2018, 28.3 million (8.8%) persons of all ages were uninsured at the time of interview—not significantly different from 2017, but 20.3 million fewer persons than in 2010.

* In the first 3 months of 2018, among adults aged 18–64, 12.5% were uninsured at the time of interview, 19.2% had public coverage, and 70.0% had private health insurance coverage.

* In the first 3 months of 2018, among children aged 0–17 years, 4.6% were uninsured, 41.9% had public coverage, and 54.6% had private health insurance coverage.

* Among adults aged 18–64, 70.0% (138.6 million) were covered by private health insurance plans at the time of interview in the first 3 months of 2018. This includes 4.2% (8.3 million) covered by private health insurance plans obtained through the Health Insurance Marketplace or state-based exchanges.

* The percent age of persons underage 65 with private health insurance enrolled in a high-deductible health plan increased, from 43.7% in 2017 to 47.0% in the first 3 months of 2018.

https://www.cdc.gov…

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Comment:

By Don McCanne, M.D.

This annual NHIS study of the uninsured done by the National Center for Health Statistics gives us the most accurate status of health insurance coverage in the United States. A few observations can show us how our system is functioning, now that the implementation of the Affordable Care Act (ACA) has relatively stabilized:

* 28.3 million individuals (8.8%) remain uninsured, the same as last year, so net enrollment seems to have stabilized for the present, with still far too many remaining uninsured.

* Of adults aged 18-64, 138.6 million were covered by private insurance, though only 8.3 million of them were covered through the ACA exchanges, which makes you think that there must be a better option considering the administrative complexity of the program.

* For children aged 0-17, the increase in public coverage (Medicaid and CHIP) reduced their uninsured rate to 4.6%, but most of that increase was prior to the implementation of ACA. Although many consider an uninsured rate of 4.6% for children to be a policy success, we really should ask why we tolerate leaving 3.4 million children uninsured when a well designed single payer system would cover all of them, and everyone else.

* One statistic that is not stable is that the percentage of individuals under age 65 with private health insurance who are enrolled in high-deductible health plans increased from 43.7% to 47.0% in the last year alone, and is up from 25.3% in 2010. This may be the most shocking result reported this year since it demonstrates that the rate of underinsurance, with its consequential epidemic of financial hardship, is skyrocketing.

Although many in the policy community will celebrate these results as a success of the Affordable Care Act, these are actually terrible results. We could have had everyone covered in a program that we could all afford, but instead our policymakers rejected single payer Medicare for all and have left us with tens of millions uninsured, almost half of the privately insured with worsening underinsurance, and persistent unjust inequities in health care coverage. Are we nuts?

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