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Powerful coalitions forming against single payer Medicare for All

Powerful coalitions forming against single payer Medicare for All

Doctor, hospital groups organize to oppose single-payer in California

By Angela Hart
The Sacramento Bee, August 28, 2018

A group of influential, deep-pocketed business and health care organizations that have long helped shape the legislative agenda in California have joined forces to oppose any future effort to craft a universal, single-payer health care system for the nation’s largest state.

The main focus of the coalition, called “Californians against the costly disruption of our health care,” is to kill any single-payer health care bill in the state Legislature, said Ned Wigglesworth, a political strategist for the coalition.

“As long as proponents plan to bring this back time and again, we think it’s important to have a strong, unified presence to oppose it,” Wigglesworth said, referring to Senate Bill 562, the 2017 single-payer bill pushed by the California Nurses Association that was shelved last year by Assembly Speaker Anthony Rendon.

The anti-single payer coalition includes powerful groups representing the interests in Sacramento of doctors, hospitals, insurers and businesses. Instead of single-payer, the coalition is expected to press for alternatives, which could include several legislative proposals on health care that failed this year and some under discussion, including expanding state insurance subsidies, allowing undocumented adults to sign up for Medi-Cal and creating a state-based individual mandate for everyone to have coverage.

“I think you’re going to hear our messaging loud and clear,” said Charles Bacchi, president and CEO of the California Association of Health Plans. “It’s going to be really focused around how expensive (single-payer) would be for California to do, and how disruptive it would be for people who currently receive health care coverage.

https://www.sacbee.com…

Partnership for America’s Health Care Future:
https://americashealthcarefuture.org

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Comment:

By Don McCanne, M.D.

The coalition, “Californians against the costly disruption of our health care,” is basically a group of vested interests and their agents, with power and money, that intends to wipe out the single payer movement in California. A national coalition, “Partnership for America’s Health Care Future,” has even more power and more money and intends to snuff out the single payer Medicare for All movement throughout the United States.

The good news is that this shows that the Medicare for All movement is viewed as a very real threat to the sponsoring organizations, which shows how effective the single payer advocates have been to date. The bad news is that power and money can extinguish our flame.

What can we do? We may not have the money but we can harness the power of the people by continuing to do what we have been doing to bring the single payer Medicare for All movement to the forefront, but we need to do a lot more of it. Education, coalitions, grassroots efforts, community organizing, creating a presence everywhere using the spoken and written word, networking with our families, friends, associates, religious and civic institutions, and more. We need to be there and do it, and bring others with us.

These coalitions that intend to defeat single payer will try to present a positive front by offering expanded programs under our existing dysfunctional and fragmented system, but that will only perpetuate the waste and inequities, thus perpetuating the health care injustices that permeate our system, not to mention that such an approach is uniquely by far the most expensive model of health care reform the world has ever known. This can only perpetuate and compound the problem of lack of affordability of health care that is tormenting us in the United States.

Our message resonates much better: include everyone for life, providing free choice of physicians, hospitals and other health services and products, simplify the financing system to reduce the profound administrative waste unique to the United States, establish fair prices that are adequate to support the system while preventing gouging, and fund the entire system equitably such that each person pays his or her fair share based on ability. Thus our simple message is that all of us receive the health care we need, and none of us suffers financial hardship as a result.

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Anthem refuses to cooperate with a federal false claims investigation

Feds want to force Anthem to comply with Medicare billing investigation

By Shelby Livingston
Modern Healthcare, August 21, 2018

Health insurer Anthem has refused to comply with the U.S. Justice Department’s investigation into its Medicare Advantage billing practices, according to federal court documents filed Tuesday.

So the Justice Department this week asked the U.S. District Court for the Southern District of New York to force Anthem to comply with a civil investigative demand issued in March to provide testimony about its chart review and risk-adjustment program for its Medicare Advantage plans.

The Justice Department initially demanded the testimony by April 13 but said Anthem has yet to provide a witness to testify. The court on Monday ordered Anthem to explain why it should not be forced to provide testimony. Anthem has until Sept. 4 to respond.

The Justice Department asked for Anthem’s testimony as part of an investigation into whether Anthem unlawfully obtained hundreds of millions of dollars in Medicare Advantage risk-adjustment payments in violation of the False Claims Act by submitting inaccurate patient diagnosis codes to the CMS.

The feds also want to know if Anthem deliberately disregarded its duty to ensure the diagnosis codes submitted were valid, and asked for testimony about the processes and people Anthem relied on to verify diagnosis codes obtained by providers and through a retrospective chart review.

An Anthem spokeswoman declined to comment.

http://www.modernhealthcare.com…

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Comment:

By Don McCanne, M.D.

Anthem has an opportunity to demonstrate to the Justice Department that they have not been cheating the taxpayers out of hundreds of millions of dollars by upcoding diagnoses of their Medicare Advantage patients, thus qualifying for higher risk adjusted payments based on the fact that their codes indicate that the patients have more costly disorders than they actually have.

If Anthem is innocent, then why does it take the order of a federal court to produce the evidence that would clear them, after failing to comply with an earlier demand? Maybe they are just trying to work the float on the heavy penalties that they know they will eventually have to pay (investing money for their own profit – money that belongs to the taxpayers). Hey, the insurers keep showing us that do know how make a buck off of us, even in a bad situation. And we want to keep them in charge?

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

There are many advantages to single-payer health care

By Ann Troy, M.D., F.A.A.P.
Marin (Calif.) Independent Journal, August 27, 2018

I am a physician and I advocate a single-payer system or Medicare for all.

Under a single-payer system we would be healthier. It is well known that people without insurance or with high deductibles wait longer to seek medical care; thus, their illnesses and problems become more deep-rooted and more difficult to treat. They suffer more from injuries, disabilities and ill-health, resulting in decreased productivity and poorer quality of life. Sometimes they die because they put off getting care.

Under a single-payer system, people would have a wider choice of doctors and would not have to change their doctors every time they change jobs or their employer finds a cheaper health plan. Continuity of care would improve and problems would be treated earlier (when easier and less expensive to treat). More people would receive vaccines and preventive care. Public health would improve and social problems associated with untreated mental illness and addiction would decrease.

The U.S. ranks at or near the bottom of the developed world on every measure of health. According to the World Health Organization, we are No. 37 on overall measures of health. Shameful for such a rich country that spends so much on health care!

A single-payer system would benefit us economically. U.S. companies are at a disadvantage compared with companies in other developed countries which are not saddled with the high cost of providing health care for their employees. Smaller companies can’t compete for the best employees because they can’t afford to provide health insurance. Unhappiness over health benefits is the leading cause of labor unrest.

Some employees commit workers’ comp fraud to gain access to care. People stay in jobs they hate because they need health insurance, rather than going back to school or creating new ventures. Families struggle to pay astronomical health insurance premiums than pay for care until they’ve met their deductibles. Half of all bankruptcies in the U.S. (approximately 1 million a year) are due to medical debt. All of this would change with a single-payer system.

Finally, there are the legal and moral arguments. Health care is considered a human right in every other developed nation. By not providing Medicare to all Americans, the government is not providing equal protection under the law: those with Medicare have more protection against the devastating effects of illness and injury, get more help overcoming or living with disabilities, and are protected against financial ruin.

People say that single-payer would cost too much. Not true.

We could provide health care for all our citizens for no more than we are currently spending on our very dysfunctional, fragmented and unfair system.

How is this possible? Currently almost half of every health care dollar is spent on something other than health care: profit for insurance companies; multi-million-dollar salaries for their CEOs; money spent on advertising, processing (and rejecting) claims; and creating mountains of paperwork and endless hassles for doctors and patients.

Then there is the money we have to spend dealing with the insurance industry: billing, authorizations, etc. Dealing with insurance companies is so cumbersome that we have created intermediary entities (such as IPAs) to deal with them. It is estimated that American hospitals spend about 25 percent of their budget on administration, most of it insurance generated! Layers and layers of costly administration would disappear under a single-payer system.

We do not need more studies to prove this. Other developed nations provide health care for all of their citizens for an average of half of what we spend per capita and an average of 10 percent of their GDP (versus our 19 percent).

It is time that we catch up with the rest of the developed world and provide health care for all with a single-payer system.

Dr. Ann Troy is a pediatrician who has been in practice for 30 years.

http://www.marinij.com…

Medicare for all can control rising costs, improve health outcomes

By Phil Caper, M.D.
Bangor (Maine) Daily News, August 26, 2018

A recent Associated Press story describing a study of Sen. Bernie Sanders’ proposal for Medicare for all carried the alarming headline: “Medicare for all projected to cost $32.6 trillion over 10 years.” Pretty scary stuff.

But the study, as reported, was misleading. Let’s correct that.

It’s true that transformation from a complicated mixed public-private system of financing health care to one that treats medical care as a public good would move a great deal of money from private, for-profit budgets to public nonprofit budgets and would result in a significant increase in taxes. But there is a big savings to doing just that. We who buy medical goods and services — including patients, employers, those buying health insurance and taxpayers — will save.

Replacing insurance with taxes will eliminate the need for much of the administrative and other sources of waste in our health care system. In fact, the study found that Medicare for all would reduce overall health care spending in the U.S. by $2 trillion over 10 years, compared to our existing system.

This waste is incurred by patients, doctors, hospitals and insurance companies as they each try to navigate the health care maze in order to maximize their revenue, and employers, patients and employees as they struggle to pay for medical care. According to the Medicare Trustees Report for 2018, Medicare’s administrative costs accounted for just 1.14 percent of all spending. But private insurance companies struggle to keep administrative costs below 20 percent. Those administrative costs do not buy a single bandage or aspirin.

A 2012 National Academy of Medicine study of America’s $3 trillion health care system identified $750 billion of waste. “Excess administrative costs” account for $190 billion. Another $575 billion is wasted by “prices that are too high,” inefficiently delivered services, unnecessary services, missed prevention opportunities and fraud.

Many of these costs are directly attributable to the use of insurance to finance medical care. Insurance requires the slicing and dicing of the insured population into “risk pools” to facilitate the pricing of premiums in our fragmented health insurance system. Medical underwriting requires a great deal of intrusively detailed information about those covered and armies of actuaries. All of that would be unnecessary and would disappear in a fully tax-funded system, because all beneficiaries would be pooled into a single fund. Everybody would be covered for life.

Insurance underwriting is not the only way to finance medical care. Instead of segmenting risk into multiple pools, Medicare puts all beneficiaries into one risk pool and payment for health care is made out of a federally administered — and controllable — fund.

A more unified system would produce many other benefits. Everybody in, nobody out would greatly increase the popularity, and therefore political stability, of our health care system. That’s what our half century of experience with Medicare has demonstrated.

A single payer negotiating prices for medical services, devices and drugs would save billions. Insurance administrative costs would drop from more than 20 percent to between 1 to 2 percent. Unpopular restrictions of pre-existing conditions and other medical underwriting would be eliminated.

New tools would be created to control rising costs. No changing your health care as individual circumstances change. “Job lock,” when employees aren’t able to freely leave a job over fear of losing health insurance, would be eliminated, decreasing business costs and increasing opportunities for entrepreneurs.

In fact, with everyone in and nobody out and everyone contributing, we could create a central database that would make the detection and remediation of fraud, waste and abuse — rampant in our current system — much easier.

Out of the savings generated, we could provide real primary prevention of disease, and gradually expand coverage to dentistry, eye care, long–term care and other beneficial services that reduce the demand for more expensive medical care.

Supreme Court Justice Oliver Wendell Holmes once said, “Taxes are the price of civilization.” We fund many popular services through taxes, including police, fire fighters, the military, schools, libraries, courts, roads and environmental protection. All are essential to a civilized society.

In the rest of the developed world, health care costs less and delivers better results. As the study actually shows, health care for all is better for the community and the economy.

And after it’s in place, we will all be thankful and will all wonder why it took so long.

Dr. Phil Caper is an internist and founding board member of Maine AllCare.

https://bangordailynews.com…

The bull market is foretelling Medicare Advantage for All

An unlikely winner in the long-running bull market: Health insurers

By Bertha Coombs
CNBC, August 19, 2018

The bull market, which is about to become the longest running in recent history, has produced healthy returns for investors. The S&P 500 is up well over 300 percent over the last nine years, but health insurance stocks have logged even more impressive gains.

The S&P Managed Care sector, made up of the largest insurers, has gained more than 1,100 percent during the market’s bull run. That’s more than twice as much as the gains in the biotech sector.

Nine years later, two of the biggest health-care winners have seen large growth in part because of Obamacare.

The Medicaid boom

Medicaid expansion under the ACA has resulted in nearly 15 million people gaining coverage under the government health program for the poor and disabled. At the same time, over the last decade, states have increasingly turned to insurers to manage their Medicaid programs.

Medicaid insurer WellCare Health Plan’s shares have gained more than 4,000 percent since March 2009, and its annual revenues have nearly tripled from $6.9 billion to an estimated $18.7 billion this year.

Rival Centene’s shares have gained nearly 1,800 percent over the last nine years. Annual revenues have ballooned from $3.4 billion to an estimated $59.8 billion this year. Centene is up 42 percent year to date, trading near record highs.

At the same time that the Medicaid business has expanded, Medicare has seen big growth over the last decade as more baby boomers have aged into the government health plan for seniors.

For the major health insurers that has meant that their government business has grown faster than the commercial employer and individual insurance plan business. Government plans now account for more than 50 percent of the industry’s insurance revenues.

More diverse businesses

Government plans have been one of the growth drivers for the nation’s largest insurer, UnitedHealth Group, which is up 19 percent year to date, and has seen shares gain nearly 1400 percent over the last nine years.

United’s health plan membership has grown from 32 million to nearly 50 million over the last nine years; its Medicaid and Medicare membership has more than doubled, during the period.

But new business segments outside of health insurance have played a big role in growing the health-care giant’s annual revenues from $87 billion in 2009 to an estimated $225 billion this year. The health services and products under the Optum division have become a key driver of top-line growth.

United’s Optum unit now accounts for 20 percent of revenues, and includes data analytic services, pharmacy benefit management, physician practices and outpatient surgical centers.

Revenues from the services businesses are not subject to the ACA regulatory caps, which require insurers to spend at least 80 percent of premium revenues on medical care. That makes them more profitable.

United’s success has been part of the impetus behind the increasing number of vertical health insurer deals. More health plans have acquired health-care providers and services in order to have greater control over medical costs in their health plans.

Pharmacy benefit giant CVS Health’s $69 billion deal for Aetna and Cigna’s $54 billion deal to buy pharmacy benefit firm Express Scripts are both predicated on trying to driving cost efficiencies by having greater control over a wider range of members’ care.

Meantime, Democrats have revived the health reform debate over single-payer Medicare For All, nine years after investors were rattled by the prospect of single-payer health care under the ACA.

If either side gains traction, analysts say the major insurers have positioned themselves to adjust more readily to the shifting landscape over the last decade.

“Even if it’s Medicare for all, it would probably be Medicare Advantage for All,” with the government funding private Medicare plans, said Deep Banerjee, health-care credit analyst at Standard & Poor’s.

“Health care today is a public-private partnership … it’s very hard to see a system without a private player meaningfully involved,” he said.

https://www.cnbc.com…

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Comment:

By Don McCanne, M.D.

Since enactment and implementation of the Affordable Care Act (ACA) we have heard stories about how tough it has been for the insurance industry. Congress and both the Obama and Trump administrations have responded with measures to ensure the viability of this industry (in spite of blowhard repeal activity of the Republicans that had essentially no detrimental impact on the insurers – they just raised their premiums). You really need to read this very brief summary of the past nine years to understand what a godsend this has been for the health insurance industry.

Much of the clamor has been over the ACA exchange plans. Yet in the overall picture that has been a very small part of what has really happened in the past decade. In fact, it has been such a small part that some of the largest insurers have pared back their involvement in the exchanges since they have been an insignificant contributor to their business successes.

So what has been the source of their success? The two government programs, Medicare and Medicaid, and the expansion and diversification of their industry.

The largest expansion as a result of ACA has been in the Medicaid program, and that has coincided with a massive shift into the private Medicaid managed care programs. The behavior of the Medicaid managed care stocks has demonstrated what a phenomenal business success this has been (even if it appears that this success has been made possible by the implementation of their business model that simply prevents their Medicaid patients from receiving much of the care that they should have). Since the private Medicaid managers have been successful in barely providing health care to huge numbers of Medicaid beneficiaries at a very low cost to the government, it its likely that this program is locked in place for the indeterminate future. The political process will be very resistant to any proposals that would increase spending on poor people – the low-income population that qualifies for Medicaid.

The success of the private Medicare Advantage plans has not been due to ACA but rather due to other programs that were set up in an effort to privatize Medicare. Again, Congress and the Bush, Obama and Trump administrations have all nurtured this program by providing them with very generous funding (much due to administrative chicanery) while at the same time giving the insurers regulatory backup to pay for health care at rates considerably below the rates paid by standard commercial plans. With high volume, generous funding, and low costs, it is no wonder that these insurance companies have become darlings of Wall Street.

What should be very alarming to us is the success that these insurance companies have had in diversifying their businesses. They are no longer just the insurers and administrators, they have now become an integral part of the health care delivery system with their acquisition of physician practices, outpatient surgery centers, pharmacy benefit managers, data analytic services, and other vertical acquisitions. Profits from these expansions are not limited by the ACA regulatory caps, and if there is anything that the private insurers understand, that is how to make a buck.

So where is the money coming from that has created this phenomenal success for the private insurers? Well, a large amount is from the taxpayers through the Medicaid managed care and private Medicare Advantage plans – part of the silent costs of health care that the taxpayers do not realize they are already paying. Some is coming from a diversion of funds from the health care providers into the coffers of the insurers. Some is coming from the Wall Street customers who are paying excessive amounts for stock purchases plus the cost of churning in this protracted bull market. And some is from the excessive administrative services that the insurers keep selling us. You can probably think of more sources of their enrichment.

We’ve been saying for three decades that it is urgent that we change to a publicly funded and publicly administered, single payer, improved Medicare for All. Not only have we wasted funds on the excesses of our current dysfunctional system, but also far too many have gone without essential health services, and tens of millions have faced unnecessary financial hardship.

But what has snuck up on us is that the insurance industry has taken over. They have planted themselves in a position to capitalize on the Medicare for All movement. Medicare for All has now become the rallying cry for the Medicare public option. Just as the private Medicare Advantage plans are engulfing the traditional Medicare program, the insurance industry is positioned to be sure that the Medicare public option will be a Medicare Advantage public option, and they will do it with the support of our politicians, including many who profess to be progressive or liberal or whatever label assuages their guilt.

The latest Reuters/Ipsos poll shows that 70 percent of Americans support Medicare for All, including half of Republicans. But, with the complicity of the neoliberals, the industry has latched onto the Medicare for All rhetoric and will use it to expand their business successes.

What can we do? Well if the public is really serious about wanting affordable health care for all, it will require massive community action – education, grassroots, coalitions, voter engagement – now! Otherwise, sit back and watch them implement Medicare Advantage for All. It’s almost here.

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

Reuters/Ipsos poll: 70 percent support Medicare for All

Reuters/Ipsos, June and July 2018

Would you support or oppose the following?

A policy of Medicare for All? (When it comes to the U.S. healthcare system)

Democrat
84.5% – Support
10.7% – Oppose
4.8% – Don’t know

Republican
51.9% – Support
37.4% – Oppose
10.7% – Don’t know

Total
70.1% – Support
20.6% – Oppose
9.3% – Don’t know

https://www.reuters.com…

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Comment:

By Don McCanne, M.D.

In this new Reuters/Ipsos poll of 2,989 American adults, 70 percent support Medicare for all, and even a majority of Republicans – 52 percent – do so as well.

Don’t forget the Republicans in your advocacy work.

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

The Democrats’ Approaching Dilemma

What should they do about health reform?

By Caroline Poplin, M.D., J.D.
MedPage Today, August 23, 2018

If the Democrats begin to retake control of the federal government in November — for example, by flipping the House — they should start thinking about their next moves on health reform.

They will have plenty of time for contemplation: President Trump and his minions will, if anything, redouble their attack on the Affordable Care Act (ACA) for the next 2 years, and the Senate (unless also flipped) will do what it can to help. Even if they regain control, all House Democrats can do, especially if the Senate doesn’t flip, is block bad bills from getting to President Trump’s desk. There is no compromise with this man.

The Choice

But in 2020 (hopefully) the Democrats will be at a fork in the road, and they will need to answer an important question: Should they restore and improve whatever survives of the ACA, based on 10 years of real-world experience, or should they respond to rising calls for “Medicare for All,” for part or all of the under-65 population?

Now is the time to start thinking.

The debate to date is not evenly balanced. As you would expect, supporting the ACA are the large (and growing) industries that benefit — for-profit insurance companies, large for-profit hospital chains, pharmaceutical manufacturers, and so forth. (Indeed, the ACA was designed precisely to garner their support, or at least buy their silence.) In addition, though, over the last 30 years, an extensive and powerful “policy” community of academics, consultants, economists, and highly regarded think tanks (likely some with industry funding) have developed an elaborate intellectual infrastructure to support market-based commercial healthcare.

On the “Medicare for All” side, we have Physicians for a National Health Program (that should tell you something); Gerald Friedman, PhD, an economist at UMass Amherst; and recently, some advocacy organizations. No leading think tanks that I am aware of.

Since Democrats now have a choice, perhaps instead of starting from where we have been — the same thinking that led to the ACA — perhaps we should start with where we want to arrive.

We should have two principal goals. First, everyone needs to get the care they need at a price they can afford — that is to say, the objective is care, not coverage. Second, we need to get the total cost of the system down. That hasn’t happened despite strenuous efforts on many sides, possibly because the policy community has been ignoring some important costs as it bears down on what we pay clinicians (of which, full disclosure, I am one).

Important Cost #1: The Sickest Patients

One of the best opportunities to reduce cost — often overlooked in this context — is the sick patient. In general, 5% of a population is responsible for 50% of its total health care cost. Treating these patients, who have multiple problems including depression, functional and cognitive impairment, as well as, often, limited social support or financial resources, is expensive, yes. But secondary and tertiary prevention, close follow-up, and improving patients’ social determinants of health saves the system money — mostly by keeping these patients out of emergency rooms, hospitals, in-patient rehabilitation, and nursing homes — and improves patients’ quality of life.

Commercial health insurers and risk-bearing accountable care organizations (ACOs) want no part of the sickest patients — the way to make money is to insure and/or care for the healthy. Low cost, excellent outcomes, and numerous healthy patients mean high profits. Insurers and ACOs also seek reinsurance from the federal government, the states, high risk pools and other programs to which to transfer the costly 5%. These maneuvers allow insurers to keep their profits and socialize the losses.

Important Cost #2: Administrative Costs

The good news is, from 1990 to 2012, the U.S. healthcare workforce grew by 75%. The bad news? Ninety-five percent of that growth was in administrative staff, not physicians. By 2012, there were 16 non-doctors for every doctor. Worse, only six of the 16 were involved in patient care.

So how much value do the 10 non-clinicians contribute to patient care?

Drs. Jiwani, Himmelstein, Woolhandler, and Kahn extensively analyzed the data for 2012 and determined that expenses related to billing and insurance in our multi-payer system totaled almost 18% of U.S. healthcare expenditures that year, far more than in any other OECD country. In 2014, in The New York Times, Elisabeth Rosenthal estimated administrative costs at 20% to 30% of the total.

Today, the ratio of administrators to clinicians is probably higher, and accounts for a larger percentage of U.S. healthcare costs. Why?

First, as politicians and the policy community have pushed a market-based system, U.S. healthcare has become a very profitable business, with many participants answering to Wall Street. To stay in business, prosper and expand (those latter two are often linked), businesses need managers, and the above-mentioned consultants, to supervise marketing, identify profit and cost centers, and extract maximum productivity from the work force. Frequent negotiations between insurers and providers over prices also require businesspeople (and generate huge transaction costs).

Managers do not come cheap: John Commins points out that in 2005, CEOs made three times as much as orthopedic surgeons (the physician heavy hitters); 10 years later, five times as much. Indeed, physician compensation represented only 8.6% of total healthcare expenditures in 2012. We know how orthopedic surgeons help patients — CEOs, not so much.

Second, hospitals, insurers, and health systems are consolidating ever more quickly, sometimes for survival, often for increased leverage with one another, and for increased profit. Consolidation of multiple hospitals or businesses requires additional administrators to manage the administrators of local systems. Or as Cathy Shoen, a senior expert at the Commonwealth Fund, put it,”[At] large hospitals there are senior V.P.s, V.P.s of this, that and the other.” Whether consolidation improves quality and reduces cost, it does move important decisions further and further from the bedside.

And finally, all these managers as well as the policy community and, alas, Congress, have an unshakable faith in the ability of health information technology to “transform” U.S. healthcare, reduce costs, and improve quality by collecting and analyzing vast amounts of data about everything.

Indeed, their faith was such that in 2009 Congress promulgated the so-called HITECH Act, “encouraging” all hospitals and doctors (first with carrots, then with sticks) who received payments from Medicare to buy electronic medical records systems so that they could send their outcomes data to CMS and other interested parties, who would presumably use them to improve care and reduce cost. Under the Medicare Access and CHIP Reauthorization Act (MACRA), passed in 2015, these required reports became even longer and more complicated.

It doesn’t appear that anyone has done a credible analysis of how much top-heavy management and its high-tech tools cost our system — my guess it’s become a significant percentage of the total. We need to reassess this before we design the system of the future. From my vantage point at the sharp end of the stick, expensive managers and HIT are not merely useless — they are counterproductive and wasteful.

And quality? At least one analyst crunched the numbers and concluded that “as countries spend a larger percentage of their healthcare dollars on administration (as opposed to public health, or providing patient care, for example), things get worse for patients and healthcare providers.”

What’s the Answer?

The cost of healthcare in the U.S. continues to rise in an unsustainable manner, particularly if we insist, as we should, that in a country as rich as this, everyone who needs medical care should get it. In 2009, the Democrats went with market based reform, based partly on what seemed politically most feasible. Truly. Not only did it undo them politically, but it did not save money. In 2020, with a little luck, they will get another chance.

The way to reduce costs, maintain quality, and cover all is to treat the sick, simplify, and decentralize, through Medicare for all. Providers must be non-profit. Now is the time to work out the details.

Dr. Caroline Poplin is an attorney and internist in Bethesda, Maryland. She is a former staff internist for the National Naval Medical Center, and currently practices medicine part-time at the Arlington Free Clinic in Virginia. She also consults for law firms on Medicare and Medicaid fraud.

https://www.medpagetoday.com…

Why Doctors Are Warming to Medicare for All

Burnout, cynicism, and endless insurance red tape. As America’s private health care system crumbles, doctors are waking up to the need for Medicare for All.

By Meagan Day
Jacobin, August 23, 2018

According to a poll earlier this year in the New England Journal of Medicine, a majority of American physicians say that single-payer is the best path forward. Doctors are not traditionally a progressive bunch — in the 1960s, the American Medical Association famously hired Ronald Reagan to attack Medicare as “socialized medicine.” So why might this be?

A new study exploring the phenomenon of physician burnout holds some clues. Researchers from University of California, Riverside School of Medicine found that under the current system, doctors are increasingly unhappy at work. They observed a sharp rise in physician burnout, which they define as “1) a feeling of a lack of accomplishment; 2) feelings of cynicism; and 3) a loss of zeal, zest, and enthusiasm for work.”

One of the reasons for this dissatisfaction is that, as researcher Kenneth A. Ballou pointed out, “the doctor-patient relationship has been morphed into an insurance company-client relationship that imposes limitations upon the treatment doctors can provide to the insurance company’s members.” In our current system, there are usually three parties involved in every medical decision: the doctor, the patient, and the insurer. The doctor and patient may agree on a course of treatment, but the insurer decides whether it will be covered. And since many Americans can’t afford ever-growing out-of-pocket medical costs, that often means that insurers have the final say in whether the treatment will be administered at all.

The majority of Americans receive health coverage from a private insurance company. And while doctors and patients are both theoretically focused on patient health, the insurer is driven by an entirely different motivation: to maximize profit. Insurance companies are financially motivated to deny claims, and they do it all the time, even in life-or-death situations. One in four patients with a chronic or persistent illness or condition have had claims for medication, tests, or procedures denied by their insurer. In 70 percent of those cases, the condition was described as serious. Only 1 percent of patients said they trusted their health insurance provider’s judgment over their doctor’s or their own — and yet the buck stops with insurance companies.

When they deny claims, insurers give doctors and patients all kinds of excuses packaged in obscure industry terminology: formulary exclusion, prior authorization. But the simple fact is that patients aren’t getting the care they need — and doctors aren’t getting the opportunity to actually do their job. All too often, this is deadly for patients. For doctors, it’s depressing and demotivating. It hinders physicians’ ability to practice medicine, makes them feel powerless at work, and divests them of a feeling of personal accomplishment.

Another factor contributing to doctor burnout is depersonalization. Patients change doctors constantly under our current system. People switch jobs, or their employers switch insurers, and as a result patients are required to change networks and providers. Or people’s income fluctuates and they drift in and out of Medicaid eligibility, often going through periods where they aren’t insured at all. The ACA marketplaces are more or less designed to rupture relationships between doctors and patients, appealing to patients as consumers and communicating that if they shop around they can find a better plan, one that will finally meet all their needs — though it rarely does.

As a result of our jigsaw insurance network system, doctors and patients meeting for the first time can’t assume they’re embarking on a meaningful long-term relationship. “The doctor–patient relationship has sustained the happiness of both doctors and patients for generations,” write the UC Riverside researchers. “This centuries-old relationship has only recently been threatened by a de facto insurer–employer–provider relationship.” Seeing little purpose in getting to know patients intimately, doctors can become cynical. The lack of continuity leads to feelings of alienation and disinvestment for physicians who may have been attracted to the profession by the prospect of helping and healing people.

Finally, the study’s authors point to the proliferation of mandated use of Electronic Health Records (EHRs) as a cause of physician burnout. “No humanistic physician gets up with zeal in the morning, hopeful for a chance to have a meaningful relationship with Epic or MEDITECH,” they write. One time-motion study found that doctors spend twice as much time on EHR and desk work as on clinical face-time with patients. These medical records software programs are designed to facilitate documentation required for billing, more than for care itself. The upshot is that the clerical tasks associated with our byzantine insurance system take physicians away from the bedside and from practicing actual medicine.

This wouldn’t be the case if we had a simpler health care financing system — for instance if there were only one insurer, or single payer, for all patients. What makes the health system so complicated and time-consuming is that it’s carved up into private insurance networks, instead of a standardized system where a single public plan finances medical care for virtually everyone, as in dozens of other countries. Of course, the health insurance companies profit from this arrangement, and so does the rapidly growing health informatics sector intent on monetizing the management of our complex system. But there is no value for patients in private insurance — and, increasingly, doctors are finding that they too get the short end of the stick.

In a 2015 international survey of primary care doctors by the Commonwealth Fund, only 16 percent of US doctors said the US health care system “works pretty well and only minor changes are necessary,” while 14 percent said it “has so much wrong with it that we need to completely rebuild it” — versus 22 percent and 11 percent in the UK and 36 percent and 3 percent in Canada, both countries with single-payer systems.

Under a single-payer or Medicare for All system, there would be no private corporations with the motivation and the power to deny coverage just to improve their bottom line. In fact, since the government would be the sole financer of every individual’s care from cradle to grave, it would be incentivized to keep people healthy in ways that insurance companies — which play musical chairs with patients and ultimately hand them off to the government in old age — simply aren’t. Under a single-payer system, the insurer would want doctors to do their jobs and treat people, instead of thwarting them when financially convenient.

Moreover, under a single-payer system, nobody would change networks — because there wouldn’t be any networks. Doctors could build long-lasting, rewarding relationships with patients again. Between less time on billing paperwork, more continuity in care, and no private insurers prohibiting them from healing the sick, it’s really not so hard to see why physicians are warming to Medicare for All.

https://jacobinmag.com…

Kip Sullivan explains ACOs to Seema Verma

Pathways To Success: A New Start For Medicare’s Accountable Care Organizations

By Seema Verma
Health Affairs Blog, August 9, 2018

For many years we have heard health care policymakers from both political parties opine about the need to move to a health care system that pays for the value of care delivered to patients, rather than the mere volume of services.

From the moment I became Administrator of the Centers for Medicare & Medicaid Services (CMS), I have been committed to using every tool at my disposal to move our health care system towards value-based care.

One set of value-based payment models that CMS has been closely reviewing are initiatives involving Accountable Care Organizations (ACOs).

In this post I will unpack key features of Medicare’s ACO initiatives and provide an overview of CMS’s new proposal for the Medicare Shared Savings Program, called “Pathways to Success.”

Upside-Only Versus Two-Sided ACOs

The majority of Medicare’s ACOs – 460 of the 561 or 82% of Shared Savings Program ACOs in 2018 – are in the upside-only “Track 1” of the Shared Savings Program, meaning that they share in savings but do not share in losses.  Currently, ACOs are allowed to remain in the one-sided track for up to six years.

The results show that ACOs that take on greater levels of risk show better results for cost and quality over time. (See Kip’s comments.)

The current combination of six years of upside-only risk, which involves bonus payments if spending is low but no risk of losses if spending goes up, along with the provision of waivers may be encouraging consolidation.  Such consolidation reduces choices for patients without controlling costs.  This is unacceptable.

The proposed changes included in Pathways to Success would shorten the maximum amount of time permitted in upside-only risk to allow a maximum of two years, or one year for ACOs identified as having previously participated in the Shared Savings Program under upside-only risk.

Streamlining the program, extending the length of agreements, and accelerating the transition to two-sided risk would result in reduced administrative burden and greater savings for patients and taxpayers.

Looking Forward

ACOs can be an important component of the move to a value-based system, but after six years of experience, the program must evolve to deliver value.  The time has come to put real “accountability” in Accountable Care Organizations.

https://www.healthaffairs.org…

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Seema Verma Hyperventilates About Tiny Differences Between ACOs Exposed to One-and Two-Sided Risk

By Kip Sullivan, J.D.
The Health Care Blog, August 21, 2018

There is no meaningful difference between the performance of Medicare ACOs that accept only upside risk (the chance to make money) and ACOs that accept both up- and downside risk (the risk of losing money). But CMS’s administrator, Seema Verma, thinks otherwise. According to her, one-sided ACOs are raising Medicare’s costs while two-sided ACOs are saving “significant” amounts of money. She is so sure of this that she is altering the rules of the Medicare Shared Savings Program (MSSP). Currently only 18 percent of MSSP ACOs accept two-sided risk. That will change next year. According to a proposed rule CMS published on August 9, ACOs will have at most two years to participate in the MSSP exposed to upside risk only, and after that they must accept two-sided risk.

That same day, Verma published an essay on the Health Affairs blog in which she revealed, presumably unwittingly, how little evidence she has to support her decision. The data Verma published in that essay revealed that one-sided ACOs are raising Medicare’s costs by six-one-hundredths of a percent while two-sided ACOs are cutting Medicare’s costs by seven-tenths of a percent. Because these figures do not consider the expenses ACOs incur, and because the algorithms CMS uses to assign patients to ACOs and to calculate ACO expenditure targets and actual performance are so complex, this microscopic difference is meaningless.

As pathetic as these figures are, they fail to take into account ACO start-up and operating costs. CMS doesn’t know or care what those costs are. The only relevant information we have are some undocumented statements by the staff of the Medicare Payment Advisory Commission (MedPAC) to the effect that ACO overhead is about 2 percent of their benchmarks (their predicted spending). I suspect 2 percent is low, but let’s take it at face value and do the math. If, as Verna’s data indicates, two-sided ACOs save Medicare seven-tenths of a percent net (that is, considering both CMS’s shared-savings payments to some ACOs and penalties other ACOs that lose money pay to CMS), but these ACOs spend 2 percent doing whatever it is ACOs do, that means the average two-sided ACO is losing one percent.

The good news is that Verma may have hastened the demise of a program that isn’t working. Whether Congress ultimately pulls the plug on the ACO project will depend on whether ACO advocates will concede at some point that the ACO fad was based on faith, not evidence, and has failed to work. I predict they will refuse to admit failure and will instead peddle another equally ineffective solution, for example, overpaying ACOs (as the Medicare Advantage insurers and their predecessors have been for the last half-century). I base my prediction on the behavior of ACO advocates. The history of the ACO movement indicates ACO proponents don’t make decisions based on evidence.

Facing the Evidence

Evidence that the ACO project is failing is piling up. All three of CMS’s two-sided ACO programs – the PGP demo, the Pioneer demo, and the Next Generation program – saved only a few tenths of a percent, while CMS’s mostly two-sided program, the MSSP, raised costs by a smidgeon. All four programs have raised costs if we take into account the ACOs’ start-up and operating costs and CMS’s cost of administering these complex programs. Evidence indicting the other major “value-based payment” fads – medical homes, bundled payments, and pay-for-performance schemes – is also piling up. The simultaneous failure of all these fads to cut costs spells trouble ahead for the Affordable Care Act (because it relies on “value-based payment reforms” for cost containment), MACRA (because it also relies on “value-based payment” theology), and our entire health care system (because the big insurance companies and the major hospital-clinic chains are spending more money on “value-based payment” fads than those fads are saving, and because these 1,000-pound gorillas are using the establishment’s endorsement of ACOs, medical homes etc. as an excuse to become 2,000-pound gorillas).

The root cause of our nation’s chronic inability to adopt effective cost-containment policies is the chronic inability of the American health policy establishment to make decisions based on evidence, not groupthink. Seema Verma’s decision to bet the farm on two-sided-risk ACOs is the latest example of this problem.

http://thehealthcareblog.com…

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Comment:

By Don McCanne, M.D.

We can thank Seema Verma for showing us that all of the talk about value-based payment – paying for value instead of volume through the establishment of accountable care organizations – was never really about value. Her insistence in shoving providers into downside risk reveals that it was always about reducing federal spending on Medicare. But that hasn’t changed her deceptive rhetoric about value and accountability.

Thank goodness we have astute analysts such as Kip Sullivan. The excerpts from his critique of Verma’s views as expressed in her Health Affairs Blog article should tempt you to read his entire critique at The Health Care Blog (link above).

The nonsense about ACOs has to go so we can get down to fixing the real problems with our health care financing system – the inequities, lack of universality, and lack of affordability for far too many individual patients. So let’s turn up the volume on a well designed, single payer, improved Medicare for all.

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Half of people in fair to poor health are uninsured or struggle with affordability

It's not just the uninsured — it's also the cost of health care

By Drew Altman
Axios, August 20, 2018

Share under age 65 who were uninsured or had problems affording care in 2017:

All people – 26.2%
15.5% – Insured but struggled with affordability
10.7% – Uninsured

People in fair or poor health – 46.4%
32.9% – Insured but struggled with affordability
13.5% – Uninsured

We still have an uninsured problem in the U.S., but we have a far broader health care affordability problem that hits sick people especially hard.

Why it matters:  It’s time to think more broadly about who’s having trouble paying for the health care they need. The combination of lack of insurance and affordability affects about a quarter of the non-elderly population at any one time, but almost half of people who are sick.

Now that the Affordable Care Act has expanded health coverage, the percentage of the non-elderly population that is uninsured is now just under 11%, the lowest level ever recorded. But as the chart shows:

* Another 15.5% who have insurance either skipped or delayed care because of the cost or reported that they or someone in their family faced problems paying their bills in 2017.

* That brings the total percentage of non-elderly people with insurance and affordability problems to 26.2%.

More striking: nearly half of all people in fair or poor health — 46.4% — are uninsured or have affordability problems despite having coverage.

* That includes 13.5% who were uninsured and in fair or poor health — arguably the worst off in the entire system — and another 32.9% percent who have insurance but said they or a family member have had a problem affording care in the last year.

It’s not surprising that people who are sicker and need more care would have more problems paying for it. But arguably an insurance system should work best for people who need it the most.

All this says a lot about current health care politics.

* It helps explain why so many people name health their top issue, despite the progress that has been made in covering the uninsured. And everyone who’s sick and can’t afford medical care has family members and friends who see what they are going through, creating a political multiplier effect.

* It is also why health care is substantially an economic issue as well as an issue of access to care. When people have trouble paying medical bills, it’s a hard hit to their family budgets — causing many people to take a second job, roll up more debt, borrow money, and forego other important family needs.

For as long as I have been in the field, we have used two measures more than any others to gauge the performance of the health system: the number of Americans who are uninsured and the percentage of GDP we spend on health. Both measures remain valid today.

The bottom line: If we want a measure that captures how people perceive the system when the number of uninsured is down and overall health spending has moderated, we need better ways of counting up the much larger share of the population who are having problems affording care.

And whatever big policy idea candidates are selling, from single payer on the left to health care choices on the right, the candidate who connects that idea to the public’s worries about paying their medical bills is the one who will have found the secret sauce.

https://www.axios.com…

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Comment:

By Don McCanne, M.D.

More boring numbers. But wait. These may be the most important numbers of all when we look at how our health care financing system is working. For the very people that our system should be designed to help – people in fair to poor health – it is not working well for nearly half of them!

Think about that.

When you need health care, the deductibles may create a financial barrier to care, potentially impairing access or creating a financial hardship.

When you need health care, the insurance premiums may be unaffordable and you end up uninsured, potentially creating an even greater financial hardship along with impaired access to care.

When you need health care, the insurers have likely limited you to physicians and hospitals that they have selected for their networks, preventing you from obtaining what may be more appropriate care outside of their networks, not to mention creating a greater financial burden when care outside of the network is unavoidable.

One-fourth of people under 65 are uninsured or struggle with affordability of health care.

But the most damning feature of our health care financing system is that nearly one-half of people under 65 who are in fair to poor health are uninsured or struggle with affordability of health care. This is a crisis that necessitates replacing our current costly but highly dysfunctional health care financing system with one that actually works – a well designed, single payer, improved Medicare for all.

This is an emergency. People are suffering, some are facing financial hardship or even personal bankruptcy, and others are dying!

We do not need more money. We are already spending enough. We merely need to restructure the financing system so that it is both universal and equitable in removing financial barriers to care. That is exactly what a single payer system is designed to do.

The clincher? Drew Altman reminds us that we have a choice between “single payer” and “health care choices.” Well, that’s not quite accurate because it is single payer that allows free choices in actual health care services whereas it is the insurers that give you choices of insurance products as they take away your choices in health care.

Altman’s challenge to find the “secret sauce” that addresses the public’s worries about paying their medical bills is the easiest challenge we’ve faced. Contrast the moral imperative of the single payer model, which brings affordable care to everyone, with the insurance industry’s “health care choices” – their deceptive euphemism for choosing a product from their highly profitable market of private insurance plans, even though they are not serving the interests of one-half of people under 65 who are in fair to poor health – the very population that an ethical health care financing system should be targeting.

This is a really simple concept that everyone should be able to understand. Share it widely.

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Not even CalPERS can guarantee that you can keep your doctor

14,000 CalPERS members and their families need to find a new 2019 health plan. Here’s why.

By Hannah Holzer
The Sacramento Bee, August 15, 2018

Changes at California’s pension giant will force more than 14,000 CalPERS members and their dependents in the Sacramento region and Bay Area to find a new health plan over the coming year.

The California Public Employees’ Retirement System recently negotiated its lowest premium increases in the past 21 years, which will mean lowered health premiums for 800,000 members in 2019.

As a result of the changes, CalPERS will part ways with two major providers — Health Net and Blue Shield — in some areas.

“The medical groups and hospitals members will have access to could change depending on their choice of health plan,” (CalPERS spokeswoman Stephanie) Buck said. “Members can call the doctor’s office and ask if they are affiliated with the health plan and the hospital they prefer to use. They may also contact the health plans directly.”

“The primary differences between most of the HMO (health maintenance organization) plans offered through CalPERS is a plan’s network of providers.”

“Blue Shield was not the only plan that struggled with the cost of care reflecting the price within the Bay Area region,” Buck said. “UnitedHealthcare also exited the region for contracting agencies and schools, and some other plans in the region had premium increases.” Contracting agencies are the employers that go through CalPERS for their health plans.

“We want to keep our insurance and our doctors. …We have not received any explanations of any reasons for this harsh decision which endangers our health,” said David Lerman, who currently has insurance coverage with Blue Shield through CalPERS.

“CalPERS health plans contract with a network of providers, and each year CalPERS and its contracted health plans re-evaluate these networks,” Buck said. “Depending on a variety of factors, not least of which is cost, providers ask that their coverage areas change for certain plans.”

https://www.sacbee.com…

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Comment:

By Don McCanne, M.D.

Think back twenty years ago and try to remember what health insurance coverage you had then. Unless you are over 85 and on Medicare the chances are very great that you do not have the same coverage now. For many reasons the market for private health plans, whether employer-sponsored or individual, continually changes.

The California Public Employees’ Retirement System (CalPERS), as the second largest system in the nation (next to the Federal Employees Health Benefit Program), has one of the most stable health care coverage programs in the U.S., but not even CalPERS can guarantee that you can keep your same coverage from one year to the next. Since most plans today use provider networks, and the composition of the networks varies from one plan to the next, that means that you may have to change your physicians and other health care professionals, and maybe even your hospitals, whenever your insurance changes.

(It should be mentioned that California has a “continuity of care” provision in which, in certain specific situations, a patient may continue with the same doctor or hospital for a limited period of time, making the transition less disruptive.)

Median employment tenure is now about four years (BLS), so, for that reason alone, change in insurance coverage is frequent. Besides changing jobs, other reasons for changing or losing coverage can include your employer changing plans offered, loss of employment, inability to afford coverage, retirement, income above the threshold for public coverage through Medicaid, loss of eligibility for COBRA, and the like.

The point is that since coverage is not stable, insurer designated networks are not stable either, and thus choice of physicians and other providers may be sacrificed merely because we insist on perpetuating our highly fragmented system of financing health care.

If we had a single health program that included everyone permanently, such as an improved version of our traditional Medicare program (without the private Medicare Advantage plans and their networks) then each of us would have our choice of physicians and hospitals – for life.

It seems foolish that we give up lifetime freedom of choice of our physicians and hospitals just to keep the insurance that we have only temporarily (changing an average of every four years) when virtually all of us look forward to going on Medicare permanently at age 65. Why should only our seniors and those with long term disabilities and chronic renal disease be treated so well? Why not all of us?

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Jonathan Chait tells us single payer is not easy

Pretending Single Payer Health Care Is Easy to Pass Doesn’t Make It Easy

By Jonathan Chait
New York Magazine, Daily Intelligencer, August 16, 2018

The American health care system developed, like a deformed tree, around employer-sponsored insurance as its core feature. This has made it extremely hard to build a single, simple universal system, because it would require moving people out of health care they have into something new, and require turning their premium contributions into taxes.

If you could sit down face to face with every American and calmly talk them through the numbers step by step, you could probably convince them to feeling comfortable giving up employer-sponsored insurance. Since you can’t do that, the only option is passing a bill in a hysterical atmosphere where the insurance industry and conservatives bombard the public with warnings of massive middle-class tax hikes and tens of millions of Americans losing their current insurance to get moved onto a government plan.

If we didn’t have an employer-based system already, it might be politically feasible to build a single-payer system. But the politics of uprooting that deformed tree are extremely imposing. You can read a history of the struggle for universal health care, like Jonathan Cohn’s Sick, or Paul Starr’s Remedy and Reaction, to understand why most liberals (and Democratic elites) believe the growth of the employer system has tragically blocked the political path to single payer.

Those conclusions, built up over decades of experience and polling data, inform the mainstream liberal view of health care. Since it’s just too hard to convince people they’ll be better off paying taxes instead of premiums, and exchanging their current insurance for a government health care plan, the path to universal coverages lies in working around the existing system. Paul Krugman made this case last year, and so did I.

To quote the column of mine… “Yes, in an imaginary, rational world, people could be reassured that Medicare will be as good as what they have, and the taxes will merely replace the premiums they’re already paying. In reality, people are deeply loss-averse and distrustful of politicians.” Krugman doesn’t deny that either. “You’d have to convince most of these people both that they would save more in premiums than they pay in additional taxes, and that their new coverage would be just as good as the old,” he writes… “This might in fact be true, but it would be one heck of a hard sell.”

It’s possible, of course, that this political analysis is wrong, or that it will change one day.

If single-payer advocates can come up with a way to get around the political obstacles in the way of single payer, they should say what they are. (I have seen many such efforts, though none have struck me as persuasive.) More to the point, you’re never going to enact single payer unless you can address the political obstacles.

http://nymag.com…

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Comment:

By Don McCanne, M.D.

Jonathan Chait is correct. The benefits of a well designed, single payer, improved Medicare for all are not in dispute. It is not the policies that are a problem, but rather it is the political obstacles that have prevented us from enacting and implementing such a system.

We are moving again into a debate on the left – the progressives supporting a bona fide single payer Medicare for all system, and the centrists expropriating the Medicare for all rhetoric to support a public option with a Medicare label. The ideologues on the right don’t have to do anything. The left will self-destruct thereby confirming that Chait’s point is correct – the political obstacles are great.

An important point here is that the policy message must remain intact. You do not discard essential policy positions as you sit down to negotiate a compromise, such as supporting the incremental step of enacting a public option with a Medicare label. We did that before.

Although the single payer purists were ejected from the process, the center-left supported a public option, but then in negotiations allowed it to be transformed from a strong public model, as described by Jacob Hacker, into a very weak model even stripped of some of the beneficial features of private commercial insurance just to be sure that it would not be a competitive threat in the private market. Even that was too much, and so the emasculated public option was abandoned. That’s what happens when you compromise on policy.

Incremental steps merely tweak our dysfunctional, inequitable, unaffordable, administratively overburdened system – perpetuating most of the defects that cry out for reform. We basically have the single payer policy right. We do not want to negotiate that away as the center-left did last time.

Although the barriers are political, it is a mistake to make them partisan. That’s obvious when you look at the obstructionism of the Republicans who for years demanded that we replace the Affordable Care Act with their own model that it turns out never really existed. It definitely would be a mistake, as mentioned above, for the Democrats to move forward now with this intra-party divide on single payer Medicare for all versus a Medicare public option for some.

The right understands the well designed single payer model. The recent Mercatus report is an example, even if the single payer concept was modified to try to discredit the concept. They still showed that everyone would be covered with a $2 trillion savings over a decade (though the results would be much more impressive had they accurately analyzed a model such as PNHP’s). Also, in a recent Quote of the Day, two libertarians in separate reports indicated that they too understand the benefits of the single payer model. So we don’t want to change policy, and, on the politics, we want to end partisanship and start communicating better.

But to the really important point in Chait’s article, he says that we are not persuasive in our suggestions on how to get around the political obstacles in the way of single payer. He has a point since we currently do not have a single payer system in spite of a quarter of a century of trying. But what we don’t want to do is to walk away because the political barriers are too great, thereby making that a self-fulfilling prophecy (Chait and Krugman, take note). So how do we get around those barriers?

First, as Chait indicates, is eduction. We must be unrelenting in getting out the word on just what an improved Medicare is all about. As the understanding of the concept increases, coalition and grassroots organizing must be utilized to help spread the word. Polling indicates that these efforts have been effective, but the process is very slow and laborious.

Chait, Krugman and others have acknowledged the clear benefits of the single payer model while they have become somewhat dismissive because of the political challenges. Rather than an expression of pessimism on their part, it seems to me that they are expressing realism with their understanding of how difficult the process is. We certainly understand that as well, as we have lived with this all these years.

Education. Coalitions. Activism. Grassroots organizing. These activities in all of their permutations. Be there and do it. Maybe Chait doesn’t think this is persuasive, but it is what we have, and it can work as those in the civil rights movement have shown us (and Social Security, and Medicare, and the end of the Vietnam war, and so on). We must keep on. As FDR said, “make me do it.”

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