Resource – Page 202

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…

***

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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Medicare for all’s time has come

By Sen. Bernie Sanders
CNN, August 16, 2018

Let’s be clear. The American people are increasingly tired of a health care system that works for Wall Street investors, insurance companies and the pharmaceutical industry — but ignores their needs. They want real change, and poll after poll shows that they want to move toward a Medicare-for-all, single-payer system. And for good reason.

Today, the United States has the most expensive, inefficient, and bureaucratic health care system in the world. Despite the fact that we are the only major country on earth not to guarantee health care for all — and have 30 million uninsured and even more who are underinsured — we now spend more than twice as much per capita on health care as the average developed country.

According to a recent Organisation for Economic Co-operation and Development analysis, we spend more than $10,300 per capita on health care. Meanwhile, Canada spends just $4,826, France spends $4,902, Germany spends $5,728, and the United Kingdom spends $4,264.

Further, despite this huge expenditure, which now constitutes almost 18% of our GDP, our health care outcomes are worse than most of these other countries. For example, our life expectancy is 2.5 years lower than Germany’s and our mortality rate for children under the age of 19 is at the top of the list compared to other developed countries.

The ongoing failure of our health care system is directly attributable to the fact that — unique among major nations — it is primarily designed not to provide quality care to all in a cost-effective way. Instead, the system makes maximum profits for health insurance companies, the pharmaceutical industry and medical equipment suppliers.

The Medicare-for-all legislation that I wrote, which now has 16 co-sponsors in the Senate, would provide comprehensive health care to every man, woman and child in our country — without out-of-pocket expenses. No more insurance premiums, deductibles or co-payments. Further, it would expand Medicare coverage to include dental and vision care. In other words, this plan would do exactly what should be done in a civilized and democratic society. It would allow all Americans, regardless of their income, to get the health care they need when they need it.

Under the current system, while thousands of Americans die each year because they lack access to the health care they desperately need, the top five health insurance companies last year made $21 billion in profits, led by the UnitedHealth Group, which made $10.56 billion.

As tens of thousands of American families face bankruptcy and financial ruin because of the outrageously high cost of health care, the CEOs of major insurance companies receive disgustingly high levels of compensation. According to Axios, in 2017, the CEO of UnitedHealth Group, Dave Wichmann, received $83.2 million; the CEO of Aetna, Mark Bertolini, received $58.7 million, and the CEO of Cigna, David Cordani, received $43.9 million.

Today, as an indication of how dysfunctional our current system is, about one out of every five Americans cannot afford to fill the prescriptions given to them by their doctors because we pay, by far, the highest price in the world for prescription drugs. A 2013 study showed that in 2010, the United States paid, on average, about double what was paid in the United Kingdom, Australia, and Switzerland for prescription drugs. Since 2014, the cost of 60 drugs commonly taken has more than doubled, and 20 of them have at least quadrupled in price.

While millions of Americans are unable to afford the medicine they desperately need, or are forced to cut their pills in half in order to save money, five top drug companies made over $50 billion in profits last year and, in 2015, 10 prescription drug CEOs made a combined $327 million in total compensation.

Would a Medicare-for-all health care system be expensive? Yes. But, while providing comprehensive health care for all, it would be significantly less costly than our current dysfunctional system because it would eliminate an enormous amount of the bureaucracy, administrative costs and misplaced priorities inherent in our current for-profit system.

Instead of doctors and nurses spending a significant part of their day filling out forms and arguing with insurance companies, they could be using their time to provide care to their patients. We’d be able to save up to $500 billion annually in billing and administrative costs. That money could be used to greatly expand primary care in this country and make certain that all Americans got the health care they needed when they needed it — saving billions on expensive emergency room care and hospital visits. Instead of paying the highest prices in the world for prescription drugs, we could save hundreds of billions over a 10 year period through tough negotiations with the drug companies.

The benefits of a Medicare-for-all, single-payer system are so obvious that even a recent study done by the right-wing Mercatus Center estimated that it would save Americans more than $2 trillion over a decade, reducing the projected cost of health care between 2022 and 2031 from $59.7 trillion to $57.6 trillion. Needless to say, that wasn’t the point the study attempted to emphasize. Rather, the author of the study was hoping the headline — “Medicare for All costs the federal government $32.6 trillion” — would frighten the American people and get them to oppose it.

While opponents of Medicare for all focus their criticism on the increased taxes the American people will have to pay, they conveniently ignore the fact that ordinary people and businesses will no longer have to pay sky-high premiums, co-payments and deductibles for private health insurance.

At a time when health care in 2018 for a typical family of four with an employer-sponsored PPO plan now costs more than $28,000, according to the Milliman Medical Index, the reality is that a Medicare-for-all system would save the average family significant sums of money.

A recent study by RAND found that moving to a Medicare-for-all system in New York would save a family with an income of $185,000 or less about $3,000 a year, on average. Even the projections from the Mercatus Center suggest that the average American could save about $6,000 under Medicare for all over a 10-year period.

A Medicare-for-all system not only benefits individuals and families, it would benefit the business community. Small- and medium-sized businesses would be free to focus on their core business goals instead of wasting precious energy and resources navigating an incredibly complex system to provide health insurance to their employees.

Needless to say, there is huge opposition to this legislation from the powerful special interests that profit from the current wasteful system. The insurance companies, the drug companies, Wall Street and the Koch brothers will undoubtedly spend billions on lobbying, campaign contributions and television ads to defeat Medicare for all. But they are on the wrong side of history.

Here is the bottom line: If every major country on earth can guarantee health care to all and achieve better health outcomes, while spending substantially less per capita than we do, it is absurd for anyone to suggest that the United States of America cannot do the same.

https://www.cnn.com…

The medical lobby is already peddling lies about Medicare-for-all

By Ryan Cooper
The Week, August 16, 2018

Medicare-for-all is getting some real momentum behind it, with several more supporters winning congressional primaries on Tuesday night. The medical industry — drug companies, insurance companies, medical providers, and others — has thus been gearing up to preserve the fat profits they enjoy under the horrendous status quo. They’ve formed a group called The Partnership for America’s Health Care Future (PAHCF) to run a propaganda campaign against universal health care.

Their main argument is pretty clearly going to be centered around loss-aversion. “Most Americans support commonsense, pragmatic solutions that don’t interrupt the coverage they rely upon for themselves and their families,” PAHCF spokesman Erik Smith told The Hill. (Jonathan Chait and Paul Krugman have made similar points.)

But this argument is garbage. Medicare-for-all would mean vastly more people enjoying good health care, and dramatically fewer people getting kicked off their insurance overall.

For starters, the status quo system leaves about 30 million people uninsured. Those people don’t get to rely on the “commonsense, pragmatic solutions” of our current system, they just go without health care, or die of preventable diseases, or are driven into bankruptcy by wildly overpriced treatment. Incidentally, the first thing most medical lobby clients do to uninsured patients is bleed them of every last penny by charging them immensely higher prices than insured ones. Many can’t pay, of course, meaning others end up being charged more to cover the difference.

But let’s examine the core of the case — the roughly half of the non-elderly population that is on employer-sponsored insurance. It is true, of course, that there would be an enormous one-time switch where those people are transferred from their current plan onto Medicare (under the Sanders bill, actually several smaller switches as the program is gradually rolled out over four years). After the program is fully implemented, private insurers would be forbidden from offering benefits that duplicate those of Medicare, effectively finishing off private health insurance since the new program would be so generous. Eventually everyone would end up switching over. But contrary to the deceptive implication of Smith that there would be some interruption in coverage — implying a period of no insurance — Medicare would kick in immediately, and permanently.

More importantly, the status quo system is constantly kicking people off their insurance. Just consider the life cycle of the average person. Children typically get coverage through their parents (if they are insured, that is), now up to age 26 thanks to ObamaCare. But once that birthday is reached, they get kicked off. If they are lucky enough to have a job with insurance benefits at that point, then they can be enrolled in a new plan. But if they ever lose that job or find a new job, then they get kicked off again, and once more every time they move jobs. Even people who remain in jobs can end up switching plans, as employers often shop around for a better deal.

There is enormous churn in the labor market, with about 60 million net job separations in 2016. Suppose half those jobs came with benefits — a conservative estimate, because while only 53 percent of firms offer health benefits to some of their workers, virtually all large employers do, and they employ the bulk of workers, meaning 89 percent of total workers are in firms that offer at least some benefits. That means something like 150 million net insurance loss events every five years.

And if people end up on ObamaCare exchanges, they routinely get kicked off their coverage if plans change at the end of the year, or their insurer withdraws from the exchange. Some exchange enrollees have even lost their coverage every single year since 2014, as exchanges have shed insurers (or even lost them completely).

Then there is Medicaid — a godsend to tens of millions of poor and working-class Americans to be sure, and the single largest insurer in the country. But because of Medicaid’s strict eligibility requirements, people routinely lose coverage if they make too much money. Millions of people bounce in and out of the program every year. Finally, there is the last insurance switch every American hits at age 65 when they become eligible for existing Medicare.

Speaking personally, I am 32 years old and have already been forced to switch insurance six times — or six-fold as many occasions as the Dread Medicare Enrollment would cause. There’s at least one more coming up when I hit old age, and realistically a lot more than that absent policy changes.

What’s more, Sanders’ Medicare-for-all program would be immensely superior to virtually all private insurance. The average family premium for an employer-sponsored plan has increased 55 percent since 2007, while average workers contributions have increased 77 percent. Some 81 percent of private plans now have a deductible (which must be paid before insurance kicks in for most care), at an average of $1,505. For primary care, 71 percent have co-pays (a flat fee) and 22 percent have co-insurance (a percentage charge), at $25 and 19 percent respectively. All those cost-sharing trends — and many others for specialty and emergency care, surgeries, and hospital admissions — have been getting steadily worse over time. Insurance networks are also narrowing over time, making it harder to find providers that will accept one’s coverage.

By contrast, Sanders’ Medicare-for-all would cover nearly all areas of medical treatment (including vision, dental, and hearing, though not long-term care) with no cost-sharing except for prescription drugs. Even that limited cost-sharing would be limited to $250 per year. And it would certainly be accepted by virtually every provider in the country — with the entire population in the program, they would have little choice (indeed, over 90 percent of primary care physicians already accept existing Medicare due to its large enrollment base of 59 million, and that is only about 18 percent of Americans). Worries about out-of-network coverage would vanish. Switching onto that plan would be cause for wild celebration for the vast majority of people, not some uncomfortable burden.

To sum up: Not only is the medical lobby’s argument mistaken, it is the exact opposite of true. Medicare-for-all would eliminate uninsurance, drastically curtail the number of people losing their coverage, and to the extent people would be forced to switch, it would be an enormous and permanent upgrade in quality.

So why is the medical lobby mobilizing against this bill? It’s simple: money. America’s total health expenditures are roughly twice that of the OECD average — nearly 5 points of GDP (or about $900 billion) higher than Switzerland, the second-most expensive country. A great deal of that spending comes in the form of big corporate profits, pointless administrative busywork, and hugely excessive doctor salaries (especially for specialists). Sanders’ Medicare-for-all bill would pay for expanded coverage and increased treatment access by wringing out some of those inefficiencies — on net, provider payments would be cut by about 11 percent.

This medical lobby effort against the idea is nothing more than greed.

http://theweek.com…

Is it about measurement or is it about patient care?

Achieving Meaningful Measurement In Medicare

By Aparna Higgins, Mark McClellan
Health Affairs Blog. August 15, 2018

The secretary of the Department of Health and Human Services (HHS) recently highlighted value-based transformation as one of the department’s top four priorities, with an emphasis on “putting the consumer in charge, letting them determine value.” While definitions of value may vary based on beneficiary preferences, objective, reliable, and meaningful quality and cost measures are important components of individuals’ and health care providers’ assessment of value. However, obtaining such measures of value in practice has proven challenging. To address concerns with the usefulness of and burden of implementing the quality measures currently in use, the Centers for Medicare and Medicaid Services (CMS) launched its Meaningful Measures initiative. Its first task is to review the extent to which existing quality measures are fulfilling the needs of consumers and providers and identifying priority gaps.

The success of APMs and patient engagement in care more generally is inextricably linked to the quality of the measures that are used in these APMs, and the burden versus benefit of collecting these measures. As CMS seeks to further evolve payment models, it is important for policy makers to consider what kinds of measures we would want to invent that can then be tied to a set of alternative payments. The approach presented in this blog post can serve as a starting point for a dialogue on this topic. Many of the concepts presented here need further discussion, refinement, and development. The Meaningful Measures initiative can provide a platform for such discussion and help launch a re-engineering of measures and measurement.

https://www.healthaffairs.org…

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Assessing the Medicare Advantage Star Ratings

By Dan Jamieson, Monisha Machado-Pereira, Stephanie Carlton, and Cara Repasky
McKinsey & Company, July 2018

Every October since 2009, the Centers for Medicare and Medicaid Services (CMS) has released comprehensive data on Medicare Advantage (MA) health plan performance through its Star Ratings program. The program’s goals are to incentivize health insurers to improve their MA plans and encourage consumers to enroll in high-quality plans. To investigate whether these goals are being met, we analyzed CMS’s data for 2018 and previous years.

On average, the plans’ scores have risen substantially, both overall and on the 22 individual quality measures that have been used consistently since the program’s inception.

The overall scores are based on the scores assigned to specific measures, many of which have been modified since the program’s inception. However, 22 of the measures have been used consistently since 2009. (We call this set the consistent measures.) After calculating the enrollment-weighted average scores for each of the consistent measures, we found that all but two have risen over time.

From the table of measures included in all Star Ratings years:

Improving or maintaining physical health

3.4 – Weighted-average Star Rating, 2009

2.8 – Weighted-average Star Rating, 2018

https://www.mckinsey.com…

***

Comment:

By Don McCanne, M.D.

These days it seems that the policy community is deeply involved in issues related to quality, accountability, incentives, and the such, through value-based alternative payment models such as accountable care organizations or systems such as Medicare Advantage plans. Is optimal care of the patient being lost in all of this?

Recently there has been some celebration of the success of the Star Ratings used for the private Medicare Advantage plans, supposedly showing that quality is improving. If you look at the McKinsey report, you will find the scores for 22 quality measures used during the last decade. The plan providers have been told repeatedly what will be measured; the measurements were taken, and the Star Ratings were assigned. It should be no surprise that the scores improved. It’s not even an open-book test; it’s a one-page cheat sheet with all the answers.

What is alarming is that the most important score – the one for “improving or maintaining physical health” – deteriorated! While the providers have been busy making sure that they scored well, the patients have been neglected (as anyone who has watched their health care professional spend their contact time staring at the computer can attest to).

Yet the governmental and private members of the policy community plow on with nebulous goals of imposing accountability and quality through alternative payment models such as accountable care organizations. But look at the hope for the future as described by Aparna Higgins and Mark McClellan:

“It is important for policy makers to consider what kinds of measures we would want to invent that can then be tied to a set of alternative payments”… though “Many of the concepts presented here need further discussion, refinement, and development.”

We’re moving forward with policies that we haven’t even invented yet?

My twin and I started in private practice the same month that Medicare and Medicaid were implemented, joining our father and older brother. To them it was almost like a miraculous change. We could just take care of the patients and not worry about other issues such as how payment would be made.

Alas, it didn’t last. Insurers were granted the right to contract with physicians. Managed care moved in with a vengeance. Medicare began its march to privatization with the opening of the Medicare Advantage market. And now we face MIPS, APMs, ACOs, and, according to Higgins and McClellan, whatever else the policy makers “would want to invent” even if lacking in “further discussion, refinement, and development.”

Let’s get back to the original precepts of Medicare: removing financial barriers to essential health care services; place the patients first. Medicare does have some problems that we can easily fix, so let’s do that, include everyone, and then move forward with health care that actually will maintain and improve physical health. The McKinsey report shows that we’re not doing that now. But we don’t need to reinvent the traditional Medicare program, we just need to fix it.

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Medicare Advantage as the true Medicare? Rhetoric won’t make it so

Creating Medicare Advantage Premium Support For All, Part 5: Which Proposal Is Actually Medicare?

By Billy Wynne
Health Affairs Blog, August 15, 2018

Now that a report funded by the Koch Brothers™ (do they have a logo?) accidentally fueled the single payer movement by demonstrating a national coverage system would be cheaper than the irrational hodgepodge we have now, it’s important to continue to weigh the evidence regarding which approach to universal coverage would be optimal.

The focal point of the single payer cause is Senator Bernie Sanders’ “Medicare for All” proposal. (Spoiler alert: it’s not actually Medicare. More on that in a minute). While I happen to believe the single payer crowd’s intentions are in the right place, I have to wonder, for starters, whether the arguably most conservative developed nation will adopt one of the most liberal, socialized approaches to health care coverage.

Instead, I continue to believe that a regime that truly leverages the existing Medicare program in a way that minimizes disruption and maximizes market forces will produce the cheapest, highest quality, most sustainable, and – to use a loaded term – American result.

Sanders Plan 101

Perhaps the most interesting thing about the Sanders Medicare for All plan, scooped above, is that it would not actually extend Medicare to everyone. To the contrary, section 901 of his bill would halt all Medicare benefits, effectively repealing the program in its entirety.

Instead, his proposal would institute a wholly new program, with different benefit design and brand new administrative infrastructure. For example, a new list of essential benefits is outlined in the legislation, the elaborate Medicare cost-sharing scheme would be replaced with first dollar coverage, and the prescription drug program would be replaced with a national formulary.

Medicare Advantage 101

Instead, what if we actually did just expand the stable, beloved Medicare program to include everyone, with emphasis on competition between the traditional benefit and increasingly popular Medicare Advantage plans? In a prior post, I took a closer look at the basic Medicare benefit design. Here, I’d like to explain how the Medicare Advantage (MA), or Part C, program works and what it could offer to a national coverage regime.

MA carriers are required to cover all traditional Medicare benefits (Parts A and B) and offer at least one plan that includes an accompanying prescription drug (Part D) component.

A key strategy that these plans use to reduce costs, which is not deployed in the traditional Medicare program, is limited provider networks. As explained in a prior post, this function lies at the core of why health plans can continue to play an important role in our system.

In 2017, MA plan payments were, on average, equal to the costs of delivering the traditional Medicare benefit.

Unlike traditional Medicare, MA plans are required to cap annual enrollee out of pocket spending on outpatient services at $6700. Using those rebates described above, 50 percent of plans offered coverage that caps that liability at below $5000 in 2017. Also, about half of plans were able to eliminate the Part D deductible altogether.

In Other Words…

I don’t think we need a wholly new coverage regime that upends 20 percent of our economy and, with its centralization of decision-making within the federal government, will never earn the broad support necessary to pass, much less make it sustainable.

After the ACA, I think we’re weary of conjuring new coverage regimes from whole cloth. We have plenty in this country already. Let’s pick the one that has proven itself for decades and increasingly leverages competition between commercial carriers and a government administered option to deliver high-value choices to its consumers. In other words: Medicare.

***

Health Affairs Comment:

By Don McCanne, M.D.

Which proposal is actual Medicare, or, for that matter, which is an “American” result? An improved version of the traditional Medicare program expanded to include everyone, or an expanded market of private Medicare Advantage health plans? Instead of diverting this into a rhetorical debate, we should look at which policies applied to nearly one-fifth of our economy would serve us all best.

Although the traditional Medicare program grants the individual the right to choose their health care professionals and institutions – a right that private Medicare Advantage plans restrict by use of provider networks – out-of-pocket expenses are still too high, especially considering the lack of a cap on those expenses.

Private Medicare Advantage plans pay physicians at the same rates as traditional Medicare – much lower than private commercial insurance rates – but they did not achieve this through competition in the marketplace; it was through government fiat – government administered pricing in the private sector. Not only are payment rates lower, but the cap was enacted only for private plans and not for the traditional Medicare program.

Since the out-of-pocket costs are too high, those in the traditional Medicare program require supplemental coverage through retiree plans, dual Medicaid coverage, or they must turn to overpriced Medigap plans which are the main competition for the Medicare Advantage plans. It is the lower premiums plus lower out-of-pocket costs plus a few expanded benefits that the Medicare Advantage plans can offer that has resulted in their popularity. In spite of this advantage, two-thirds still enroll in the traditional Medicare even though it may cost them more (unfairly so since the government gives this advantage to the private plans while denying it to the traditional Medicare program – as part of an ongoing effort to privatize Medicare).

Suppose Congress made the premiums and cost sharing equivalent in the two programs, which of them would be in a better position to manage our health care financing? It is well known that the traditional program has much lower administrative costs (under 3%) thus more of the funds go to health care. But what is not commonly realized is that “Medicare Advantage insurer revenues are 30 percent higher than their healthcare spending” (NBER No. 23090). 30 percent! The taxpayers are getting a terrible deal from the private Medicare Advantage insurers.

There are, of course, many other advantages to a single payer, improved Medicare for all such as true universality, savings from administrative efficiency, improved resource allocation, and an equitable method of progressive financing that removes financial barriers to care while making health care affordable for all.

That rhetoric about an American result? Improving the traditional Medicare program that is still revered by a majority of Americans, or disrupting the system by turning our public funds over to the private insurance industry profiteers? Which America do we really want?

https://www.healthaffairs.org…

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Faith community must embrace single-payer health system

By Fran Quigley
National Catholic Reporter, August 15, 2018

Mark Trover of Indiana had a job and access to health insurance, but the premiums and co-pays were too high for him to afford. A doctor had prescribed medicine for his dangerously high blood pressure, but the cost was high and Trover stopped filling the prescription — right up until the time he suffered a stroke that left him permanently disabled.

Karyn Wofford of Georgia has type 1 diabetes, and has often been forced to ration the insulin she needs to survive. The cost of the medicine has risen over 1,000 percent in recent years, and the 29 year-old knows there are many other Americans who have suffered and even died from diabetic ketoacidosis because they could not afford the medicine. “Having access to diabetic supplies and insulin, to feel okay when I wake up in the morning — that’s my dream,” she wrote for the T1 International blog.

These stories represent the status quo of U.S. health care. Even after the Affordable Care Act, there are over 28 million people in our country living completely without health coverage, a group disproportionately made up of people of color. Among those who do have insurance coverage, nearly a third are enrolled in high-deductible insurance plans that can force them to skip filling prescriptions or go without other necessary care.

For those who do obtain care, the side effect is often crippling debt: one out of four Americans under 65 carry past-due medical debt, and health care costs are the leading cause of family bankruptcies. For millions of Americans, dental care means relying on what one magazine recently called “pliers, chisels, and whiskey” for removal of their decayed teeth.

Our health care system has turned us into a country of beggars. GoFundMe’s CEO says that the website’s hundreds of thousands of pages pleading for help paying for medical procedures and prescriptions “put GoFundMe on the map.” This state of affairs may be good for the company, but the vast majority of medical treatment crowdfunding campaigns don’t meet their target.

In response to the mean-spirited and fiscally self-sabotaging efforts to repeal the Affordable Care Act last year, faith groups raised their collective voice, and to great effect. Dozens of denominations and organizations from a wide range of faith traditions issued joint statements, mobilized their members, and conducted a dramatic Capitol Hill vigil. They brought a morally powerful foundation to the resistance to Affordable Care Act repeal efforts.

As a March 2017 letter signed by leaders of 40 faith organizations said, “The scriptures of the Abrahamic traditions of Christians, Jews, and Muslims, as well as the sacred teachings of other faiths, understand that addressing the general welfare of the nation includes giving particular attention to people experiencing poverty or sickness.”

That shared mandate compelled us as people of faith to act to preserve the Affordable Care Act, which has expanded care to millions of Americans who needed it. Now, those same sacred teachings require us to speak out with just as much urgency to fully repair the gaps left behind even after the act is preserved.

Profiting from sickness

The foundational flaw in our U.S. health care system is its cruel focus on extracting corporate profits from the struggling and the sick. We generate billions of dollars each year for for-profit insurance companies and monopoly-protected pharmaceutical corporations, but the resulting injustice and inefficiencies have made us the globe’s most notorious underachiever in health care. Among comparable nations, we consistently pay the most for our care while enduring worse outcomes.

Let’s be clear about the real-world meaning of “worse outcomes:” every year, tens of thousands of Americans die preventable deaths due to the lack of adequate health insurance. Millions more suffer needlessly from grinding pain and disability.

Many of the gaps in U.S. health insurance coverage can be traced back to our reliance on employment-based health insurance. In this respect, we are an outlier in the global economy, clinging to a mid-20th century model that is mismatched with current economic realities and the nature of our workforce. But other gaps are found within our government health care programs, where corporate campaign contributors and lobbyists from the so-called medical-industrial complex have persuaded our elected leaders to divert taxpayer health dollars into the coffers of for-profit companies.

The Affordable Care Act handed a key to the health care cash register to private insurance companies, thus requiring taxpayers to pay for those companies’ administrative bloat, quarterly profits, and CEO salaries that can go as high as $17 million per year. Medicare and Medicaid also carve out a large piece of their resources for the benefit of private insurance companies and sweetheart no-negotiation deals for pharmaceutical corporations. These handouts to corporations exact their cost on patients and taxpayers alike: Medicare and Medicaid both have significantly less effective coverage compared to the programs of other nations that refuse to subsidize for-profit companies.

Pope Francis is among many faith leaders who has condemned the treatment of life-essential care and medicines as a commodity to be leveraged for maximum corporate profits. “Health is not a consumer good, but a universal right,” Francis said in 2016. “So access to health care services cannot be a privilege.”

Faith and the human right to health

The U.S. faith community can take justifiable pride in providing direct charity health care, and our response to the current crisis should continue to embrace that legacy. But when even our best charitable efforts leave enormous gaps in coverage, people of faith in the U.S. are also called to do more. We must loudly and insistently affirm that health care is a human right, foundational for the exercise of all other human rights. Despite its lack of realization in the U.S., the right to health care has been well-established in international law for more than 70 years. Its roots in faith traditions go far deeper, with all major religious traditions embracing a clear responsibility to provide for the poor and the sick.

Of course, there are dozens of New Testament references to Jesus performing acts of healing, so many that he was often referred to in the early church as “The Great Physician.” The Old Testament includes health care mandates throughout, including in Proverbs 31:9, Isaiah 1:17 and Deuteronomy 15:11 (“You shall open wide your hand to your brother, to the needy, and to the poor.”) History’s first structured charity hospitals were built by Islamic communities, fulfilling that faith’s unequivocal mandate to care for the needs of the poor. The Buddhist, Taoist, and Confucian traditions are replete with similar health care examples dating back as far as 400 B.C.

Health care needs across our society are vast in both their scope and complexity, and even political conservatives concede that a market-driven approach is a poor fit for meeting the needs of the sick and the struggling. The same is true for our societal challenges of ensuring public safety, a functioning infrastructure, and protection of our legal rights. We meet those challenges with communal systems, where our government acts in our names and is accountable to us all. With health care, we must do the same.

There is a proven model for achieving that type of health care system, a compassionate alternative to the cobbled-together, profit-oriented mess that we endure now in the U.S. That model is a single-payer health care system. Single-payer is simple and efficient. Its hallmark feature is a guarantee that all U.S. residents are covered from birth to death for all of our health needs, from doctor visits to prescription medicines to dental and vision care.

Single-payer health care

The term single-payer refers to the government being the responsible party for health care bills, as is the case now in countries like Canada and Taiwan. It is also the foundation for the core components of our own Medicare system. Under single-payer, coverage is no longer tied to the fine print in private insurance policies or the whims of employment. Premiums, co-payments, and deductibles disappear.

That may sound like a utopia, but universal coverage and low-cost care is the norm for other countries with the resources the U.S. enjoys. Their experiences prove that we can provide better care thanks to the hundreds of billions of savings gained by bypassing the bloated administrative costs associated with for-profit claims processing, billing and marketing. Further savings come from using single-payer bulk purchasing power to negotiate down the skyrocketing costs of prescription drugs, as other nations do quite successfully.

People of faith can help debunk some of the myths about single-payer, most of them originally concocted by corporations desperate to preserve their lucrative healthcare business models. First of all, single-payer is not so-called “socialized medicine.” As in the Medicare system, the government under single-payer pays the bills but does not operate hospitals and hire physicians. Compared to restrictive private insurance policies, our choices for where we obtain care will actually expand under single-payer.

Second, stories of delayed medical procedures in single-payer countries like Canada are greatly exaggerated, especially since there is never a waiting list for urgent care. Instead, generations of Canadians have grown up not knowing what it is like to worry about paying a medical bill, and universal coverage is obtained at about half the cost of our patchwork U.S. system. A whopping 94 percent of Canadians report taking national pride in the success of their health care system.

The faith community embrace of single-payer would put us in good company. Frustrated by the hours they spend every day on private insurance paperwork, a majority of U.S. physicians now support a single-payer system. So do many business leaders, who struggle with ever-increasing insurance costs for their employees. Warren Buffett calls the U.S. health care system the tapeworm of U.S. competitiveness, which is why he supports a single-payer alternative. Legislation packaged as “Expanded and Improved Medicare for All” has over 120 co-sponsors in the U.S. House of Representatives and support from a growing number of senators, reflecting polls that show a majority of Americans support a single-payer system.

But the will of the people does not always translate into changed policies, especially when heavily financed lobbyists and campaign contributors from insurance and pharmaceutical companies block the path. That is where the faith community comes in. The economic argument in favor of a single-payer, universal health care system is undeniably powerful, but the moral case for health care as a human right is even stronger. The faith community stands in the ideal place to advance that moral argument.

People of faith, acting individually and in concert with their congregations, denominations and other organizations, played central roles in the great human rights movements of the modern era. Faith community action was central to the success of the U.S. civil rights movement, the anti-apartheid movement, and the slavery abolition movement. We can make change happen again. That is especially true in the context of health care, where generations of “walking the walk” in providing direct care endows the faith community with well-deserved moral authority on this issue.

We are called to speak out and to take action for health care as a human right. Our brothers and sisters are suffering, but we carry the prescription for their healing in our pockets.

Fran Quigley is director of the Health and Human Rights Clinic at Indiana University McKinney School of Law and coordinator of People of Faith for Access to Medicines.

https://www.ncronline.org…

Irrationality of work requirements for Medicaid

The Relationship Between Work and Health: Findings from a Literature Review

By Larisa Antonisse and Rachel Garfield
Kaiser Family Foundation, August 7, 2018

Summary

A central question in the current debate over work requirements in Medicaid is whether such policies promote health and are therefore within the goals of the Medicaid program. Work requirements in welfare programs in the past have had different goals of strengthening self-esteem and providing a ladder to economic progress, versus improving health. This brief examines literature on the relationship between work and health and analyzes the implications of this research in the context of Medicaid work requirements. We review literature cited in policy documents, as well as additional studies identified through a search of academic papers and policy evaluation reports, focusing primarily on systematic reviews and meta-analyses. Key findings include the following:

Being in poor health is associated with increased risk of job loss, while access to affordable health insurance has a positive effect on people’s ability to obtain and maintain employment.

There is limited evidence on the effect of employment on health, with some studies showing a positive effect of work on health yet others showing no relationship or isolated effects. There is strong evidence of an association between unemployment and poorer health outcomes, but authors caution against using these findings to infer that the opposite relationship (work causing improved health) exists. While unemployment is almost universally a negative experience and thus linked to poor outcomes, especially poor mental health outcomes, employment may be positive or negative, depending on the nature of the job (e.g., stability, stress, hours, pay, etc.). Further, most studies note major limitations in our ability to draw broad conclusions on health and work, including:

Job availability and quality are important modifiers in how work affects health; transition from unemployment to poor quality or unstable employment options can be detrimental to health.
Selection bias in the research (e.g., healthy people being more likely to work) and other methodological limitations restrict the ability to determine a causal work-health relationship.

Studies note several caveats to and implications of the research on work and health that are particularly relevant to work requirements in Medicaid. For example:

The work-health relationship may differ for the Medicaid population compared to the broader populations studied in the literature, as Medicaid enrollees report worse health than the general population and face significant challenges related to social determinants of health.
Limited job availability or poor job quality may moderate or reverse any positive effects of work.
Work or volunteering to fulfill a requirement may produce different health effects than work or volunteer activities studied in existing literature.
Loss of Medicaid coverage under work requirements could negatively impact health care access and outcomes, as well as exacerbate health disparities.

https://www.kff.org…

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NBER Working Paper No. 24899: The Effect of Disenrollment from Medicaid on Employment, Insurance Coverage, Health and Health Care Utilization

By Thomas DeLeire
National Bureau of Economic Research, August 2018

This study examines the effect of a Medicaid disenrollment on employment, sources of health insurance coverage, health, and health care utilization of childless adults using longitudinal data from the 2004 Panel of the Survey of Income and Program Participation. From July through September 2005, TennCare, the Tennessee Medicaid program, disenrolled approximately 170,000 adults following a change in eligibility rules. Following this eligibility change, the fraction of adults in Tennessee covered by Medicaid fell by over 5 percentage points while uninsured rates increased by almost 5 percentage points relative to adults in other Southern states. There is no evidence of an increase in employment rates in Tennessee following the disenrollment. Self-reported health and access to medical care worsened as hospitalization rates, doctor visits, and dentist visits all declined while the use of free or public clinics increased. The Tennessee experience suggests that undoing the expansion of Medicaid eligibility to adults that occurred under the Affordable Care Act likely would reduce health insurance coverage, reduce health care access, and worsen health but would not lead to increases in employment.

http://www.nber.org…

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New in GOP logic: Antipoverty programs worked so well, we must get rid of them

By Sasha Abramsky
Los Angeles Times, August 10, 2018

For many decades now the GOP has sought to undo the New Deal and the Great Society. But a report released last month from the White House’s Council of Economic Advisors, lost in a sea of grabbier news items, applies a new logic to the goal of shredding the safety net.

According to “Expanding work requirements in non-cash welfare programs,” comprehensive antipoverty programs are no longer necessary because 50 years of antipoverty programs — yes, those same interventions long hated, and their effectiveness belittled, by the GOP — have succeeded so spectacularly that poverty is largely a thing of the past.

The report claims that the War on Poverty led to “the success of the United States in reducing material hardship,” but “that it also came at the cost of discouraging self-sufficiency.” It proceeds to lay out a case for limiting access to benefits and setting in place work requirements in exchange for basic nutritional and medical benefits.

This is beyond disingenuous. Yes, in the years after 1964, when President Lyndon Johnson launched the War on Poverty, the percentage of poor Americans did significantly decline; by some measures it was cut in half from about 22% of the population down to about 11%. But over the last 40 years it has rebounded with a vengeance.

http://www.latimes.com…

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Expanding Work Requirements in Non-Cash Welfare Programs

The Council of Economic Advisers, July 2018

Aiming to transition more non-disabled working-age Americans into the workforce, President Trump signed an executive order in April 2018 instructing agencies to reform their welfare programs by encouraging work and reducing dependence, in part by strengthening and expanding work requirements.

https://www.whitehouse.gov…

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Comment:

By Don McCanne, M.D.

Heath care financing programs should be designed to enable individuals to have affordable access to the health care that they need. Medicaid is specifically designed to assist low-income individuals in obtaining that care who otherwise do not have the resources to pay for it. How does having a work requirement to qualify for Medicaid help with this goal of improving access? Well, it doesn’t.

The Kaiser Foundation report shows that a Medicaid work requirement can have many deleterious effects. In fact, penalizing unemployed individuals by disqualifying them from Medicaid coverage can “negatively impact health care access and outcomes, as well as exacerbate health disparities.” Isn’t that the opposite of what we should be doing? So why should we have a policy in place that does that?

The NBER paper shows that disenrolling individuals from the Tennessee Medicaid program reduced health care coverage, reduced health care access, worsened health outcomes, but did not lead to increases in employment. There is a disconnect between Trump’s executive order to expand work requirements to qualify for non-cash welfare programs and achieving the goals of those programs, including health care under Medicaid.

What is this, tying health care to work? A well designed health care financing program should ensure affordable access to health care for everyone, regardless of any other considerations. A work program should be designed to ensure that all capable individuals can get the work that is most appropriate for them. But one program should not be dependent on the other.

Again, health care for low-income individuals should not be dependent on their work status. Everyone who needs health care should have it. Instead of a separate program for those with lower incomes – Medicaid – we should have one program that is equitable, affordable, efficient, and accessible for everyone – a well designed, single payer, improved Medicare for all. We can also go to work on ensuring that decent jobs with decent wages are available to individuals based on their capabilities, but that should be a separate project.

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

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Assessing the Medicare Advantage Star Ratings

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NBER Working Paper No. 24899: The Effect of Disenrollment from Medicaid on Employment, Insurance Coverage, Health and Health Care Utilization

New in GOP logic: Antipoverty programs worked so well, we must get rid of them

Expanding Work Requirements in Non-Cash Welfare Programs

Comment:

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