Resource – Page 207

It’s time for a single-payer health care system in the US. Here’s why.

There are many arguments for a single-payer system, but for us it comes down to this: the incentive structure of the current system isn’t working.

By Kate de Klerk, OMS IV, and Mayra Salazar, OMS III
The DO, Opinion, July 17, 2018

The Student Osteopathic Medical Association is asking the House of Delegates to take up an important question: should AOA support a “Medicare for All” single-payer health care system? Support is steadily growing in the U.S., with a majority of Americans and many physicians indicating that they support a single payer health care system.

This is a controversial topic and some may consider support for a single-payer system naive and idealistic. However, we invite you to suspend any skepticism and engage in this conversation with us.

As DOs and medical students, there is probably much more that unites us than divides us. As students, we want to work in an efficient health care system, but not one where arbitrary cost-cutting trumps clinical judgment and evidence-based approaches to care. We want to see equitable distribution of resources in health care, but when many DO students’ debt burdens are over $240,000, we also want to protect wages so that we can pay back loans and achieve financial stability.

Issues in the health care space are multi-faceted and Medicare for All is not a panacea. However, we think this shift would greatly benefit both patients and providers.

A fundamentally flawed system

Health care is exceedingly complicated and prohibitively expensive for patients. Despite many positive changes introduced by the Affordable Care Act, patient satisfaction with health insurance reached a 10-year low in 2015, according to the American Consumer Satisfaction Index, with many patients reporting that they don’t understand their health plans.

Our current system is also unaffordable for many Americans. As high-deductible, high co-pay plans become the norm in health care, 29% of patients with high-deductible plans report not seeking care because of cost. A system that discourages patients from getting care when they need it is fundamentally flawed.

The current system also presents challenges for physicians. Physicians report that they are spending more time on paperwork and less time interacting with patients. In 2017, 70% of physicians reported spending more than 10 hours on administration per week, with 32% of doctors spending more than 20 hours.

A 2014 study estimated that billing and insurance-related costs in health care were roughly $471 billion annually, a number that has grown exponentially since the 1970s. Physicians also experience frustrating limitations placed upon them by insurance companies, with formularies dictating treatment plans, rather than medical best practices or clinical judgment.

How Medicare for All would work

The current Medicare for All plan is outlined in House (H.R. 676) and Senate (S. 1804) bills that would expand and improve Medicare. In brief, this would be a publicly funded, privately operated health care system. The system would introduce universal coverage, spreading cost and risk out among all taxpayers. It’s predicted that a majority of Americans would spend significantly less on health care each year than they currently do. The proposed system would do away with co-pays and deductibles, and patients would have autonomy when choosing their health care providers. Physicians would benefit from simplified administrative processes and have greater autonomy in treating patients.

There are many strong arguments in favor of a single-payer system, but for us it comes down to this: the incentive structure of the current system isn’t working.

Health insurance companies are by-and-large for-profit, with inherent tensions between the provision of health care and the goal of maximizing profits. A quick look at the Fortune 500 reveals that the business of health insurance is one of the most profitable industries. UnitedHealth ranks fifth on the Fortune 500, ahead of Amazon.com at #8 and Alphabet (Google) at #22.

Insurance companies are not lean operations. They are large bureaucracies that have increased inefficiency in the health care system and deprioritized health outcomes. It is thought that switching to a single payer system would save roughly $200 billion annually by eliminating overhead costs alone and also reduce billing and paperwork expenses. Rising out-of-pocket costs and decreased usage of the health care system help a company’s bottom line, but have dangerous consequences on the health of Americans.

People over profits

When compared to other developed nations, the United States consistently ranks near the bottom for most health metrics. While there are interesting disruptors entering the market, such as Oscar and Collective Health, a for-profit system will never yield the kind of efficiency and equitable distribution of health care resources that we think are possible.

A Medicare for All system is also unlikely to result in major sacrifices on the part of providers. Various economic projections suggest that, for most physicians, transitioning to a single-payer system would not significantly impact income or satisfaction in the long-term.

We think that movement toward a Medicare for All system is inevitable. Perhaps it will look different than the current bills, but there is a groundswell of support for a system that places people over profits. The question members of the AOA House of Delegates should ask themselves is, do you want to be at the forefront of this change, or will you sit back and wait for others to lead the way?

https://thedo.osteopathic.org…

NYT: Austin Frakt accurately describes administrative waste in health care

Hidden From View: The Astonishingly High Administrative Costs of U.S. Health Care

By Austin Frakt
The New York Times, July 16, 2018

It takes only a glance at a hospital bill or at the myriad choices you may have for health care coverage to get a sense of the bewildering complexity of health care financing in the United States. That complexity doesn’t just exact a cognitive cost. It also comes with administrative costs that are largely hidden from view but that we all pay.

Because they’re not directly related to patient care, we rarely think about administrative costs. They’re high.

A widely cited study published in The New England Journal of Medicine used data from 1999 to estimate that about 30 percent of American health care expenditures were the result of administration, about twice what it is in Canada. If the figures hold today, they mean that out of the average of about $19,000 that U.S. workers and their employers pay for family coverage each year, $5,700 goes toward administrative costs.

That New England Journal of Medicine study is still the only one on administrative costs that encompasses the entire health system. Many other more recent studies examine important portions of it, however. The story remains the same: Like the overall cost of the U.S. health system, its administrative cost alone is No. 1 in the world.

One obvious source of complexity of the American health system is its multiplicity of payers. A typical hospital has to contend not just with several public health programs, like Medicare and Medicaid, but also with many private insurers, each with its own set of procedures and forms (whether electronic or paper) for billing and collecting payment. By one estimate, 80 percent of the billing-related costs in the United States are because of contending with this added complexity.

“The extraordinary costs we see are not because of administrative slack or because health care leaders don’t try to economize,” said Kevin Schulman, a professor of medicine at Duke. “The high administrative costs are functions of the system’s complexity.”

“One can have choice without costly complexity,” said Barak Richman, a professor of law at Duke. “Switzerland and Germany, for example, have lower administrative costs than the U.S. but exhibit a robust choice of health insurers.”

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Reader Comment:

By Don McCanne, M.D.

European private plans such as those in Switzerland and the Netherlands have very little similarity to private plans in the United States since they are very tightly regulated. Changing our fragmented system of public and private plans into a system of highly regulated private plans would be about as disruptive as improving Medicare and providing it to everyone. But the efficiencies of an improved Medicare for all would be much greater (lower administrative costs), and the financing would be more equitable, not to mention that there would be a multitude of other advantages through an improved Medicare for all.

It’s clear that we can’t continue with the same dysfunctional system. If we are going to change it, we might as well do it right.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

It is refreshing to see The New York Times publish an article accurately describing the profound administrative waste that uniquely characterizes the health care financing system in the United States. The public needs to understand how huge this waste is in order to better understand how we would be able to pay for a health care system that was expanded to include everyone without requiring deductibles and copayments.

Austin Frakt’s well researched article includes links to several classic articles on administrative excesses, some of which were authored by the PNHP leadership, especially cofounders Steffie Woolhandler and David Himmelstein. The article is well worth retaining to keep as a reference on administrative waste.

A well designed single payer system – an improved Medicare for all – not only recovers most of the administrative waste (while continuing to finance essential administrative services), it also attacks the problem of out-of-control health care pricing. Other single payer policies such as improving allocation of our health care resources also would make our health care system more affordable and equitable so that all of us can be assured that we could receive the essential health care services that we need.

That starts with getting rid of silly ideas such as the concept that patient-consumers can make health care affordable by shopping wisely, or that health care professionals need to be more accountable for costs when they are already swamped just trying to take care of their patients. Rather we need to begin by recovering the half a trillion dollars that we are wasting on administration and exorbitant pricing and redirecting that to patient care instead.

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The health coach is ready to see you

Transforming Health Care from the Ground Up

By Vijay Govindarajan and Ravi Ramamurti
Harvard Business Review, July-August 2018

The U.S. health care system desperately needs reform to rein in costs, improve quality, and expand access. Federal policy changes are essential, of course; however, top-down solutions alone cannot fix a wasteful and misdirected system. The industry also needs transformation from the bottom up, by entrepreneurs and intrapreneurs.

Innovation by Start-Ups: Iora Health

Rushika Fernandopulle realized that in order to build the right business model and scale it, he needed private capital. In 2010 he cofounded Iora Health, a for-profit company, and raised more than $6 million from three venture capital firms. The new company opened four offices, each with a self-insured employer or union benefits manager as its chief insurance partner. From the start, he wanted to be sure his model could be scaled geographically, so he selected sites from different parts of the country with different patient mixes. One was in Hanover, New Hampshire (in partnership with Dartmouth College), another in Las Vegas (with the Culinary Health Fund), the third in Brooklyn (with Freelancers Union), and the fourth in Dorchester, Massachusetts (with the New England Carpenters Benefit Funds).

This time, Fernandopulle didn’t mess around with partial solutions. He instituted a fully capitated payment system focused on primary care that required no fees, no coinsurance, and no copays. Instead Iora charged insurers a flat monthly fee per member that was twice their historical spending on primary care. He hired four health coaches for every doctor—paying them a fifth of a doctor’s salary and half of a nurse’s. He spent an outsize chunk of his start-up money on a custom IT system—and had no reservations about the cost.

Patient focus.

Iora’s goal was not to deliver health care but to empower patients to take control of their own health. “What we are really trying to do is change behavior,” Fernandopulle told us. At Iora, that change was driven by three innovations that worked together in a virtuous cycle: a capitation-based business model, a health coach for every patient, and a customized IT platform. Capitated payments eliminated any concern about whether a particular patient interaction was billable, so consultations that once required a visit to a doctor’s office could now take place via convenient technologies such as phone, e-mail, and Skype, and they didn’t necessarily involve a doctor. That cleared the way for more involvement from health coaches, whose frequent patient interactions were facilitated by the IT platform. The platform, which tracked all patient data and made it available to doctors, health coaches, and patients, was designed not to facilitate fee-for-service billing but to enable better health outcomes.

Iora wasn’t the only provider to use health coaches in its practice. Omada Health and others used them, too, but they recruited coaches with prior health care experience, whereas Iora recruited people with qualities such as empathy, compassion, and gregariousness and then trained them in the medical skills they would need.

Iora’s health coaches proactively managed each patient’s well-being and intervened the moment trouble arose, especially with chronic-care patients whose costliest problem was noncompliance. Health coaches did some work that doctors and nurses did—such as taking vital signs and drawing blood—but they also engaged patients in new ways. They ran smoking cessation clinics, and they took diabetic patients to the grocery store and helped them shop for food. They led Zumba classes and served as confidants and cheerleaders. They trained patients to manage some of their care, such as monitoring blood pressure and insulin levels. This kind of task shifting, from doctors to health coaches and from health coaches to patients, saved money. More important, the coaches were better at many aspects of care than doctors—and they loved their work. But it was the capitated payment system that was the real game changer. Under the legacy fee-for-service systems, providers need a high volume of patient visits and procedures in order to make money. Under its capitation system, Iora makes money only if its patients stay healthy and thus require fewer tests and procedures. It was a completely different business model, one focused on value, relationships, outcomes, and the long game. Hybrid payment systems like Renaissance, Fernandopulle realized, created internal conflict. It had to be all or nothing. Iora’s capitated model would save on administrative costs by reducing paperwork and would encourage other cost-saving measures to make the most of the flat-fee dollars. Iora clinics, for example, performed many of their own lab tests and processed their own blood work, which was cheaper and faster than sending the tests out. But the big savings would come from the investment in intensive and creative primary care that would reduce downstream expense on specialist and hospital care as patients stayed healthier. For patients with chronic conditions, Fernandopulle expected to see returns in the first year; the payoff for healthier patients would take longer. But he believed that every dollar he saved his partners in fees for ultrasounds, kidney dialysis, bypass surgeries, and other downstream costs generated additional buy-in for his capitated model.

Cost control.

When necessary, Iora provided patients with specialist care, but there, too, Iora saved money by contracting specialists as consultants to the primary care practice—essentially inviting cardiologists, nephrologists, and others to join the gig economy. When Fernandopulle asked the head of endocrinology at a top hospital what percentage of endocrine clinic patients could be managed by a primary care physician with a little expert advice by phone or e-mail, the answer was an astonishing 80%. A formal study of e-consultations by PCPs across 10 specialty areas, including neurology, rheumatology, dermatology, and nephrology, confirmed that on average, primary care physicians were able to address problems in those areas for 60% of patients. By 2017, seven years after he launched Iora Health, Fernandopulle’s premise had proved itself. It had reduced hospitalizations for its members by 40% and cut total health care spending by 15% to 20%—far beyond the 4% to 5% needed to recoup Iora’s higher spending on primary care. Its patient retention rate was 98%, and its Net Promoter Score among patients was in the 90s. Some 90% of patients had their blood pressure under control, compared with an average of 60% across providers in the industry. Employee attrition, at a mere 2.5%, was off the charts. Iora was increasing the number of patients it served by well over 50% a year, largely by attracting seniors through contracts with Medicare Advantage plans. Iora now has 24 locations in eight cities and employs more than 400 people. It has raised $125 million in venture capital, including from long-term investors such as Rice University’s endowment fund and Singapore’s Temasek.

Lessons for start-up innovators.

Iora’s success, and that of half a dozen other start-ups we studied, suggests some general principles by which innovators can attack U.S. health care’s bloated costs, uneven quality, and access limitations. Fernandopulle and the other visionary founders took a clean-slate approach, building new business models from scratch. They launched ambitious, for-profit ventures right out of the gate. They thought from day one about how to scale their models by tapping into venture capital and private equity funding. They did not hesitate to make big strategic investments, including in technology, as Iora did with its customized IT system. Finally, they thought carefully about what kind of payment system would best fit their purpose, considering risk-sharing alternatives such as capitation and bundled payments.

In our research, we’ve seen several Iora-like start-ups. CareMore, for example, uses health coaches called extensivists to deliver capitated primary care, with a focus on geriatric patients. Other disruptive start-ups we studied look quite different. Consider Health City Cayman Islands, a for-profit hospital launched in 2014 by Dr. Devi Shetty, the founder of Narayana Health in India. Seeking to replicate innovative practices honed in India and to target American patients, Health City opened in a location near the United States but outside its regulatory sphere. This approach involved making innovative, even radical, decisions about where to locate, whether to build or buy (management opted to build from scratch), whom to partner with (it chose Ascension), how to price (bundles), and how to crack the U.S. market. Health City launched as a modest 104-bed facility for cardiology and orthopedic care, but the plan is to develop a large for-profit system, investing $2 billion over the next 10 to 15 years. Health City’s transparent, bundled prices—which are 60% to 75% lower than those in the United States—serve its disruptive strategy of luring American patients from legacy hospitals.

As Fernandopulle points out, if his company and others like it can capture even 20% of the $350 billion in wasted health care spending per year, it would amount to a staggering sum. By our calculation, if companies with Iora’s primary care–focused approach enrolled one-third of America’s projected 55 million seniors in 2020 into Medicare Advantage plans, the country could save $30 billion to $40 billion a year in avoided spending on secondary and tertiary care. And if those companies reaped 20% of the value thus created, their market capitalization could be upwards of $100 billion, even with a price-earnings multiple of just 15.

Numbers like that are a powerful incentive for change. They will no doubt motivate many health care innovators to expand access to quality care, enabling patients to enjoy good health. If you’re looking for a starting point, start there.

https://hbr.org…

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Comment:

By Don McCanne, M.D.

For a health care system that is overpriced and underperforming, it seems that reform should be based on improving our allocation of higher quality essential health care services. By any measure, that requires a top down, comprehensive approach for which governments are best suited. Yet much of the effort comes from the bottom up in the medical-industrial community, with the support and encouragement of business academics such as these authors.

A quick read of the endorsement by Professors Govindarajan and Ramamurti of Rushika Fernandopulle’s creation of Iora seems like just anther description of the successes of venture capital and the individuals driving the innovations. But for those who want to see the changes in our health care system that we desperately need, especially in the financing, Fernandopulle’s model is particularly disconcerting.

In perhaps overly simplified terms, let’s look at what he has done. He begins with venture capital – a financing method designed solely to create monetary rewards – a terrible start when applied to health care since the goal should be to maintain and improve health which requires spending money, not generating more. He then structures his health care model based on primary care, but not the usual team of physicians, nurses and other health care professionals, but rather on an army of health coaches – individuals with no health care qualifications but rather who receive only on-the-job training. These health coaches are intended to replace a significant portion of the functioning of fully trained health care professionals, especially doctors and nurses (ratio of four health coaches to one physician), though much of the work they do is song and dance (taking diabetics grocery shopping, and leading Zumba classes?). For those patients who have more serious problems, often requiring the services of specialists, they have managed to keep the majority of them away from the specialists. They make a big point that a major element of their success is capitation which is why they provide specialized services within the primary care environment. Referring patients out requires paying for those services whereas retaining them within the practice allows them to keep more of their capitation payments (success defined by net profit).

Most of the health care professionals with whom I have been associated would find problems with this. There is something sacred about the science and art of health care as it is applied to the patient. The model described here places business success above all else, and any quasi-semblance of sanctity must fall under other unfamiliar gods that do not frequent the halls of health care justice.

We know what health policies would work to improve the welfare of the American patient. So what is this diversion from health policy science into what some might describe as ethics? Well, that’s precisely it. The business community thrives on matters of money and profits, but the health professions thrive on the well being of the individual.

The authors of this article in Harvard Business Review have simplified this as the advantages of bottom up versus top down management, but if that is what this really is all about, then we need to unify the nation for the top down approach that would bring health care justice to all.

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Higher premiums, higher deductibles, and narrower networks in exchange markets

The High Cost of Healthcare: Patients See Greater Cost-Shifting and Reduced Coverage in Exchange Markets 2014-2018

Physicians for Fair Coverage, Research by Avalere, July 2018

Executive Summary

The expansion in coverage due to the Affordable Care Act (ACA) increased the number of insured Americans by 20 million. Although access to health insurance has expanded significantly in recent years, and the ACA instituted important protections for patients, those who gained insurance through ACA health insurance exchanges are being offered plans that make them bear an increasing portion of their healthcare costs since the law was implemented. Access to health insurance is not sufficient if patients cannot afford to purchase coverage or utilize their benefits due to high premiums, high out-of-pocket costs, limited networks, and insufficient state and federal patient protections.

This paper outlines the key challenges facing patients in plans insurance companies offer through ACA health insurance exchange markets and details the changes in patient cost-sharing. This paper will demonstrate that:

1. Health plan networks have grown increasingly narrow, limiting patient access to in-network providers, with specialties like anesthesiologists, radiologists, and emergency physicians often out-of-network in exchange plans;

2. Non-subsidized exchange marketplace premiums have increased faster relative to other markets, such as employer-sponsored insurance and Medicare Advantage, since 2014;

3. Deductibles and maximum out-of-pocket limits (MOOPs) have grown across all payers, placing a higher financial burden on sicker patients;

4. Despite the growth in deductibles and MOOPs, cost-sharing for services after the deductible has remained relatively constant, though patients are increasingly required to pay coinsurance to access their care; and

5. Federal and state rules around network adequacy have not kept pace with the growing patient burden.

Key Stats

* In 2017, 68% of healthcare plans in the exchange market offered restrictive networks, compared with 48% in 2014.

* Average ACA exchange market premiums increased 28% from 2014 to 2017.

* Plans covered between 34% – 66% fewer providers than other markets.

* Almost 90% of enrollees in ACA exchange plans had deductibles above $1,300, the IRS definition of a high deductible plan.

* Several top insurance companies saw profit margins in Q1 for 2018 that were the highest in a decade, and all six of the largest insurance companies paid their CEOs over $17 million in 2017.

https://endtheinsurancegap.org…

Full report:
https://endtheinsurancegap.org…

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Comment:

By Don McCanne, M.D.

A decade ago the individual health insurance market was in total disarray and thus was one of the primary motivators to enact the Affordable Care Act (ACA). Under ACA these plans became more tightly regulated and subsidies inversely related to income were provided to make the premiums and cost-sharing more affordable. How is this working?

To try to keep premiums affordable, the more popular plans were designed to have low actuarial values – the insurers pay a lower percentage of the allowed charges – and the insurers were allowed to limit their networks enabling them to negotiate lower prices. This kept costs down for those eligible for subsidies and credits, but for middle-income individuals who were not eligible, out-of-pocket spending has been excessive and often not affordable.

Has the situation improved since the plans were first implemented? No, it’s worse now. Premiums have increased, high deductibles have become routine, and the use of restrictive networks has expanded, all this while profit margins have increased for the top insurers and their CEOs.

The problem is that this is the nature of private health insurance. Plans are designed to be successful business products. To improve markets they shift risk and costs to patients and they impair patient access to health care through network restrictions and the financial barriers of high deductibles.

Does anybody believe it will get better? Are insurers going to lower their premiums, lower their deductibles, and expand their networks while covering all essential health care benefits? No, they are going to continue to squeeze to enhance their margins. We can anticipate even higher deductibles, higher coinsurance instead of copays, greater tiering of health care services and products, more restrictive access, especially to specialized services, and the new thing will be the introduction of plans with sharply curtailed benefits such as the association health plans that the Trump administration will be pushing.

Yet the politicians have been saying that we need to protect our current system but add the option of being able to purchase a public plan. Some are now latching on to the Medicare for all rhetoric but when pressed they say, “yes, Medicare for all by allowing a buy-in to the Medicare program” – merely a public option with a new but misleading label. Merely adding a public option to our highly dysfunctional, fragmented financing system will have virtually no impact on resolving the problems inherent in our system.

If we want true universality, comprehensiveness, equity, assured access, and affordability for every one us, we are going to have to dump the current system and enact and implement a well designed, single payer, expanded and improved Medicare for all. Nothing else will do, that is unless we are ready to nationalize our entire health care delivery system and convert it into a national health service. Shall we do a poll?

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‘Medicare Advantage Premium Support For All’ – a terrible proposal

Creating Medicare Advantage Premium Support For All, Part 4: Financing

By Billy Wynne
Health Affairs Blog, July 9, 2018

In this post, I will illustrate how current spending by the federal government, states, and employers could be repurposed to fund universal Medicare coverage that emphasizes competition among private, Medicare Advantage plans and the traditional fee-for-service option, deployed via a premium support benefit model.

As pundits, commentators, and industry stakeholders begin to converge on the wisdom of “Medicare Advantage for All,” let’s take another step down the path of specifying exactly what that means and why it is both economically and politically viable.

The Tally

Starting with the current Medicare per capita spending of $12,139, age-adjusting that by 44 percent, then taking a 4 percent haircut for premium support-induced competition yields an average cost of providing the existing Medicare benefit to a non-Medicare enrollee of $5,127. That is more than 10 percent less than the per capita funding available from current non-Medicare health care programs ($5,721).

(Here I pause for rabid, health policy wonk golf clapping.)

I’m not here to fool anyone or advance a political agenda. I just think our current approach is radically, audaciously absurd. It’s like we’re investing every last morsel of our industriousness and ingenuity into getting it wrong. I posit that, with about the same amount of effort, we can get it right.

(For a full understanding of the proposal by Billy Wynne you should read all four of his posts. Links to the previous three posts are available in Part 4.)

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Posted Comment:

By Don McCanne, M.D.

Premium support is supposedly dependent on competition between private plans, but we’ve had competing private plans for well over half a century, and yet our costs are highest of all nations. This also neglects the profound administrative waste that is uniquely characteristic of our fragmented, dysfunctional health care financing system.

Besides high prices and administrative waste, the premium support model would also perpetuate the loss of choice of health care professionals and institutions because of the dependence on provider networks. Perhaps even worse, the perpetuation of high deductibles and other cost sharing would continue to impair access because of lack of affordability, not to mention creating financial hardship, especially for America’s working families.

A model that would correct these defects without increasing spending would be a single payer, improved Medicare for all. The efficiency of such a system would save a few hundred billion dollars in administrative costs, and administered (negotiated) prices would become sustainable over time. Planning and separate budgeting of capital improvements would improve allocation of our health care resources. That wouldn’t reduce spending much, but it would redistribute it to better serve the currently uninsured and underinsured. Everyone would have free choice of actual health care, not the artificial choice of health plan intermediaries. And the system would be funded equitably though progressive tax policies without the necessity of erecting cost-sharing financial barriers to care.

Considering the money that’s already being wasted in private Medicare Advantage plans, a “Medicare Advantage for All” seems to only perpetuate the high costs and impaired choices in our current health care financing system. It is no wonder that AHIP finds it attractive, but instead we should be supporting reform that would be attractive to patients.

https://www.healthaffairs.org…

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Financing Medicare Into The Future: Premium Support Fails The Risk-Bearing Test

By Sherry A. Glied
Health Affairs, July 2018

Abstract

One often-discussed option for controlling Medicare spending is to switch to a premium-support design. This would shift part of the risk of future health care cost increases from the federal treasury to Medicare beneficiaries. The economics of risk bearing suggests that this would be a mistake for three reasons. First, political decisions, not beneficiary choices, are the critical determinants of future health care costs. Second, only Congress can take into account the consequences of cost-containment decisions for both current and future generations. Third, the federal government is best able to diversify against the risk of future cost growth. Tying Medicare spending to the government’s budget so that Congress sees the benefits of tough cost containment choices is the only way to force the program to make those politically difficult decisions. Economic efficiency is served by retaining the program’s current structure instead of shifting risk to beneficiaries.

From the Introduction

Some members of Congress see entitlement reform—namely, a restructured Medicare program—as the best strategy for bringing federal expenditures in line with newly reduced revenues, particularly as the baby-boom generation swells Medicare rolls.

One frequently touted option is to shift the program to a premium-support structure. Under this structure, the federal government would provide each Medicare beneficiary with a specified allotment (sometimes called a voucher or defined contribution) that the beneficiary could use to purchase health insurance. Beneficiaries would be responsible for all additional premium costs if they chose insurance costing more than the allotted amount.

In some respects, premium support resembles the current Medicare Advantage program, under which many beneficiaries opt in to private health plans. If beneficiaries choose a plan that costs less than the Medicare Advantage benchmark, which is based on the local per capita cost of traditional fee-for-service Medicare, they gain extra benefits and save money on premiums and cost sharing. But premium support would change that model in one very significant respect.

The current Medicare Advantage benchmark rises over time as Medicare utilization and congressionally mandated provider payment levels rise. The savings from premium-support plans, however, are realized by changing that benchmark so that it rises more slowly over time.

Advocates of premium support argue that it would control Medicare expenditures by harnessing competition among health plans and by giving beneficiaries strong incentives to make wise health plan choices. That can be debated. But what is clear is that premium support would transform the federal government’s current open-ended obligation, or entitlement, by making the government’s liability more fixed and predictable and shifting much of the risk and burden of unanticipated future health care cost increases to Medicare beneficiaries. Such a reallocation is bad policy because it leads to inefficient risk bearing. It is inconsistent with the clear guidance that economics provides about how to most efficiently allocate risk.

Who should bear the uncertainty of cost projections?

Legislators see the uncertainty of Medicare spending forecasts and the challenges of designing and implementing legislation to slow the growth of Medicare spending as reasons to shift more of the risk of future Medicare spending growth to beneficiaries through a move to premium support. This intuition is backward. Political decisions, not beneficiary choices, are the critical determinants of future health care costs.

Leaving beneficiaries with the responsibility for cost increases also doesn’t make sense. Beneficiaries cannot plausibly forecast their future health care costs, so they cannot effectively save to protect themselves against these costs. They also cannot turn to private insurance for protection. No private market does or can exist against risks that are highly correlated across everyone in a society, and the costs associated with political decisions and unforeseen health care technologies are exemplars of such correlated costs.

The federal government is best situated to bear the risks associated with unanticipated changes in future health care costs, the federal government is best able to shape the future costs of the program, and only the federal government can appropriately trade off current costs and future technological advances against each other. The economic case is clear: The federal government, not individual beneficiaries, should bear the risk of future increases in the cost of Medicare. Premium support is bad economics.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

You can access on the PNHP website (www.pnhp.org) a multitude of articles on why competing private Medicare Advantage plans and the financing of them through premium support are terrible ideas. The quirk covered today has to do with the extreme to which others are going in order to latch onto the popular “Medicare for All” rhetoric to advance their inadequate or detrimental schemes for reform.

“Medicare Advantage Premium Support For All” is a real head-shaker, representing policies that are just about the opposite of what we mean by a “single payer, improved Medicare for all” (my posted comment on the HA Blog, reproduced above, clarifies this).

Sherry Glied, dean of the Robert F. Wagner Graduate School of Public Service at New York University, explains why premium support is bad economics. She concludes, “The federal government, not individual beneficiaries, should bear the risk of future increases in the cost of Medicare.” That should apply to all of us, and that is why we need an improved Medicare for all.

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Corporate medicine is about money – duh!

Is private equity helping or hurting healthcare?

By Harry Gamble
Modern Healthcare, July 10, 2018

Some view third-party investment in physician practices as a vital trend that offers economies of scale that make healthcare more efficient. Others believe it fosters monopoly control while driving up prices. But nearly everyone agrees that further consolidation within the U.S. healthcare market is coming.

“The days of Marcus Welby are behind us,” said Anthony LoSasso, professor of health policy and administration at the University of Illinois at Chicago’s School of Public Health. “The uncertainty over healthcare policy in Washington is probably driving the integrated healthcare delivery systems and large hospitals to bulk up almost as a counterweight to the uncertainty they face. They know that if you are bigger, you are in a better position to survive whatever may come your way.”

“I think the jury is still out on whether those larger systems can translate that scale into quality improvements,” he said. “What I do know is they can translate that scale into price increases. That means insurers are going to have to pay more, which translates on the consumer side into higher premiums.”

But the jury is in for Marni James-Carey, executive director of the Association of Independent Doctors.

“We know that when corporate medicine takes over the practice of independent medicine, costs go up, quality goes down, and patients and doctors lose,” she said. “We don’t need a study for any of this. We just need common sense to prevail.

“This is all about capturing market share so you can have more bargaining power with payers, and get more money in reimbursement for the same procedure. That’s what causes costs to go up,” she said.

Craig Garthwaite, director of the Health Enterprise Management Program at Northwestern’s Kellogg School of Management, said recent pricing controversies in the pharmaceutical industry (think Martin Shkreli) have left some consumers fearing a repeat performance by large-scale physician practices.

“Some see private equity firms as really for-profit for-profits, for lack of a better term,” Garthwaite said. “These are firms that are often not involved in the medical field, but move in because they see an attractive investment opportunity.”

“To date, we see this more in pharmaceuticals rather than in providers,” he continued. “Outside companies realized a glaring market imperfection in pharmaceuticals, and found that if they were willing to price to the limit of their monopoly power, they could make an exceptional amount of money. So people might be worried that the same thing could happen with providers.”

http://www.modernhealthcare.com…

***

The real driver of health care spending

By Edward M Murphy
CommonWealth, July 9, 2018

The revenue and profitability of these corporations support the proposition that high pharmaceutical prices and insurance-related administrative costs account for much of the extraordinary expense of our system. US health policy, or the absence thereof, has enabled these businesses annually to drive costs up for the benefit of their bottom line. That effect will continue. Not surprisingly, the big health care companies are developing new strategies to enhance their businesses and drive their profits going forward.

The term now heard often among health care giants is “vertical integration,” which means combining upstream suppliers with downstream buyers to control the flow of business. If this strategy persists, health care delivery will evolve significantly although it is unlikely to become less expensive. The most prominent current example of vertical integration is the planned $68 billion acquisition of Aetna by CVS.

How would these companies work together? A Wall Street analyst recently described the vision as a way to “identify high risk patients and preemptively get them into a Minute Clinic.” Thus, your health insurer could send you to a local store for diagnosis, treatment, drugs, and anything else you might need from the shelves. This will keep even more of the health care dollar under their control.

Similarly, Cigna is in the process of acquiring Express Scripts, a huge pharmacy benefits manager, for $54 billion, another attempt to bring more services under one roof. United Health, a leader of vertical integration, previously bought a pharmacy benefit manager but co-pays and deductibles for its patients have continued to climb.

If this course continues, the health care system will evolve quickly, giving fewer and larger companies even more market leverage. Integration of this kind benefits the large corporations that initiate it but there is no evidence it will lead to lower costs, improved access, or enhanced quality. These changes are driven by highly focused corporate financial interests and are occurring without reference to public policy. That’s because there is no coherent public policy to guide these changes.

It is not in the interest of huge profit-making corporations to restrain the overall cost of the US health care system. In fact, their interest is served by driving health care expenditures higher. Any progress will require driving down pharmaceutical pricing and reducing administrative costs imposed by middlemen. We are not doing that yet but, ultimately, we must.

https://commonwealthmagazine.org…

***

Comment:

By Don McCanne, M.D.

Three quotes from these two articles say it all:

“Outside companies realized a glaring market imperfection in pharmaceuticals, and found that if they were willing to price to the limit of their monopoly power, they could make an exceptional amount of money. So people might be worried that the same thing could happen with providers.”

“It is not in the interest of huge profit-making corporations to restrain the overall cost of the US health care system. In fact, their interest is served by driving health care expenditures higher.”

“These changes are driven by highly focused corporate financial interests and are occurring without reference to public policy. That’s because there is no coherent public policy to guide these changes.”

Ouch.

No coherent public policy? How about enacting and implementing a publicly financed, publicly administered, single payer, improved Medicare for all? Now!

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Interruptions in private health insurance are routine, but hazardous

Interruptions In Private Health Insurance And Outcomes In Adults With Type 1 Diabetes: A Longitudinal Study

By Mary A. M. Rogers, Joyce M. Lee, Renuka Tipirneni, Tanima Banerjee, and Catherine Kim
Health Affairs, July 2018

Abstract

Type 1 diabetes mellitus, which often originates during childhood, is a lifelong disease that requires intensive daily medical management. Because health care services are critical to patients with this disease, we investigated the frequency of interruptions in private health insurance, and the outcomes associated with them, for working-age adults with type 1 diabetes in the United States in the period 2001–15. We designed a longitudinal study with a nested self-controlled case series, using the Clinformatics Data Mart Database. The study sample consisted of 168,612 adults ages 19–64 with type 1 diabetes who had 2.6 mean years of insurance coverage overall. Of these adults, 24.3 percent experienced an interruption in coverage. For each interruption, there was a 3.6 percent relative increase in glycated hemoglobin. The use of acute care services was fivefold greater after an interruption in health insurance compared to before the interruption and remained elevated when stratified by age, sex, or diabetic complications. An interruption was associated with lower perceived health status and lower satisfaction with life. We conclude that interruptions in private health insurance are common among adults with type 1 diabetes and have serious consequences for their well-being.

From the Introduction

The Bureau of Labor Statistics estimates that between the ages of 18 and 50, Americans hold an average of twelve different jobs. Particularly for younger workers, the jobs tend to be of short duration: 69 percent of jobs held by people ages 18–24 last for less than one year, as do 36 percent of jobs held by people ages 35–44. This has health consequences because, for the majority of working adults in the United States, health insurance coverage has traditionally been tied to employment. For working adults without employer-sponsored insurance, the Affordable Care Act (ACA) Marketplaces provide an opportunity for coverage. However, there remain challenges regarding affordability with self-funded plans and disparities in premiums across different areas of the country.

Interruptions in health insurance affect access to health care services, particularly for patients with chronic conditions. Type 1 diabetes mellitus is one such lifelong chronic disease, often originating in childhood, and requires intensive daily medical management. People with type 1 diabetes are at exceptional risk because of their requirement for insulin and the supplies necessary for insulin delivery.

From the Discussion

Interruptions in private health insurance are common among working-age adults with type 1 diabetes in the United States. Overall, one in four experienced at least one interruption in coverage, over an average period of 2.6 years. There were considerable consequences associated with the interruptions. Use of acute care services increased greatly after an interruption in coverage—with differences ranging from fourfold to sevenfold, depending upon the length of the interruption. As the number of interruptions increased, so did HbA1c levels, in a dose-response manner. For each additional break in coverage, there was a 3.6 percent relative increase in HbA1c. Satisfaction with life and perceived health status were lower among adults with interruptions in insurance, compared to those with continuous coverage.

Patients with type 1 diabetes face particular challenges in the management of their disease. Interruptions in health insurance are common in the United States, and such interruptions increase the use of costly acute care services such as ED visits and hospitalizations. We do not anticipate that these challenges will diminish in the near future, because of the instability of health insurance markets and the increase in temporary employment and contract work without employer-sponsored insurance. In the US, 50.1 percent of private-sector establishments offered health insurance to their employees in 2012, a share that declined to 45.3 percent in 2016.

https://www.healthaffairs.org…

***

Comment:

By Don McCanne, M.D.

One of the most serious policy defects of the U.S. health care financing system is that it is uniquely characterized by interruptions in health care coverage, yet we seem to take that for granted. This study of type 1 diabetics who have a continual need for health care brings into focus the seriousness of gaps in health care coverage, but these gaps can affect all of us because of the unpredictability of future health care needs.

Our health care coverage is heavily dependent on employer-sponsored plans, yet job stability is no longer the norm; it is the exception. Almost everyone can anticipate some interruptions in their health care coverage.

For the type 1 diabetics in this study, interruptions in private insurance coverage resulted in poorer control of their diabetes as measured by their glycated hemoglobin levels; they required a fivefold increase in health care services, and the interruptions were associated with lower perceived health status and lower satisfaction with life. Imagine the difficulties that other individuals with interruptions in coverage would have if they suddenly experienced severe traumatic events or the onset of a major illnesses.

Yet we accept this, even praising our employer-sponsored plans as the part of our health care financing system that is working very well and that we want to protect. Nonsense. As the authors state, “We do not anticipate that these challenges will diminish in the near future, because of the instability of health insurance markets and the increase in temporary employment and contract work without employer-sponsored insurance.”

By design, a single payer national health program – an improved Medicare for all – never has any interruptions in coverage, throughout life. And this is only one of a great multitude of advantages of a well designed, single, publicly financed and publicly administered health care financing program that covers absolutely everyone and would cost no more than our current, highly dysfunctional system. What are we waiting for?

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U.S. opposes WHO breast feeding resolution

U.S. Opposition to Breast-Feeding Resolution Stuns World Health Officials

By Andrew Jacobs
The New York Times, July 8, 2018

A resolution to encourage breast-feeding was expected to be approved quickly and easily by the hundreds of government delegates who gathered this spring in Geneva for the United Nations-affiliated World Health Assembly.

A 2016 Lancet study found that universal breast-feeding would prevent 800,000 child deaths a year across the globe and yield $300 billion in savings from reduced health care costs and improved economic outcomes for those reared on breast milk.

Based on decades of research, the resolution says that mother’s milk is healthiest for children and countries should strive to limit the inaccurate or misleading marketing of breast milk substitutes.

Then the United States delegation, embracing the interests of infant formula manufacturers, upended the deliberations.

American officials sought to water down the resolution by removing language that called on governments to “protect, promote and support breast-feeding” and another passage that called on policymakers to restrict the promotion of food products that many experts say can have deleterious effects on young children.

When that failed, they turned to threats, according to diplomats and government officials who took part in the discussions. Ecuador, which had planned to introduce the measure, was the first to find itself in the cross hairs.

The Americans were blunt: If Ecuador refused to drop the resolution, Washington would unleash punishing trade measures and withdraw crucial military aid. The Ecuadorean government quickly acquiesced.

Health advocates scrambled to find another sponsor for the resolution, but at least a dozen countries, most of them poor nations in Africa and Latin America, backed off, citing fears of retaliation, according to officials from Uruguay, Mexico and the United States.

In the end, the Americans’ efforts were mostly unsuccessful. It was the Russians who ultimately stepped in to introduce the measure — and the Americans did not threaten them.

A Russian delegate said the decision to introduce the breast-feeding resolution was a matter of principle.

“We’re not trying to be a hero here, but we feel that it is wrong when a big country tries to push around some very small countries, especially on an issue that is really important for the rest of the world,” said the delegate, who asked not to be identified because he was not authorized to speak to the media.

https://www.nytimes.com…

***

Comment:

By Don McCanne, M.D.

It is almost beyond belief that United States delegates at the World Health Assembly of WHO opposed a resolution to “protect, promote and support breast-feeding.” It is difficult to imagine any other reason than that the Trump administration representatives place a much higher priority on protecting, promoting and supporting the baby formula business than they do on protecting and nurturing the health of the world’s infants.

Even the Russians, who stepped in to introduce the resolution, said it was a matter of principle. By extrapolation, it seems that the Trump administration is unprincipled. Threatening retaliation against poorer nations if they supported breast feeding? “Unprincipled” is too mild of a word. Considering that they are placing corporate interests above the people, perhaps “corrupt” is a more accurate term.

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The conservative case for universal health care

Why in five years, the American right will embrace socialized medicine.

By Chase Madar
The American Conservative, July 25, 2017

Don’t tell anyone, but American conservatives will soon be embracing single-payer healthcare, or some other form of socialized healthcare.

Yes, that’s a bold claim given that a GOP-controlled Congress and President are poised to un-socialize a great deal of healthcare, and may even pull it off. But within five years, plenty of Republicans will be loudly supporting or quietly assenting to universal Medicare.

And that’s a good thing, because socializing healthcare is the only demonstrably effective way to control costs and cover everyone. It results in a healthier country and it saves a ton of money.

In fact, in every first-world nation that has socialized medicine–whether it be a heavily regulated multi-insurer system like Germany, single-payer like Canada, or a purely socialized system like the United Kingdom–-it costs less. A lot, lot less, in fact: While healthcare eats up nearly 18 percent of U.S. GDP, for other nations, from Australia and Canada to Germany and Japan, the figure hovers around 11 percent. (It’s no wonder that smarter capitalists like Charlie Munger of Berkshire Hathaway are bemoaning the drag on U.S. firm competitiveness from high healthcare costs.) Nor are healthcare results in America anything to brag about: lower life expectancy, higher infant mortality and poor scores on a wide range of important public health indicators.

The barrier to universal healthcare is not economic but political. Is profligate spending on health care really a conservative value?

The objections to socialized healthcare crumble upon impact with the reality. One beloved piece of folklore is that once people are given free healthcare they’ll abuse it by going on weird medical joyrides, just because they can, or simply let themselves go because they’ll have free doctor visits. I hate to ruin this gloating fantasy of lumpenproletariat irresponsibility, but people need take an honest look at the various health crises in the United States compared to other OECD (Organisation for Economic Cooperation and Development) countries.

If socialized medicine could be in conformity with conservative principles, what about Republican principles? This may seem a nonstarter given the pious market Calvinism of Paul Ryan and Congressmen like Reps. Scott Perry (R-Pa.) and Mo Brooks (R-Ala.), who seem opposed to the very idea of health insurance of any kind at all. But their fanaticism is surprisingly unpopular in the U.S. According to recent polling, less than 25 percent of Americans approve of the recent GOP healthcare bills. Other polls show even lower numbers. These Republicans are also profoundly out of step with conservative parties in the rest of the world.

Strange as it may seem to American Right, $600 EpiPens are not the sought-after goal of conservatives in other countries. In Canada, the single-payer healthcare system is such a part of national identity that even hard-right insurgents like Stockwell Day have enthusiastically pledged to maintain it. None of these systems are perfect, and all are subject to constant adjustment, but they do offer a better set of problems–the most any mature nation can ask for–than what we have in the U.S.

And virtually no one looks at our expensive American mess as a model.

Even in the GOP, this is where the votes are: Trump’s move to the center on questions of social insurance–Medicare, Medicaid, Social Security–was a big part of his appeal in the primaries. The rising alt-Right, not to hold them up as any moral authority, don’t seem to have any problem with universal Medicare either.

It will fall on “reform conservatives” to convince themselves and others that single-payer or some kind of universal care is perfectly keeping with conservative principles, and, for the reasons outlined above, it’s really not much of a stretch. Lest this sound outlandish, consider how fully liberals have convinced themselves that the Affordable Care Act–a plan hatched at the Heritage Foundation for heaven’s sake, and first implemented by a Republican governor–is the every essence of liberal progressivism.

The real obstacle may be the Democrats. As Max Fine, last surviving member of John F. Kennedy’s Medicare task force, recently told the Intercept, “Single payer is the only real answer and some day I believe the Republicans will leap ahead of the Democrats and lead in its enactment,” he speculated, “just as did Bismarck in Germany and David Lloyd George and Churchill in the UK.” For now, an invigorating civil war is raging within the Democrats with the National Nurses Union, the savvy practitioner-wonks of the Physicians for a National Health Program, and thousands of everyday Americans shouting at their congressional reps at town hall meetings are clamoring for single-payer against the party’s donor base of horrified Big Pharma executives and affluent doctors. In a few years there might even be a left-right pincers movement against the neolib/neocon middle, whose unlovable professional-class technocrats are the main source of resistance to single payer.

I don’t want to oversell the friction-free smoothness of the GOP’s conversion to socialized healthcare. Our funny country will always have a cohort of InfoWars ooga-boogas, embittered anesthesiologists and Hayekian fundies for whom universal healthcare is a totalitarian jackboot. (But, and not to be a jerk, it’s worth remembering that Hayek himself supported the socialized healthcare of Western Europe in one of his most reasonable passages from the Road to Serfdom.)

So even if there is some banshee GOP resistance at first, universal Medicare will swiftly become about as controversial as our government-run fire departments. Such, after all, was the trajectory of Medicare half a century ago.

http://www.theamericanconservative.com…

***

Comment:

By Don McCanne, M.D.

Although this article was published a year ago it is even more pertinent today considering the ever-deteriorating political milieu. Not only are the left and right divided, the left is divided amongst itself over support for a market-based versus a public service approach to financing health care, and the right is divided amongst itself over a Trumpian-style market-based versus a nihilistic drown-Medicare-in-a-bathtub approach.

Liberals or progressives – whatever you want to call them – have long been supportive of a national health program along the line of Medicare. However, their concept of political pragmatism has stifled their open support of such an approach, though that is now changing as we see how popular advocacy for Medicare for all has become.

Conservatives or libertarians have fixated on anti-government rhetoric, though views such as those of Friedrich Hayek, and those of the conservative leaders of European nations have long supported a prominent government role in ensuring health care for everyone. So it is not surprising that a conservative publication – The American Conservative – publishes an article on anticipated conservative support of “socialized medicine.”

Though we may have continued political turmoil, it is agreed that health care costs must be contained, waste reduced, and that everyone should have health care when needed. Those are concepts shared by conservatives and liberals. It’s about time that we adopted policies that would make them a reality, i.e., an improved Medicare for all.

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‘I can’t afford that’: A viral tweet shows why we need Medicare for all

By Helaine Olen
The Washington Post, July 5, 2018

The concept of “having skin in the game” is popular among those who still believe we can utilize the free market to rein in the cost of health care in the United States. The idea is that if people have to pay a decent percentage of the cost of medical care, they will turn into savvy medical shoppers when they need to see a doctor. This, in turn, will bring the costs down, ultimately resulting in a more affordable health-care system.

That’s the theory. The reality is different. Last week in Boston, Maria Cramer, a reporter for the Boston Globe, witnessed a horrifying accident on the city’s mass transit system:

Awful scene on the orange line. A woman’s leg got stuck in the gap between the train and the platform. It was twisted and bloody. Skin came off. She’s in agony and weeping. Just as upsetting she begged no one call an ambulance. “It’s $3000,” she wailed. “I can’t afford that.”

— Maria Cramer (@GlobeMCramer) June 29, 2018

A nurse who witnessed the aftermath of the accident said the victim most certainly needed an ambulance.

It seems almost beyond obvious to say that there is something cruel and out-and-out immoral about making people think about their financial skin in the game when their personal dermis is literally hanging off them. Other developed countries do not do this, and somehow they manage to spend less money overall on health care and often get better outcomes, too.

There is no real mystery about the United States’ sub-par performance. We are all but alone among developed countries in not offering universal health care. Most other comparable nations subsidize medical costs in some way or another, and they negotiate on behalf of all those they cover, too. Here we leave it to consumers, who despite having more and more “skin in the game” with each passing year still face increasing costs. More than 4 in 10 of those with private health insurance use a high-deductible plan, which means they are responsible for at least $1,300 in expenses before insurers will help with most of their medical bills.

The impact on household budgets is significant. According to a poll conducted earlier this year by the West Health Institute and Norc at the University of Chicago, 44 percent of those surveyed said they skipped visiting the doctor in the past year even when they thought they believed they needed the care, because of cost. Four in 10 also said they refused a doctor-recommended test or treatment because of the expense. More people said they were afraid of the cost of an illness than who said they were afraid of sickness itself. Another survey, this one by Ipsos for Consumers for Quality Care, found people more concerned about the costs of health care than those of college education, housing, child care or retirement. Cramer’s tweet demonstrates how this plays out in real time.

Little wonder. Costs are excessive, to say the least. Pfizer has raised the price of some of its pharmaceutical offerings by 20 percent since January of this year alone. Even the most determined consumer finds it all but impossible to price-check most medical services in advance, and that goes double in emergency situations. Surprise medical bills are a growing problem. Moreover, few know when they need a recommended procedure, further hindering their supposed ability to shop for health care. A study published last year in the Quarterly Journal of Economics of a firm where employees were switched over to a high-deductible health-insurance plan found that the workers and their families did indeed cut back on their medical spending — but they did it with seemingly no regard to need or quality.

Americans routinely say health care is one of the most important issues the country faces, and they have done so for years. When more than a few Democrats and Republicans responded to Alexandria Ocasio-Cortez’s surprise victory in a New York congressional primary by pointing out her support for Medicare for all would not play in other parts of the country, all they did was reveal how out of touch they are: Polls routinely find that a majority of voters support it. Many politicians are likely blinded to the reality of health care in the United States by money: The health-care industry is among the largest lobbies in Washington. A study by the nonprofit MapLight, which studies money in politics, found that Democratic senators who had not signed on to support Sen. Bernie Sanders’s Medicare-for-all bill received twice as much funds from the sector as those who attached their name to it.

Rising costs are shifting the health-care debate rapidly, and they would almost certainly would be doing so even if President Trump and the Republican Party supported the Affordable Care Act instead of ceaselessly undermined it. We are, I suspect, entering the end game for our free-market-dominated health-care system, shedding its skin, if you will, so we can regenerate it. Voters increasingly want no part of it. Doctors are increasingly likely to say they support a single-payer system. Insurance-company C-suite executives are known to claim they are open to discussing it, too. Even Trump, according to journalist Michael Wolff in his book “Fire and Fury: Inside the Trump White House,” asked after he was elected, “Why can’t Medicare simply cover everybody?” Why not, indeed.

https://www.washingtonpost.com…

Krugman redefines ‘Medicare for all,’ but gets it wrong

Radical Democrats Are Pretty Reasonable

By Paul Krugman
The New York Times, July 3, 2018

Alexandria Ocasio-Cortez’s upset primary victory has produced a huge amount of punditry about the supposed radicalization of the Democratic party, how it’s going to hurt the party because her positions won’t sell in the Midwest (and how well would Steve King’s positions sell in the Bronx?), etc., etc.. But I haven’t seen much about the substance of the policies she advocates, which on economics are mainly Medicare for All and a federal job guarantee.

So here’s what you should know: the policy ideas are definitely bold, and you can make some substantive arguments against them. But they aren’t crazy. By contrast, the ideas of Tea Party Republicans are crazy; in fact, Ocasio-Cortez’s policy positions are a lot more sensible than those of the Republican mainstream, let alone the GOP’s more radical members.

So, about Ocasio-Cortez’s positions: Medicare for all is a deliberately ambiguous phrase, but in practice probably wouldn’t mean pushing everyone into a single-payer system. Instead, it would mean allowing individuals and employers to buy into Medicare – basically a big public option. That’s really not radical at all.

https://www.nytimes.com…

***

The “pleasant ambiguity” of Medicare-for-all in 2018, explained: Are we talking about single-payer health care or something else?

By Dylan Scott
Vox, July 2, 2018

Democrats across the country are running on three simple words, recognizable to every American: Medicare for all.

In Democratic primaries around the country, Medicare-for-all candidates are winning.

Even before these candidates started winning, polling was showing that Medicare-for-all is really popular: 62 percent of Americans liked the sound of it in last November. Almost every single rumored 2020 candidate in the Senate has backed Sen. Bernie Sanders’s Medicare-for-all bill. It’s clear the idea is in ascendancy among Democrats.

But someday, a reckoning will come. When Democrats hold power again — especially control of Congress and the White House — they will be expected to actually deliver on these Medicare-for-all promises. And when that day arrives, the party will have to decide whether they want to blow up America’s current health care system to build something new or figure out a less disruptive path, but risk falling short of truly universal coverage.

What does “Medicare-for-all” actually mean?

Historically, Medicare-for-all has meant single-payer health insurance, a national government-run program that covered every American and replaced private coverage entirely, similar to the government-run health care programs in Canada and some European countries.

Then-Rep. John Conyers (D-MI) first introduced the Expanded and Improved Medicare for All Act in 2003. It’s now sponsored by Rep. Keith Ellison (D-MN) and it is still a single-payer proposal.

But these days, other plans are falling under the Medicare-for-all umbrella. Some progressives are even comfortable with the term being applied to the various proposals to allow all Americans buy into Medicare. Some of those plans used to be branded as a “public option”; they would not end private insurance that more than half of Americans get, usually through work, as a true single-payer would. But these plans would also not provide the same guarantee of universal coverage that a single-payer system does.

“For anybody who supports Medicare-for-all single payer, what better way to debunk the right wing lies than to allow millions and millions of Americans to voluntarily opt into Medicare and love it?” (Adam Green, co-founder of the lefty Progressive Change Campaign Committee) told me. “As a political strategy, having Medicare-for-all be a broad umbrella where any candidate can embrace some version of it… that moves the center of gravity in the Democratic party.”

Medicare-for-all is uniting Democrats for now — but it could divide them later

That explains why there’s this fledgling competition over what Medicare-for-all is really describing.

The best example might be the health care plan from the Center of American Progress, which is, tellingly, called “Medicare Extra For All.” It’s a seriously ambitious plan, one that would achieve universal coverage through a combination of government plans and private insurance, while preserving employer-based insurance for those who want it. But it is not single payer. And it is notably produced by an organization closely aligned with the Democratic establishment.

The scars from the Obamacare reveal themselves in this debate. For all the health care law has achieved, it also showed the limits of incrementalism. Even Medicaid expansion, the closest thing the law had to a single-payer pilot, was undermined by the Supreme Court by allowing Republican-led states to refuse it. The Obamacare insurance markets have been susceptible to sabotage from Republicans in Congress and the Trump administration.

Yes, the uninsured rate has reached historic lows under Obamacare, but 10 percent of Americans still lack coverage. Democrats will be faced again, at some point, with a choice between a more incremental approach, like the Medicare public options introduced by some Democrats in Congress, or a sweeping overhaul like single-payer.

https://www.vox.com…

***

Comment:

By Don McCanne, M.D.

“Medicare for all…would mean allowing individuals and employers to buy into Medicare – basically a big public option.” Who says? Well Paul Krugman and many others. This is not simply a debate about labels. This is a debate about fundamental policy. Are we going to accept the status quo with the tweak of a public option, or are we going to address the fundamental defects in our system that have driven up costs, perpetuated mediocrity, and left tens of millions vulnerable with impaired access to health care with all of its consequences and often with intolerable financial hardship?

This is similar to the debate that took place within the Democratic Party just before Hillary Clinton and Barack Obama began jockeying for the 2008 presidential nomination. The Democratic Party machine was in complete control of the policy debate on health care reform. The neoliberal party elite had decided that we were going to “build on what works” – employer-sponsored and union-supported plans – and reject single payer based on their concepts of what was politically feasible. Those of us advocating for the expanded and improved Medicare for all single payer approach were ejected from the conversations (often rudely so – they were in charge!).

Similarly, with the contest for the 2016 Democratic presidential nomination, the debate at the platform committee confirmed that the battle had not changed. The neoliberal leadership, represented by Neera Tanden, was successful in rejecting the single payer Medicare for all plank.

Tanden, of the Center of American Progress, has continued the fight for control of the policy debate by releasing their new proposal, “Medicare Extra For All.” Although some of the tweaks proposed seem beneficial, it basically continues the current dysfunctional, fragmented financing system, but with one important political change. They have stolen the “Medicare for all” label! This has contributed to the ubiquitous deception that the public option is Medicare for all. When the current candidates campaign on Medicare for all but behind the scenes are supporting an option to buy into Medicare while accepting campaign funds from the insurance and pharmaceutical industries, we need to call them on their deception.

It is no wonder the public is confused, even if they do not realize it. When Nobel laureate Paul Krugman jumps in and says Medicare for all is allowing individuals and employers to buy into Medicare as a public option, then we know that the political campaigns are corrupted with deceptions. How can we get the public to understand that a well designed, single payer national health program – a bona fide Improved Medicare for All – is the reform that they crave?

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Emergency departments: the ‘chewing gum and duct tape’ holding together U.S. health care

By Paul Seward, M.D.
STAT, July 3, 2018

The evolution of emergency care in the United States is a fascinating story. Sadly, what became a hugely successful solution to an important problem in health care is now being eroded by its misapplication to another problem.

The modern U.S. health care system began with so much promise. After World War II, the economy was booming and employers were quick to provide health care for their workers. The addition of Medicare and Medicaid in 1965 further fueled a dramatic expansion in the quality and availability of health care services.

Throughout this time, emergency care was still in its dark days. Ambulance services were operated mostly by funeral directors, with minimally trained helpers. Emergency rooms were commonly staffed by a nurse whose job was to conduct an initial evaluation of patients and then contact the on-call physician — who may or may not have had any training in the management of emergencies.

Soldiers and health care personnel who served in World War II, Korea, Vietnam, and our undeclared wars had experienced how effective a well-organized system for taking care of acutely injured people could be. Their knowledge put pressure on hospitals to look for a new way to manage emergency care.

In that new way, hospitals contracted with physicians to ensure that there was always a doctor in the emergency room. Beginning in 1976, I was one such physician.

I was a pediatrician at the time, with little experience treating adult patients. Fortunately, I could call any physician on the staff for help. Equally important, when they came in to assume care for the patient, I was there to help. In that way, I learned how to care for all sorts of emergencies.

One day, an ophthalmologist taught me how to remove small bits of metal from the surface of a metalworker’s eye. His instructions were simple: put some anesthetic drops in the patient’s eye; use a “spud,” a metal tool with a point on the end, to scrape out the metal fragments; then use a small electric burr, like a tiny sander, to buzz off the residual rust granules. The patient did fine, and I learned how tough an organ the eye really is.

I did that procedure entirely by myself. I had to: The ophthalmologist stayed home and told me what to do over the phone. That was also a part of emergency medicine.

During the 1970s and early 1980s, professional organizations formed; leaders emerged; the science of emergency medicine developed; new emergency procedures and better techniques for old procedures were invented; textbooks were written; and examination and certification procedures came into being. Emergency rooms became departments of emergency medicine. In 1983, I took and passed the second Emergency Medicine Board Examination ever given, making me certified in the new specialty of emergency medicine.

Today, if you are acutely ill or have experienced trauma, you can go to an emergency department anywhere in this country and receive immediate, excellent, lifesaving care from people who have spent their careers learning how it’s done.

That’s the good news.

The bad news is that, in parallel with the rise in emergency medicine, health care costs steadily surged upward. Today, medical debt is the most common cause for personal bankruptcy, particularly in the elderly. At the same time, health care insurance is becoming increasingly difficult to afford.

Until health care reform happens, the stopgap measure is the emergency department. Why? Because it is like mom and dad: When no one else will take you in, the emergency department can’t turn you away. It’s against the law to do that. But using emergency departments to create access to health care is like putting a snow plow on a Porsche. It costs much more, does a bad job, and it trashes the Porsche.

Although emergency departments are set up to handle anything, they can’t handle everything at once. As more and more people turn to the emergency department for non-emergency care, it is common, especially in metropolitan areas, to have waiting times in them measured in large parts of a day and to have patients kept in stretchers in the hallways after they have been admitted to the hospital because they cannot get an inpatient bed.

Wealth does not make people immune to being swallowed up by the emergency department. Here’s a story for the one-percenters out there. Several years ago, while working in the emergency department of a busy metropolitan hospital, I cared for a middle-aged Wall Street stockbroker. Certain he was having a heart attack, I admitted him to the cardiac care unit. Two days later, when I returned to work, he was still in the emergency department, standing amidst a collection of gurneys in front of the nurses’ station. Wires attached to his chest tethered him to a monitor 20 feet away. He was still there because no bed had opened up in the cardiac care unit.

People sometimes ask me how long I think it will be before our health care system collapses. There certainly are signs that it is coming apart: Our legislatures routinely block attempts to create a rational health care system. Old people are regularly financially ruined by the costs of illness. Health insurance is becoming increasingly unaffordable. And politicians, while decreasing taxes for wealthy people, are crying that federal health insurance must be cut back.

I believe that one reason our health system still functions at all is because emergency departments are the chewing gum and duct tape holding it together. That may work for a few more years.

Or maybe it won’t.

Dr. Paul Seward practiced medicine for nearly 50 years, mostly in emergency departments. He is the author of “Patient Care: Death and Life in the Emergency Room” (Catapult, July 2018).

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