PNHP

Why cost sharing should be abandoned

Why cost sharing should be abandoned

Down With the Copay

By Natalie Shure
Jacobin, October 6, 2017

In the week preceding the release of Bernie Sanders’s Medicare for All bill, the Vermont senator’s office was flooded with calls — so many, in fact, that the legislative aides on the other line often guessed callers’ purpose before being prompted. At issue was whether the single-payer health care system Sanders’s bill envisions should include copayments, out-of-pocket payments for health services at the point of care.

For the single-payer advocacy group Physicians for a National Health Program (PNHP), the answer was a resounding “no.” So upon discovering that copays remained in Sanders’s penultimate draft, they sprang into action. After a week of open letters, tweets and appeals from like-minded organizations, Sanders ultimately struck copays from the bill’s final version.

Earlier versions of Sanders’s bill probably included copays for doctors visits and prescription drugs for the same reason that economists like them: they drive down health care usage and costs. After all the attacks branding Sanders’s relatively pedestrian social-democratic platform as fantastical promises of ponies for all, perhaps Sanders’s legislative aides believed meager copays gave their proposal an air of seriousness.

But the obliteration of copays isn’t a bug in the thinking behind Medicare for All — it’s the feature.

“Cost-sharing” features like copays, coinsurance, and deductibles are major manifestations of market logic in the US health-care system. If we want to overturn for-profit health care’s rebranding of “patients” as “consumers,” we have to eliminate financial barriers at the point of care.

The cliched justification for charging copays is to relieve doctors’ offices of the burden of patients showing up at the first sign of a sniffle. (Never mind that we observe no such behavior among the wealthy, for whom copays are no barrier.) But we do know that even meager copays make people seek less care, and that the poor suffer worse health outcomes as a result.

“I spent my entire career taking care of low-income people, and trust me — a copayment will keep people away from a doctor. I’ve seen it again and again in my practice,” Dr. Steffie Woolhandler, the co-founder of PNHP, told me over the phone. “It’s a huge amount of money for a low-income person.”

While several countries with universal health care systems do charge copayments at the point of use, they don’t tolerate the amount of poverty that we do in the United States. No other wealthy country does. In a grotesquely unequal society, a copayment doesn’t create “better consumers” of care — it helps us scrimp by shoving the most powerless out of the system.

Over decades of bending over backwards to accommodate the internal contradictions of the private health insurance industry, few made the one point that really mattered: we never built an insurance system that strove to guarantee universal health care; we built one that strove to protect capitalists’ profits. We can build one based on addressing all people’s health care needs right now.

Medicare for All could create a universal health-care system designed to provide health care for everyone. The logic of the market has no place in such a system. Winning a truly universal system means zero deductibles and zero copays.

https://www.jacobinmag.com…

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Physicians for a National Health Program, August 23, 2017

Dear Senator Sanders:

We are writing to express our concern about elements of your draft single payer legislation, especially the inclusion of copayments for medically-necessary care.

Copayments

Copayments undermine the goal of eliminating financial barriers to care, a goal that is at the heart of our single-payer advocacy. Copayments, even relatively modest ones, deter patients from seeking needed medical care.

For instance, in the Rand Health Insurance Experiment, compared to persons with entirely free care, those with copayments (as low as 16% of costs) reduced their use of essential and low-value medical services to a similar degree. Among non-poor adults, copayments reduced the use of “highly effective” care for acute conditions such as chest pain, urinary tract infections and fractures by 29% and “rarely effective” care (e.g. for a cold) by 22%. Highly-effective care for chronic conditions fell by 15%, and for acute-on-chronic conditions fell by 21%. For non-poor children, copayments reduced highly-effective care (e.g. for ear infections and strep throat) by 15%, and cut well-child visits by 21%. Cost sharing reduced prescriptions for several potentially life-saving medications such as insulin, asthma inhalers, and beta blockers by about 50% and oral contraceptive use by 25%. While the Rand Experiment was too small and too short to detect the expected deleterious outcomes of these shortfalls in care, it documented that copayments resulted in significantly worse control of blood pressure, a key cause of heart attacks, kidney failure and strokes.

More recent studies confirm the health-endangering effects of out-of-pocket charges for care. Among persons with employer-paid coverage, raising out-of-pocket charges cut care much more for those in poor health. When Medicare added new copayments, outpatient visits dropped but hospitalizations rose. Among insured post-heart-attack patients, eliminating medication copayments increased compliance, and (for minority patients), led to a 35% reduction in major complications such as recurrent heart attacks. Similarly, among insured school-age children with asthma, those with higher copayments used fewer medications but had a 41% greater risk of asthma-related hospitalization. For nearly one- third of lower-income asthmatic children with high-cost-sharing coverage through the Kaiser Health Plan, parents reported delaying or avoiding outpatient visits, and 14.8% reported non-adherence to medications because of cost. The low income group in the study included those with family incomes up to 250% of poverty, some of whom would be hit by copayments under the proposed legislation. In that study, 15.6% of all parents (including those with higher incomes) reported borrowing money or cutting back on necessities to pay for their children’s asthma care.

Paradoxically, the reduction in care-seeking because of copayments may fail to cut system-wide utilization, instead shifting care from sicker and lower-income persons to the healthy and wealthy. When lower-income patients avoid care, doctors and hospitals fill the empty appointment slots and beds with less price-sensitive patients, an example of supply-sensitive demand.

International evidence indicates that cost-sharing is neither necessary nor particularly effective for cost control. Canada, which outlawed copayments and deductibles in 1981, has seen both faster health improvement and slower cost growth. Notably, Canada experienced no surge in care when it abolished copayments. Similarly, in the U.S. there was no overall increase in doctor visits or hospitalizations when Medicare and Medicaid were first implemented in 1966; care shifted from more affluent and healthier persons to those who were sicker and poorer. Scotland, which has eschewed patient payments—even going so far as to abolish parking fees—has costs about half those in the U.S. Strikingly, the U.S. has the world’s highest health care expenditures despite its extensive patient cost sharing.

The inclusion of copayments would also undermine the breadth of support for single-payer reform. Many Americans would see no improvement in their current coverage. In 2014, about 28% of Americans incurred no out-of-pocket costs, and 84.3% had out-of-pocket costs of less than $1,000. For them, the proposed coverage would not reduce out-of-pocket costs, at least in the short run. About 5% of those with employer coverage—about 8 million people—currently have plans with zero deductibles and zero copayments. They would have worse coverage under the proposed reform.

Finally, retaining copayments would substantially diminish the administrative savings achievable through a single-payer reform. In order to implement copayments, the single payer insurer would need to track individuals’ changing incomes, family status (to calculate their income relative to the poverty level) and their copayments to date (to ascertain whether they’ve exceeded the out-of-pocket cap), and make that information available in real time to every hospital, clinic, lab, doctor’s office, etc., in the U.S. Providers would need to collect the copays, and bill patients unable to pay at the time of a visit.

Conclusion

In sum, Physicians for a National Health Program cannot endorse or wholeheartedly advocate for a reform that includes copayments for medically-necessary services. While we would welcome the proposed reform as a useful step forward in advancing health justice, the persistence of copayments would unacceptably compromise the legislation’s ability to improve health and foster equality in care. We urge you to reconsider the inclusion of copayments.

Sincerely,

David U. Himmelstein, M.D., Co-founder PNHP
Carol Paris, M.D., President, PNHP
Steffie Woolhandler, M.D., Co-founder, PNHP

References available at link:
https://pnhp.org/docs/SandersLetter_2017.pdf

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Comment:

By Don McCanne, M.D.

It is irrefutable that deductibles, copayments, and coinsurance cause patients to forgo beneficial health care services, and that often results in physical suffering and sometimes death. For those who cannot avoid health care, financial hardship is frequently a consequence.

A health care financing system should be designed to assist patients in getting the health care they should have by removing financial barriers to care. Since cost sharing has the opposite effect, it should be abandoned as a policy designed to reduce health care spending. There are other much more patient-friendly policies in a well-designed single payer system that are more effective in containing health care spending.

It is a specious argument that people who do not need health care will seek health care anyway simply because it is free. Some say that it would reduce low-value care, but what is low-value care? When a patient is legitimately concerned about his or her health but then doesn’t require any therapeutic intervention other than reassurance, is that low-value care? No. We want patients to come in to reassure them and ourselves that there isn’t anything more serious that requires medical intervention.

The letter by Himmelstein, Paris and Woolhandler provides an excellent explanation as to why cost sharing should be rejected – why individuals should be approached as patients rather than as consumers.

Their letter also demonstrates that it is imperative that we all continue to speak up with the truth about health care reform. Important people are listening.

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

Down With the Copay

We can’t eliminate the profit motive in health care without eliminating copays.

By Natalie Shure
Jacobin, October 6, 2017

In the week preceding the release of Bernie Sanders’s Medicare for All bill, the Vermont senator’s office was flooded with calls — so many, in fact, that the legislative aides on the other line often guessed callers’ purpose before being prompted. At issue was whether the single-payer health care system Sanders’s bill envisions should include copayments, out-of-pocket payments for health services at the point of care.

For the single-payer advocacy group Physicians for a National Health Program (PNHP), the answer was a resounding “no.” So upon discovering that copays remained in Sanders’s penultimate draft, they sprang into action. After a week of open letters, tweets and appeals from like-minded organizations, Sanders ultimately struck copays from the bill’s final version.

Earlier versions of Sanders’s bill probably included copays for doctors visits and prescription drugs for the same reason that economists like them: they drive down health care usage and costs. After all the attacks branding Sanders’s relatively pedestrian social-democratic platform as fantastical promises of ponies for all, perhaps Sanders’s legislative aides believed meager copays gave their proposal an air of seriousness.

But the obliteration of copays isn’t a bug in the thinking behind Medicare for All — it’s the feature.

“Cost-sharing” features like copays, coinsurance, and deductibles are major manifestations of market logic in the US health-care system. If we want to overturn for-profit health care’s rebranding of “patients” as “consumers,” we have to eliminate financial barriers at the point of care.

“Medical Loss”

There’s a contradiction at the heart of American health care: the insurance companies that are supposed help us access care actually have a vested interest in us receiving as little treatment as possible. The history of the American health-care system is the story of a private sector incapable of doing the thing it supposedly exists to do, while the public sector steps in try to fill the gaps but is far too underresourced to do so. The introduction of copays into the American system is rooted in that contradiction.

As health-care quality and costs began to rise in the early twentieth century, FDR quickly dropped health insurance from his New Deal wish list, apparently out of concern too ambitious a program could kill the whole thing on arrival. Meanwhile, to stay afloat during the Great Depression, conglomerations of hospitals and physicians tried to ensure their communities could still get medical care through a nonprofit monthly “subscription fee.” As these community plans expanded in scope, their rising monthly premiums were eventually undercut by profit-seeking competitors playing by different rules. These private plans drove down fees by only accepting healthy, desirable enrollees — while the nonprofit model struggled to extend coverage to everyone.

The tight labor markets of World War II gave for-profit plans an additional boost. In the midst of frozen wages and mass overseas deployment, skittish employers saw the plans as a way to entice workers. Before long, these private plans served employers in other ways: by making health care contingent on employment, they disempowered workers while undercutting the nonprofit insurers’ ability to bargain with hospitals and providers.

Once the postwar push for national health insurance collapsed for good in 1948, we were stuck with a workplace-tethered insurance system dominated by commercial players that no one (save for those looking to get rich off of health care) would have purposefully designed. But the nonprofit and commercial plans differed in one more crucial way: while the nonprofit setup covered costs from the first dollar of care, commercial benefits generally kicked in only after patients forked over deductibles or copayments — dissuading them from seeking care to begin with, and limiting companies’ liability for it when they did.

This wasn’t some minor semantic difference. It reflected completely different reasons for existing.

While the nonprofit plans aimed to generate New Deal–style collective security, the commercial plans just wanted to make money. The best way to do that was to get people to pay for their plans while avoiding having to pay for people’s treatment. For private insurance companies, a client going to the doctor and receiving care was not a good thing — it was “medical loss” and needed to be prevented.

The health insurance companies parroted the logic of property insurers, who saw all their customers as potential vandals willing to damage their cars and houses in order to defraud the insurance company. If an auto insurance policy holder has dirty car windows, they asked, what’s to stop them from smashing up the windows to get shiny new ones?

In 1921, Aetna — the same company that, nearly one hundred years later, would exit a struggling ACA exchange market in retaliation against the federal government for blocking its megamerger — devised an innovative method to hedge against the would-be dirty window scammers. Enrollees would pay a deductible before the rest of the coverage kicked in, which would incentivize them to protect their “property,” giving health insurance users “skin in the game.”

The idea that patients are apt to sabotage their own health to get brand new, upgraded body parts is as condescending as it is gruesome, and the idea that deductibles give people a reason to stay healthy and minimize medical needs is a paternalistic misreading of the dynamics that affect health. It’s no wonder this patchwork of private plans failed to engineer a system of universal care; it’s not what they were designed to do.

A Better Way

By the early 1960s, it was glaringly obvious that the private insurance sector was incapable of funneling elderly, poor, and disabled patients into the health care system. The fact that these companies’ business model was incompatible with supporting those who most needed it ought to have been a decisive repudiation against private insurers’ right to be doing this in the first place.

Instead, the US government enacted Medicare and Medicaid in 1965, shifting the care of vulnerable populations to the public sector and leaving the easiest and cheapest patients in the same private market whose failures the government had just stepped in to alleviate. Even worse, these new federal programs eventually adapted one of the private sector’s cost-reduction tricks: the copayment.

The cliched justification for charging copays is to relieve doctors’ offices of the burden of patients showing up at the first sign of a sniffle. (Never mind that we observe no such behavior among the wealthy, for whom copays are no barrier.) But we do know that even meager copays make people seek less care, and that the poor suffer worse health outcomes as a result.

“I spent my entire career taking care of low-income people, and trust me — a copayment will keep people away from a doctor. I’ve seen it again and again in my practice,” Dr. Steffie Woolhandler, the co-founder of PNHP, told me over the phone. “It’s a huge amount of money for a low-income person.”

While several countries with universal health care systems do charge copayments at the point of use, they don’t tolerate the amount of poverty that we do in the United States. No other wealthy country does. In a grotesquely unequal society, a copayment doesn’t create “better consumers” of care — it helps us scrimp by shoving the most powerless out of the system.

Once state Medicaid programs began charging copays in the 1970s, the new fees were associated with patients dropping out of health care plans. In some cases, there was a demonstrable impact on health: in 1975, California’s MediCal program reduced doctors’ visits with copays, only to have those savings offset by higher hospitalization rates.

Meanwhile, cost-sharing arrangements have continued in the private insurance market, shifting responsibility for systemic dysfunction onto individuals — as if soaring health care costs are caused by patients unnecessarily demanding CAT scans and blood tests like a spiteful customer at the Old Country Buffet piling their plate high in an effort to make the restaurant take a loss.

The burden of high-deductibles and copays continues to spawn new profit centers for the industry that imposed them: private Medigap insurance offsets costs not covered by Medicare, and Health Savings Accounts siphon off the public tax base to help holders save cash to cover costs like high deductibles. Insurance regulations, like those introduced by the Affordable Care Act, have left companies once again searching for savings through cost-sharing: in 2016, over 39 percent of Americans from ages eighteen to sixty-four held high-deductible health plans, up from 26 percent in 2011. In the past decade, cost-sharing payments have risen at more than twice the rate of wages.

The persistence of cost-sharing isn’t prudent health policy; it’s an indictment of a system whose basic functionality depends on making it as difficult as possible for us to participate in. No matter how many people in #StillWithHer shirts beseech legislators to “improve the Affordable Care Act” rather than back “Medicare for All,” the for-profit framework that the ACA uses does little to challenge is fundamentally incapable of delivering universal care.

Over decades of bending over backwards to accommodate the internal contradictions of the private health insurance industry, few made the one point that really mattered: we never built an insurance system that strove to guarantee universal health care; we built one that strove to protect capitalists’ profits. We can build one based on addressing all people’s health care needs right now.

Medicare for All could create a universal health-care system designed to provide health care for everyone. The logic of the market has no place in such a system. Winning a truly universal system means zero deductibles and zero copays.

https://www.jacobinmag.com…

MedPAC will recommend repeal of MIPS

MIPS Takes a Beating at MedPAC

By Shannon Firth
MedPage Today, October 5, 2017

The Merit-based Incentive Payment System (MIPS) should be spiked, virtually all members of the Medicare Payment Advisory Commission (MedPAC) said during a meeting on Thursday morning.

MedPAC, whose members include physicians, healthcare executives, and other policy experts charged with advising the Department of Health and Human Services on Medicare policy issues, has been set on defeating MIPS for a long time; but whether the program should be simply “repealed” or “repealed and replaced” wasn’t clear at Thursday’s meeting.

The MIPS program is one of two payment vehicles created as a result of the the Medicare Access and CHIP Reauthorization Act (MACRA) — which replaced the almost universally despised Sustainable Growth Rate (SGR) formula. The other payment pathway consists of an array of advanced Alternative Payment Models (APMs), which weren’t discussed in any detail at the meeting.

The main problem with the MIPS program, as MedPAC’s analysts see it, is that MIPS won’t achieve the policy goals that it’s designed to achieve.

“Our most basic concern is that the measures in MIPS have not been proven to be associated with high-value care,” said (David Glass, a principal policy analyst for MedPAC).

Alternative Proposed

Glass and MedPAC senior analyst Kate Bloniarz suggested an alternative policy approach that leverages population-based measures.

The Voluntary Value Program, as they’ve dubbed the alternative, would get rid of the MIPS program and all three types of reporting requirements — Advancing Care Information (ACI), Clinical Practice Improvement Activities (CPIA), and quality measures — and scrap CMS support for Electronic Health Records reporting.

In the new model, all clinicians would see a portion of their fee schedule dollars withheld, which would be lumped into a pool — for example 2%, though analysts stressed the percent amount had not been decided.

Clinicians would then have three options:

* Choose to be measured with a “sufficiently large entity” of clinicians and be eligible for value payments

* Choose to participate in an advanced APM model

* Lose the withheld fee schedule dollars

In the end, (Commission Chairman Francis J. Crosson, MD) determined that MedPAC’s technical team would return to the group with draft recommendations for repealing the MIPS program and offer two options: a voluntary replacement program similar to the one discussed at Thursday’s meeting with some revisions, and suggestions on how to make the advanced Alternative Payment Models more accessible for physicians.

The commission could then decide whether to recommend one or both options to HHS.

https://www.medpagetoday.com…

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URGENT: Explaining MIPS; Action required

Comment by Don McCanne, M.D.
PNHP Quote of the Day, March 21, 2015

Yesterday’s Quote of the Day message (March 20, 2015) sounded the alarm on legislation that would replace the flawed Sustainable Growth Rate formula (SGR) for updating Medicare payments with a new Merit-based Incentive Payment System (MIPS) – legislation with strong bipartisan support that will be taken up in Congress this week and is expected to pass.

The SGR formula is considered to be flawed primarily because economic factors considered in the formula would result in inappropriate payment reductions in many of the yearly adjustments. Thus there is consensus that the formula should be repealed.

The concern is over its replacement: MIPS. On reading the summary of the “SGR Repeal and Medicare Provider Payment Modernization Act,” you will see that MIPS places a tremendous administrative burden on health care professionals in a health care system that is already overwhelmingly overburdened with administrative excesses. The only way to escape this additional burden is to participate in Alternative Payment Models (APMs) which, in themselves, create further significant administrative burdens (ACOs, PCMHs, etc.). MIPS is an administrative nightmare.

The problem is that those who do not game the system, and especially those with practice situations and patient populations that make it very difficult to score higher points, will almost automatically receive performance scores below the threshold since their performances will be compared with the gamers. This will result in negative payment adjustments – reducing payments by up to nine percent. If you think SGR is unfair, MIPS robs from these hard-working professionals who are just trying to make the system work for their patients, and gives the spoils to those who likely have consultants to show them how to game the system.

https://pnhp.org…

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Comment:

By Don McCanne, M.D.

Lost in the celebration two years ago over ending the highly flawed SGR method of updating Medicare payments was the fact that its replacement, the Merit-based Incentive Payment System (MIPS), would create an administrative nightmare while failing to achieve its goal of higher quality care at lower cost.

It’s not that the problem wasn’t recognized (see the March 2015 comment), but the policy community and the politicians just don’t get it. They make up theory, knowing that with their genius, these proposals will be phenomenal. Then they do the policy research. Well, MIPS is not working.

So what do they recommend? Let’s push physicians into the other part of the MACRA legislation, the Alternative Payment Models (APMs) – accountable care organizations and the like. After all, they have been under study for several years now and they say that they are just beginning to show slight improvements in a couple of quality measurements, and they also say that they are beginning to show a very slight downward trend in costs in some instances, unless you look at the details. In truth, they are adding to the administrative complexity with higher administrative costs that they are deliberately leaving out of their calculations, and, worse, they are increasing physician burnout.

In spite of the pessimism, they defend their position by saying that we can’t go back to the way things were. We have to start paying for value instead of volume. Yet they have failed to demonstrate two things: how you do that, and, more importantly, how a system using fee-for-service, capitation, salary, global budgeting, and rate negotiation, as appropriate, is somehow inferior to their screwball theories of value-based financing.

Of course, we offer up a well-designed single payer system as a much better alternative. And what is their response?  Single payer might be a consideration for some time in the distant future, but not now. We have to build on what is working – our administratively complex, dysfunctional, overpriced system that leaves tens of millions without appropriate care and often destitute. But they say they can fix those things by adding a public option or a Medicare buy-in, except that we will still be faced with even more administrative complexity, higher costs, too many uninsured and even greater numbers who face intolerable medical debt as the insurers place even more risk on the health care consumers (formerly known as patients).

The good news is that MIPS is going away. The bad news is that the rest of the crap stays in place and will get worse simply because we need to postpone single payer and instead build on the Affordable Care Act and its offshoots like MACRA and APMs.

Time to take a knee for single payer, or is that still a fantasy?

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

California Game Changers: Birthing a Single-Payer Health Care System

Healthy California’s single-payer plan could deliver coverage to every Californian for about $331 billion, vs. the $370 billion the state currently spends.

By Bill Raden
Capital & Main, October 6, 2017

This autumn could prove decisive for the question of whether California may again be on track to enjoy what the rest of the industrialized world has long taken for granted — universal, government-provided health insurance, a dream that dates back to the Truman administration. Although the Affordable Care Act was spectacularly successful in lowering the state’s uninsured rate from 17.2 percent to 7.3 percent, according to the latest census data, that still represents a roughly 2.8 million-person gap in California’s health coverage. And health care advocates argue that too many with private insurance continue to fall victim to the catastrophic failure of a for-profit health care model plagued by extraordinary complexity and costly administrative inefficiency.

Paul Y. Song, an oncologist who sits on the board of Physicians for a National Health Program, told Capital & Main that with or without a GOP repeal, the withering Republican assault on the ACA has exacerbated the financial hardships of many recently insured Californians struggling simply to maintain their coverage. Song is also the co-chair of Healthy California, a campaign that supports passage of state Senate Bill 562, a single-payer measure that stalled in Sacramento when Assembly Speaker Anthony Rendon (D-Lakewood) tabled it in June.

“The number of people reporting difficulty paying monthly premiums has gone up to nearly 37 percent,” Song noted. “California ranks third from the bottom in terms of narrow networks, which means that if you have an emergency and you need to see a doctor, chances are the majority of the time a doctor will not be in your network and you’ll get charged all of these out-of-network prices. … Anthem announced earlier this year that they were going to raise rates. They were either going to pull out of the exchange in California in certain areas, or raise rates 35 percent. People are now waking up and saying enough is enough.”

California Democratic leaders, state labor and health care advocates have never seemed more galvanized around the principle that quality health care is a fundamental right for all Californians. The divisive question of how to best achieve it is set to be taken up in a series of hearings over the next several months by the Assembly Select Committee on Health Care Delivery Systems and Universal Coverage, announced in March by Speaker Rendon. The hearings begin October 23-24.

For both single-payer advocates and opponents in Sacramento, as well as Washington, the debate is ultimately about far more than health care. Battle lines have formed around bedrock questions of who we want to be as a people: Should suspicion of “big government” take priority over the broader welfare of the population? Will the cruelties of the unfettered marketplace be tolerated in the name of American individualism?

In the meantime, experiencing the harrowing contradictions of California’s health care system continues to be the day-to-day reality of front-line caregivers. Melissa Johnson-Camacho, an oncology nurse in Davis who has also spoken in favor of single payer before the U.S. Senate, told Capital & Main how she remains haunted by the experience of caring for a young woman riddled with metastasized cancer.

Because the girl’s cancer had spread to her lungs, she was at risk of drowning in her own pleural fluid and her life now hinged on a daily supply of pharmaceutical-grade catheter bags to safely drain the lungs.

“Her mom was with her as a caregiver, so she starts telling me about the drains and that she would change them more often, but they couldn’t afford it,” Johnson-Camacho said. “It was unspoken, but I know her mom was [thinking], ‘How much supplies am I going to need when I know she’s not going to be here much longer?’”

Facing renewal of the girl’s crippling annual deductible of her private insurance plan, the family was trying to stockpile her supply of bags, which can list for around $5,000 per day, by exceeding their recommended capacity.

“Nobody should ever have to make a decision like this,” said Johnson-Camacho. “Especially when you’re paying into a system. It was just angering. It was sobering. It was tragic. That was one of many times that I thought, ‘We’ve got to change this.’”

That’s why, Johnson-Camacho offered, she’ll be joining in the Healthy California campaign’s Medicare-for-All October Weekend of Action, in which she and fellow activists hope to canvass all 80 Assembly districts across the state to urge voters to flood Sacramento with letters demanding action on SB 562.

“There’s a lot of different forces out there that don’t want to see this bill move forward,” explained Don Nielsen, chief lobbyist for the California Nurses Association (CNA), which is a sponsor of the bill (and a financial supporter of this website). “Select committees can’t do anything other than take testimony. They can’t move our bill. And we’re concerned that the process is more about slowing down the momentum of the incredible public support for Medicare for All, single payer and SB 562. People know that the system is broken. They want to see it fixed.”

Rendon’s press spokesperson, Kevin Liao, countered that far from being a stalling maneuver, the Select Committee was designed to allow a broader discussion on getting to health care for all, and that nothing was stopping SB 562’s authors from redressing the bill’s “potentially fatal flaws”: “Speaker Rendon laid out a clear path for SB 562 — the Senate can send to the Assembly workable legislation that includes financing, delivery of care and cost control.”

But Healthy California’s timetable to iron out those critical details and then get the bill through committee and floor votes, and finally to the desk of a less-than-enthusiastic Governor Jerry Brown by the end of the 2018 session is ambitious, reflected Anthony Wright, executive director of Health Access California. The veteran consumer health advocate, who has lobbied on behalf of universal, single-payer health care bills and initiatives dating back to Proposition 186’s Medicare for All-type ballot initiative in 1994, said that the coalition has its work cut out.

“A health system can be very complex and confusing,” said Wright. “The same obstacles that prevented us in previous attempts still remain, and in fact loom even larger. Vermont had an Obama administration that was willing to work with them to figure out the various financing and other issues. For the next three, four years, we’ll have a Trump administration in that same role, which will probably not be helpful.”

The executive director of the California School Employees Association, Dave Low, concurred. “We need federal waivers to a California single-payer bill,” he explained. “We know that there is a heavy lift. Just the poll that recently came out showing that we don’t even have a majority support on the single-payer issue shows that we have work to do, and we want to do that work.” (Disclosure: CSEA is a financial supporter of this website.)

Trump aside, it turns out that there’s little economic reason why California couldn’t go it alone with single payer, and a host of reasons why it should. A CNA-commissioned study found that by lowering administrative costs, controlling the prices of pharmaceuticals and fees for physicians and hospitals, reducing unnecessary treatments and expanding preventive care, Healthy California’s single payer could deliver coverage to every California resident for about $331 billion, or 10 percent less than the $370 billion the state currently spends.

And California has size in its favor. The state’s $2.4 trillion annual gross domestic product ranks neck-and-neck with France’s GDP, and California’s population of 39 million puts it above Canada’s. Yet at $7,549 per person, the state spends considerably more on health care with its market-based system than both countries — $5,292 for Canada; $4,959 for France — do with their universal single-payer systems, while getting substantially less bang for its buck. According to the Commonwealth Fund, while California ranks 14th in the nation on health care access, efficiency and equity, the U.S. consistently comes in last or near last on those measures relative to its industrialized peers. In terms of infant mortality, the state’s 4.7 deaths per 1,000 births places it just behind Cuba (4.51), Canada (4.53) and Greece (4.58), and 40 places behind Japan.

“What I see daily on my job is that many children who have serious illnesses, their families have delayed care because they couldn’t afford access to care early on,” observed Martha Kuhl, a pediatrics oncology nurse at UCSF Benioff Children’s Hospital in Oakland, who has been in the field for 36 years. “Even when they had insurance, they couldn’t afford the point-of-care copays. They were having trouble with deductibles, so they would delay care until it felt absolutely necessary. In a child with cancer, that can seriously affect the outcome and the treatment protocol, and actually whether or not your child survives.”

Although Dickensian accounts of parents being forced to choose between losing their home or losing a sick child are common, Kuhl attributes much of the system failure to the nightmarish administrative labyrinth imposed by the private insurance marketplace.

“It’s tragic,” Johnson-Camacho agreed. “I went to school to help people, not to follow up with the pharmacy to make sure my patients’ meds are going to be covered.”

For the private insurance and pharmaceutical industries, the single-payer fight in California, which has historically been a national political bellwether, represents a struggle for their very survival. Not surprisingly, groups opposing SB 562 have given more than $1.5 million to the Assembly’s Democratic caucus since the 2012 election cycle. In just the last three election cycles, the International Business Times recently reported, Assembly Democrats have received more than $2.7 million in pharmaceutical and health insurance industries contributions.

“I’ve been a nurse for a long time, and I have watched the system change,” Kuhl reflected ruefully. “There were always people who didn’t have health insurance or couldn’t afford the care that they needed, but it felt like a nicer system in some way. These days, business is the first priority. Insurance companies’ primary goal is to make money, and they do that by denying care.”

https://capitalandmain.com…

Paying for CHIP with means-tested Medicare Parts B and D premiums

Bill to Rescue Children’s Health Program Hits Snag in House

By Robert Pear
The New York Times, October 4, 2017

Legislation to rescue the Children’s Health Insurance Program sailed through a Senate committee on Wednesday, but touched off a partisan conflict in the House, diminishing hopes that the popular program would be quickly refinanced.

By voice vote, the Senate Finance Committee approved a bill on Wednesday that would provide more than $100 billion over five years for the program, which insures nearly nine million children.

The Senate bill does not specify how the government would pay for extending the children’s health program.

But in the House Energy and Commerce Committee, lawmakers brawled Wednesday over a similar bill to provide money for the children’s health program. Democrats strongly support the program, but complained that Republicans would take money from Medicare and the Affordable Care Act to offset the cost.

The House committee eventually approved the bill, by a vote of 28 to 23, with all of the opposition coming from Democrats.

One provision of the House Republican bill would require older Americans with income of more than $500,000 a year to pay higher Medicare premiums.

“Folks that earn a half-million dollars a year and are over 65, they can pay a little bit more for Medicare,” said Representative Fred Upton, Republican of Michigan. “And you know what? If they don’t want to pay, they don’t have to enroll. That’s a choice they will have.”

https://www.nytimes.com…

“Helping Ensure Access for Little Ones, Toddlers, and Hopeful Youth by Keeping Insurance Delivery Stable Act of 2017” – See Sec. 203:
http://docs.house.gov…

Modifies Section 1839(i)(3)(C)(i)(II) of the Social Security Act:
https://www.ssa.gov…

***

Means testing Medicare

Comment by Don McCanne, M.D.
PNHP Quote of the Day, December 11, 2012

Now that health care costs are unbearably high, Medicare must be progressively financed since moderate- and low-income individuals can no longer bear the full costs. A major step forward was the removal of the cap on wages subject to Medicare taxes, so higher income individuals pay more. The Affordable Care Act also added a new 0.9% Medicare tax for incomes over $200,000/$250,000.

In addition, in order to help cover Medicaid expansion and subsidies for the exchange plans, the Affordable Care Act also added a 3.8% tax on investment income, again for those with incomes over $200,000/$250,000. So we have already embarked on policies that make health care financing progressive, though we need to do more, but only on the financing end.

Medicare benefits should be the same for everyone. We should eliminate premiums and cost sharing, and we should expand benefits so that administratively wasteful Medigap and retiree health benefit programs are no longer necessary. Low income individuals should receive the same standard of care as the wealthy, just as was the intent in enacting the traditional Medicare program.

Introducing means testing, which we have already begun with Part B and Part D premiums, reduces support of wealthier beneficiaries who are annoyed by these additional charges. Once the principle of means testing is established, the budget hawks ratchet it up, driving wealthier individuals to look for private options, currently available as the Medicare Advantage plans. It is only one small additional step to introduce premium support – vouchers – where the wealthy will take their money and run. Once you lose support of wealthier individuals who have a strong political voice, then Medicare will descend down the path toward becoming a welfare program.

https://pnhp.org…

***

Comment:

By Don McCanne, M.D.

There seems to be consensus that the Children’s Health Insurance Program (CHIP) should be renewed but there is considerable disagreement on how to pay for it. One proposal is to increase Medicare premiums for those with incomes over $500,000, making them pay the full Medicare Part B and D premiums with no contribution from the government. They can certainly afford it, so why shouldn’t we do that?

Because of the high costs of health care and the modest incomes of most beneficiaries, the funding of Medicare must be progressive. We are already doing that to a limited extent through the taxes that fund the Medicare program. But it is imperative that we limit progressive funding to the revenue side of the ledger while keeping benefits uniform for everyone on the spending side. Why?

Medicare is an egalitarian program designed to provide everyone who is eligible with the health care that they need regardless of ability to pay. Everyone has the same health care benefits. But the Part B and D premiums are means-tested – higher-income individuals pay larger premiums. The extra premiums paid can be considered to be a net reduction of the Medicare benefits. When the government contribution is reduced by 100 percent, then the individual is paying the full costs for Parts B and D in addition to what has been paid through payroll taxes and general revenues.

Inevitably this would cause high-income individuals to look for other options in the private sector. Since this is the Medicare segment with the strongest political voice, support for the program would decline, converting Medicare into a chronically underfunded welfare program.

Of course, the politicians are fully aware of this. As Representative Fred Upton says, “And you know what? If they don’t want to pay, they don’t have to enroll. That’s a choice they will have.”  Obviously this advances the efforts to privatize Medicare, opening the door for premium support (vouchers).

Medicare premiums, deductibles, and coinsurance are unnecessary and should be eliminated. The entire program can be funded much more equitably through the tax system, which is the way it should be when we convert it to an improved Medicare for all.

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Taking a knee for single payer – a fantasy

The Choice Between Kneeling and Winning

By David Leonhardt
The New York Times, October 2, 2017

Symbols matter in politics. They often matter more than the detailed arguments that opposing sides make. Symbols are a shortcut that help persuadable outsiders figure out where to line up.

The professional athletes doing political battle with President Trump are heirs to the civil-rights movement. They are protesting government-sanctioned violence against African-Americans. Risking popularity for principle, they have shown a courage frequently lacking among the affluent and famous.

From a moral standpoint, this issue is clear. The athletes are right — and have every right to protest as they have. Trump is wrong, about the scourge of police violence and about freedom of speech.

But righteousness does not automatically bring effectiveness.

The kneeling argument needlessly alienates persuadable people, and it’s one the athletes don’t need.

Why? Because most Americans respect the country’s symbols and because standing is a simple sign of respect.

Beyond the athletes, there is a bigger question: Do Trump’s opponents want to oppose him in ways that are merely just and satisfying? Or do they want to beat him? “You can’t get angry,” as the longtime activist Vernon Jordan has said, describing a different civil-rights battle, in the 1950s. “You have to get smart.”

Getting smart means nominating progressive candidates who can win, even if they aren’t progressive on every issue. Getting smart means delaying internal fights (like single-payer health care) and unifying against Trump’s agenda (as Democrats in Congress have).

https://www.nytimes.com…

***

Responding to Ta-Nehisi Coates

By David Leonhardt
The New York Times, October 4, 2017

Ta-Nehisi Coates has criticized my column on kneeling athletes, and several readers also made a version of his point, in emails.

Here is part of what he said:

“And David says, ‘While I’m in sympathy with these players, they need to look at the past and learn that it’s possible to appeal to the masses of Americans, that you can get Americans on your side if you can find something that bridges the gap, that brings us all together. And kneeling doesn’t do that.’

“And he shows some polling data to show that. I read that, and I almost threw my computer across the room. Because in fact there is polling data about what Americans thought of Martin Luther King, and the Freedom Riders, and the March on Washington. It wasn’t a high opinion at all.”

I understand why many Americans feel despair today and why many on the political left aren’t in a patriotic mood. Racial inequities remain shameful. Gun violence continues unabated. The planet warms. And Trump creates one new crisis after another.

I also understand that protest movements need both radicals and pragmatists to succeed. The civil rights movement had both, and today’s athletes deserve credit for the stir they’ve created. But if progressives choose to reject pragmatism, optimism and, yes, patriotism, I suspect they will spend many years protesting the country’s direction instead of setting it.

https://www.nytimes.com…

***

Civil-Rights Protests Have Never Been Popular

By Ta-Nehisi Coates
The Atlantc, October 3, 2017

The idea here is that kneeling NFL players are committing an act of such blatant disrespect that they hand Trump an easy image with which to demagogue.

(David) Leonhardt goes on to contrast this species of activism, which aligned “the civil-rights movement with the symbols and ideals of America,” with kneeling during the national anthem, which presumably signals opposition to those same symbols. Leonhardt is sympathetic to the aims of Kaepernick’s protest but he contrasts this “angry” approach with the “smart” approach of the civil-rights movement.

The trajectory of Leonhardt’s argument is doomed by the defective pad from which it was launched. The problem here is not just a just-so chain of events, but the actual effects of the events. Implicit in Leonhardt’s critique is the idea that Martin Luther King and other civil-rights pioneers, and their protests, were better able to appeal to the hearts of white Americans than Kaepernick and his allies.

As The Washington Post noted last year, only 22 percent of all Americans approved of the Freedom Rides, and only 28 percent approved of the sit-ins. The vast majority of Americans—60 percent—had “unfavorable” feelings about the March on Washington. As FiveThirtyEight notes, in 1966, 63 percent of Americans had a negative opinion of Martin Luther King. The popular hostility toward King extended to the very government he tried to embrace—King was bugged and harassed by the FBI until the end of his life. His assassination sprang from the deep hostility with which he was viewed, not by a fringe radical minority, but by the majority of the American citizenry.

Leonhardt is a smart and knowledgeable columnist. It is thus surprising to see him embrace a mythical rendition of the civil-rights movement that runs counter to the the facts and figures of the time. But Leonhardt’s column seems less interested in offering an accurate apprehension of the civil-rights movement than in employing the civil-rights movement as a club against radicalism in general, and the Bernie Sanders-wing of the left in particular:

“Getting smart means nominating progressive candidates who can win, even if they aren’t progressive on every issue. Getting smart means delaying internal fights (like single-payer health care) and unifying against Trump’s agenda (as Democrats in Congress have). Getting smart means understanding, as civil-rights leaders did, that American symbols are a worthy ally.”

Kaepernick did not inaugurate his protest in hopes of helping elect more centrist Democrats, or any kind of Democrat. That said, he was not immune to compromise. When his initial efforts were met with disdain and deemed disrespectful, he actually consulted a group of veterans to see how he might better pursue a protest. That is the origin of Kaepernick kneeling, and the fact that it too has been met with scoffs points to deeper problem. If young people attempting to board a bus are unacceptable, if gathering on the National Mall is verboten, if preaching nonviolence gets you harassed by your own government and then killed, if a protest founded in consultation with military veterans is offensive, then what specific manner of protest is white America willing to endure?

It’s almost as if the manner of protest isn’t the real problem.

https://www.theatlantic.com…

***

Comment:

By Don McCanne, M.D.

Pragmatism means getting smart. It means respecting our national symbols. It means not offending football fans by protesting injustice through the act of kneeling before the playing of the national anthem. It means “delaying internal fights (like single-payer health care).” Some would say it even means praising the second amendment with fervor regardless… (I can’t go there right now).

How can a nation become incensed at symbolic gestures while ignoring and walking away from the horrendous injustices that provoke those gestures?

David Leonhardt, in advising us essentially to walk away from an internal fight over single payer is merely expressing the view of the smart pragmatists on the left who have been repeatedly telling us that we need to forget single payer and patch ACA with a public option or Medicare buy-in – an approach that would extinguish the fire under the single payer movement.

If a knee were my choice for a symbol, I don’t think I’d place it on the ground; I fantasize about lodging it in a spot where it would really get the attention of these smart pragmatists.

“What’s that for?”

“It’s about social justice and health care justice, you dumb pragmatist. Instead of worrying about where some person’s knee is, you need to help lead the movement to end the massive suffering, hardship and even death that plague our nation.”

Smart pragmatism, my foot. Or is it my knee?

(Please excuse my anger, but I’m really having trouble with this.)

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The public judges health care by the ‘medical bill score’

The medical bill score: How the public judges health care

By Drew Altman
Axios, October 3, 2017

We track a lot of numbers in health care: how much we spend on health as a share of our economy; the number of uninsured; and the share of the federal budget allocated to health programs. What we don’t track — and a number the Congressional Budget Office cannot score — is the statistic that means the most to the American people: the share of the public having problems paying their health care bills.

Percent saying they have taken action in order to pay medical bills:

72% – Put off vacations, household purchases

70% – Cut back on food, clothing, basic items

59% – Used up all or most of savings

41% – Taken an extra job or worked more hours

37% – Borrowed money from friends or family

34% – Increased credit card debt

26% – Taken money out of long-term savings

17% – Changed your living situation

15% – Taken out another type of loan

13% – Borrowed from a payday lender

12% – Sought aid of a charity or non-profit

02% – Taken out another mortgage

15% – Made other significant changes

The bottom line:

The “medical bills score” is the single most important measure of how we are doing in health care from the public’s perspective. And ultimately, if Congress ever passes a new health care bill, it is how the public will evaluate that plan — from Graham-Cassidy to Medicare for All and everything in between.

The numbers that matter:

As we found in a Kaiser Family Foundation poll in February:

* 31% of Americans age 18-64 report they or a family member face problems paying their health care bills.

* But that number shoots up to 57% for people who are sick.

It makes sense that people who use more care have more health care bills, but it also reveals how poorly our system performs from a consumer perspective when people who need care the most are protected the least by insurance coverage.

The impact:

Not surprisingly, the uninsured (41%) are more likely to have problems paying medical bills. But this is not a problem limited to the uninsured: 30% of the insured – think voters — have problems with medical bills.

The back story:

The share of the public reporting problems paying their medical bills has not moved much in recent years. The Affordable Care Act has extended coverage and better financial protection to tens of millions, but it doesn’t have much of an impact on affordability beyond people covered by the Medicaid expansion and the marketplaces.

In the far larger employer-based health insurance sector, deductibles and other forms of cost sharing have been growing about five times faster than wages, and deductibles have been growing especially sharply for people who work for smaller employers.

What to watch:

Health care is a pocketbook issue for most of the public and the American people have their own scoring system. They may give this or that mostly partisan response about a health reform idea on a poll, but until they see how they’ll get help paying their health care bills, they will ultimately be disappointed by every health reform plan.

https://www.axios.com…

***

Comment:

By Don McCanne, M.D.

“Yes, but how will health care reform affect me?” For most people that means, how much will I have to pay for my insurance, and how much will I have to pay out of pocket for my health care?

Except for low-income individuals with heavily subsidized insurance, members of the work force are paying too much for their insurance, either directly or through forgone wages, and they are paying too much when they need to access health care, especially through high deductibles.

Under the Physicians’ Proposal – a single payer model advocated for by Physicians for a National Health Program – insurance premiums would be eliminated and replaced by equitable funding  of a universal risk pool that would be affordable for each of us, and deductibles and other cost sharing would be eliminated for all essential health care services since other, more patient-friendly methods of cost containment would allow the removal of financial barriers to care.

As Drew Altman states, “until they see how they’ll get help paying their health care bills, they will ultimately be disappointed by every health reform plan.” The obvious lesson is that we need to show the public how a single payer, improved Medicare for all program will give them the “medical bill score” they have been looking for, and thus end the scourge of medical debt.

A Physicians’ Proposal for Single-Payer Health Care Reform:
https://pnhp.org/nhi

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Multispecialty consolidation drives prices up

NBER Working Paper 23871: Does Multispecialty Practice Enhance Physician Market Power?

By Laurence C. Baker, M. Kate Bundorf, and Daniel P. Kessler
National Bureau of Economic Research, September 2017

Abstract

In markets for health services, vertical integration – common ownership of producers of complementary services – may have both pro- and anti-competitive effects. Despite this, no empirical research has examined the consequences of multispecialty physician practice – a common and increasing form of vertical integration – for physician prices. We use data on 40 million commercially insured individuals from the Health Care Cost Institute to construct indices of the price of a standard office visit to general-practice and specialist physicians for the years 2008-2012. We match this to measures of the characteristics of physician practices and physician markets based on Medicare Part B claims, aggregating physicians into practices based on their receipt of payments under a common Taxpayer Identification Number. Holding fixed the degree of competition in their own specialty, we find that generalist physicians charge higher prices when they are integrated with specialist physicians, and that the effect of integration is larger in uncompetitive specialist markets. We find the same thing in the reciprocal setting – specialist prices are higher when they are integrated with generalists, and the effect is stronger in uncompetitive generalist markets. Our results suggest that multispecialty practice has anticompetitive effects.

http://www.nber.org…

***

Comment:

By Don McCanne, M.D.

Advocates of consolidation in health care tell us that both horizontal and vertical integration improve efficiency and improve the services delivered, thus improving quality and reducing costs. The secret, they say, is to allow the markets to work. But what does this study tell us?

Integration of generalist and multispecialty practices drives up prices of both the generalists and the specialists, which the authors attribute to the anticompetitive nature of multispecialty practices.

Of significance is that this study did not use Medicare data but rather used data from the Health Care Cost Institute which compiles data on commercially insured individuals – the private sector. This study shows, once again, that the U.S. system is unique in relying heavily on the medical-industrial complex, and we are paying dearly for that.

This trend in consolidation has been increasing, and yet where is the government when we need it? Does Medicare do any better? Well, yes. Prices are lower under Medicare than under the private insurance plans, except for the private Medicare Advantage plans (though more is paid to the insurers for administration and profits).

What would happen under an Improved Medicare for All program? Prices would be negotiated to cover legitimate costs and fair margins. That might mean that some Medicare fees would be adjusted upward, especially for primary care, but the chicanery of the private insurers in partnership with their contracted providers would no longer be a factor since they would be replaced by the single payer system.

No doubt progressive members of the policy community will say, “There goes PNHP again with their pipe dreams about single payer nirvana.” But other wealthy nations cover everyone at an average of half of our per capita costs, precisely because they rely on greater government oversight. “Only in America” do we put up with this – American exceptionalism that bites us.

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

Single-payer in Penn. and beyond

Panel featuring Dr. William Davidson

WITF, Smart Talk, October 2, 2017

The Senate’s third attempt to repeal and replace the Affordable Care Act, or Obamacare, failed last week before the vote made it to the floor. It was the third attempt since the inauguration of Donald Trump, who campaigned with the promise to overturn the ACA, saying on many occasions the plan “…is unaffordable and it’s a disaster.”

Earlier in September, Vermont Senator Bernie Sanders proposed a “Medicare-for-all” bill that, according to Sanders’ own website, would “…create a federally administered single-payer health care program.” The plan would cover all aspects of healthcare; preventative and emergency care, primary, specialized, vision, dental, mental – everything for everyone. People could choose any doctor and prescriptions would be covered.

Supporters of universal single-payer healthcare are thrilled that the bill brings the topic to the national narrative, though it has little chance of passing the Republican-controlled congress. Critics contend that further government involvement in the healthcare process would only take choices away from consumers and cost would skyrocket.

On the Monday edition of Smart Talk, we will spend the hour discussing the merits and drawbacks of a single-payer healthcare system.  Pennsylvania State Representative Pamela DeLissio (D – 194th) will discuss her proposal – the Pennsylvania Health Care Plan – a single payer plan administered by the state.

We’ll also speak with Dr. William Davidson, a cardiologist who has served Central Pennsylvania for 30 years and is a member of Physicians for a National Health Program, an organization of doctors advocating for a universal single-payer system.

We’ll also speak with critics of the single-payer concept; Vince Phillips is a retired lobbyist who advocated for the Pennsylvania Association of Health Underwriters and Eric Beittel, a financial planner and the former President of the Board of the Central Pennsylvania Association of Health Underwriters. We’ll also hear from Elizabeth Stelle, the Director of Policy Analysis for the Commonwealth Foundation.

http://www.witf.org…

The policy community’s approach to narrow networks

A better approach to regulating provider network adequacy

By Mark Hall and Paul B. Ginsburg
USC-Brookings Schaeffer Initiative for Health Policy, September 14, 2017

Health care reforms, including those put in place by the Affordable Care Act, are making insurers more competitive. However, in their effort to lower costs, health insurers more often are selling health plans that cover fewer hospitals, and many fewer physicians.

This narrowing of provider networks is a sign that market reforms may be improving consumer value,  but network narrowing also raises a number of concerns. For example, a narrow network may have insufficient capacity to serve the number of people enrolled, or the providers may be too geographically dispersed to be reasonably accessible.

Rules dictating the adequacy of care in these networks have been in place for several decades, but state and federal regulators have begun to assess whether these rules are suited for the modern conditions.

In “A better approach to regulating provider network adequacy,” Mark Hall and Paul B. Ginsburg argue that the current set of regulations are not sufficient to ensure network adequacy without placing undue constraints on market innovation. Instead, the authors argue that a more layered approach is needed, including a form of patient-specific [or case-specific] dispute resolution.

This layered approach to network adequacy consists of the following recommended eight elements:

1. A general qualitative standard for network adequacy is needed

2. Insurers should provide reasonably up-to-date and user-friendly network directories, and network size should be more clearly labeled for consumers.

3. Some basic baseline quantitative standards should be considered that are fairly easy to administer, such as a minimally acceptable number of higher-volume providers in the major areas of primary care and specialty practice, and at least one such provider within a defined distance of most of the plan’s enrolled population.

4. Quantitative standards should be presumptive, but not conclusive.

5. If quantitative standards are adopted, consideration should be given to maximum wait times (rather than simply number and distribution of providers).

6. Regardless of the substantive adequacy standards in place, a backstop dispute resolution process is also needed to protect patients who might face inadequate access due to a restricted network.

7. Patients should be held financially harmless when a reviewer determines there are grounds to receive care out of network.

8. If network adequacy requirements might add substantially to the cost of insurance, then states should consider creating an additional dispute resolution process focused on financial implications.

The authors conclude that a robust dispute resolution process can ease the administrative burden of overseeing network adequacy. “Nevertheless, well-designed regulation of network adequacy is not easy to achieve. Because no single regulatory approach is likely to be sufficient, we need to think more in terms of a layered approach – one that thoughtfully melds together different dimensions and techniques of oversight.”

https://www.brookings.edu…

Full report:
https://www.brookings.edu…

***

Comment:

By Don McCanne, M.D.

Why do private insurers establish narrow provider networks? They claim that they contract for higher quality at lower costs, but quality has nothing to do with it. They reduce costs by granting physicians and hospitals greater numbers of patients in return for contracted lower prices. They also lower costs by reducing patient access to care as a result of failure to use the full complement of heath care resources in the community. This not only allows insurers to offer more competitive premiums and thus greater insurance sales, but it also enhances profits and shareholder returns.

Narrow networks are a business tool of for-profit, private insurers. They are detrimental for patients because they lose access to their choices in their health care professionals and institutions. They are also detrimental to care provided by dedicated primary care physicians because they reduce access for their patients to specialists and their specialized services (often without the knowledge of patients when physicians remain silent on potential health care resources that are out-of-network).

Traditional Medicare does not use narrow networks. Medicare’s mission is to enable access to care for the beneficiaries, not to obstruct access to that care. Although entrepreneurial endeavors and public service health programs may superficially appear to have similar goals, their primary targets are quite different – investor returns versus optimal health care.

These differences have been widely recognized. So what should be done about this problem? To see what the policy community recommends, skim through the eight elements listed above. With a little thought, you can immediately recognize the problem, and that is that they have not acknowledged what the real problem is.

The elements listed would hardly tweak the current system, yet they are the type of approaches that are taken when you make the assumption that we are going to leave our health care system under the control of the medical-industrial complex. The real problem is the dysfunctional health care financing system that we continue to support.

If we were to change to a well designed, single payer national health program, the narrow provider networks would be eliminated because they counter the goals of a premier performing health care system. The sooner we do that, the better.

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

Atul Gawande: Is health care a right?

Is Health Care a Right?

By Atul Gawande
The New Yorker, October 2, 2017

Is health care a right? The United States remains the only developed country in the world unable to come to agreement on an answer. Earlier this year, I was visiting Athens, Ohio, the town in the Appalachian foothills where I grew up. The battle over whether to repeal, replace, or repair the Affordable Care Act raged then, as it continues to rage now. So I began asking people whether they thought that health care was a right.

***

“My personal opinion is that anytime the government steps in and says, ‘You must do this,’ it’s overstepping its boundaries,” Joe said. “A father, mother, two kids working their asses off—they’re making minimum wage and are barely getting by—I have no problem helping them. If I have someone who’s spent his whole life a drunk and a wastrel, no, I have no desire to help. That’s just the basics.”

Such feelings are widely shared. They’re what brought the country within a single vote of repealing major parts of President Obama’s expansion of health-care coverage. Some people see rights as protections provided by government. But others, like the Duttons, see rights as protections from government.

***

People don’t think about their water, Tim said, but we can’t live without it. It is not a luxury; it’s a necessity of human existence. An essential function of government, therefore, is to insure that people have clean water. And that’s the way he sees health care. Joe wanted government to step back; Tim wanted government to step up. The divide seemed unbridgeable. Yet the concerns that came with each viewpoint were understandable, and I wondered if there were places where those concerns might come together.

***

Monna considered herself a conservative. The notion of health care as a right struck her as another way of undermining work and responsibility: “Would I love to have health insurance provided to me and be able to stay home?” Of course, she said. “But I guess I’m going to be honest and tell you that I’m old school, and I’m not really good at accepting anything I don’t work for.”

She could quit her job and get Medicaid free, she pointed out, just as some of her neighbors had. “They have a card that comes in the mail, and they get everything they need!” she said. “Where does it end? I mean, how much responsibility do tax-paying people like me have? How much is too much?” She went on, “I understand that there’s going to be a percentage of the population that we are going to have to provide for.” When she was a young mother with two children and no home, she’d had to fall back on welfare and Medicaid for three months. Her stepson, Eric, had been on Medicaid and Social Security Disability Insurance before he died. Her eighty-three-year-old mother, who has dementia and requires twenty-four-hour care, was also on Medicaid. “If you’re disabled, if you’re mentally ill, fine, I get it,” Monna said. “But I know so many folks on Medicaid that just don’t work. They’re lazy.” Like the Duttons, she felt that those people didn’t deserve what they were getting.

But then we talked about Medicare, which provided much of her husband’s health care and would one day provide hers. That was different, Monna told me. Liberals often say that conservative voters who oppose government-guaranteed health care and yet support Medicare are either hypocrites or dunces. But Monna, like almost everyone I spoke to, understood perfectly well what Medicare was and was glad to have it. I asked her what made it different.

“We all pay in for that,” she pointed out, “and we all benefit.” That made all the difference in the world. From the moment we earn an income, we all contribute to Medicare, and, in return, when we reach sixty-five we can all count on it, regardless of our circumstances. There is genuine reciprocity. You don’t know whether you’ll need more health care than you pay for or less. Her husband thus far has needed much less than he’s paid for. Others need more. But we all get the same deal, and, she felt, that’s what makes it O.K.

“I believe one hundred per cent that Medicare needs to exist the way it does,” she said. This was how almost everyone I spoke to saw it. To them, Medicare was less about a universal right than about a universal agreement on how much we give and how much we get.

Understanding this seems key to breaking the current political impasse. The deal we each get on health care has a profound impact on our lives—on our savings, on our well-being, on our life expectancy. In the American health-care system, however, different people get astonishingly different deals. That disparity is having a corrosive effect on how we view our country, our government, and one another.

***

Arnold, with his code of self-reliance, had eliminated nearly all sources of insecurity from his life. But here was one that was beyond his control. “The biggest worry I have would be some sort of health-care need,” he said. A serious medical issue would cost him his income. As an independent contractor, he isn’t eligible for unemployment benefits. And, having passed the age of fifty, he was just waiting for some health problem to happen.

So did he feel that he had a right to health care? No. “I never thought about it as a matter of rights,” he said. “A lot of these things we think are rights, we actually end up paying for.” He thinks that the left typically plays down the reality of the costs, which drives him crazy. But the right typically plays down the reality of the needs, which drives him crazy, too.

In his view, everyone has certain needs that neither self-reliance nor the free market can meet. He can fix his house, but he needs the help of others if it catches fire. He can keep his car running, but he needs the help of others to pave and maintain the roads. And, whatever he does to look after himself, he will eventually need the help of others for his medical care.

“I think the goal should be security,” he said of health care. “Not just financial security but mental security—knowing that, no matter how bad things get, this shouldn’t be what you worry about. We don’t worry about the Fire Department, or the police. We don’t worry about the roads we travel on. And it’s not, like, ‘Here’s the traffic lane for the ones who did well and saved money, and you poor people, you have to drive over here.’ ” He went on, “Somebody I know said to me, ‘If we give everybody health care, it’ll be abused.’ I told her that’s a risk we take. The roads are abused. A lot of things are abused. It’s part of the deal.”

As he saw it, government existed to provide basic services like trash pickup, a sewer system, roadways, police and fire protection, schools, and health care. Do people have a right to trash pickup? It seemed odd to say so, and largely irrelevant. The key point was that these necessities can be provided only through collective effort and shared costs. When people get very different deals on these things, the pact breaks down. And that’s what has happened with American health care.

***

We relied on government to establish a system of compulsory public education, infrastructure for everything from running water to the electric grid, and old-age pensions, along with tax systems to pay for it all. As in other countries, these programs were designed to be universal. For the most part, we didn’t divide families between those who qualified and those who didn’t, between participants and patrons. This inclusiveness is likely a major reason that these policies have garnered such enduring support.

Health care has been the cavernous exception.

***

To win passage, the A.C.A. postponed reckoning with our generations-old error of yoking health care to our jobs—an error that has made it disastrously difficult to discipline costs and insure quality, while severing care from our foundational agreement that, when it comes to the most basic needs and burdens of life and liberty, all lives have equal worth. The prospects and costs for health care in America still vary wildly, and incomprehensibly, according to your job, your state, your age, your income, your marital status, your gender, and your medical history, not to mention your ability to read fine print.

Few want the system we have, but many fear losing what we’ve got. And we disagree profoundly about where we want to go. Do we want a single, nationwide payer of care (Medicare for all), each state to have its own payer of care (Medicaid for all), a nationwide marketplace where we all choose among a selection of health plans (Healthcare.gov for all), or personal accounts that we can use to pay directly for health care (Health Savings Accounts for all)?

***

What we agree on, broadly, is that the rules should apply to everyone. But we’ve yet to put this moral principle into practice.

***

Two sets of values are in tension. We want to reward work, ingenuity, self-reliance. And we want to protect the weak and the vulnerable—not least because, over time, we all become the weak and vulnerable, unable to get by without the help of others. Finding the balance is not a matter of achieving policy perfection; whatever program we devise, some people will put in more and some will take out more. Progress ultimately depends on whether we can build and sustain the belief that collective action genuinely results in collective benefit. No policy will be possible otherwise.

https://www.newyorker.com…

***

Comment:

By Don McCanne, M.D.

Years ago, here in conservative Orange County, I learned not to ask audiences whether they believed health care is a right. The “tis so,” “tis not” that followed was not productive. Nevertheless, the question frequently came up during Q&A, with the same result.

Atul Gawande’s long article is interesting because conservatives he interviewed used different framing to express the concept that people should have health care when they need it, without deeming it to be a right. Health care should be a basic service like trash pickup, water, a sewer system, roadways, police and fire protection, and schools. We don’t speak of a right to trash pickup, and we don’t need to anger others by getting into a cat fight over a “right” to health care.

It is no wonder that we are beginning to see conservatives supporting single payer, not as a right but as a necessity.

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