I’m a Former Surgeon General and I Couldn’t Believe My $10k Medical Bill, MedPage Today, May 17, 2024, by Jerome Adams, M.D., M.P.H.

While attending a conference in Arizona in January, I embarked on a popular hike up the renowned Camelback Mountain. Unfortunately, mirroring the experiences of many who preceded me, I underestimated the effects of the dry desert air and midday temperature. I consequently found myself dizzy and dehydrated, necessitating an emergency department visit. 6 weeks later, I received medical charges approaching $10,000. Despite my insurance company negotiating it down to $4,800, the onus of the entire amount still fell on me due to my high-deductible health plan (HDHP).

The ordeal underscores a harsh reality: Millions of Americans face unforeseen out-of-pocket expenses, but few can shoulder such a burden.

Surprise medical bills, such as the one I received, often stem from patients unwittingly receiving care from out-of-network providers, resulting in substantially higher costs that insurance fails to cover.

Despite healthcare purportedly operating as a free market, I was not furnished with the requisite information to make an informed decision regarding my purchase. Moreover, I was not apprised of the cost of my care until 6 weeks later!

The proliferation of HDHPs, encompassing almost 60% of individuals with employer-provided health insurance post-ACA, compounds the issue.

To address the scourge of surprise and exorbitant medical bills and ameliorate the healthcare system for all Americans, I proffer several recommendations:

1. Enhance transparency in healthcare pricing
2. Institute arbitration for billing disputes
3. Advocate for consumer protections
4. Support legislative efforts to address surprise medical bills
5. Foster collaboration between providers and insurers
6. Improve HDHPs

My advocacy transcends personal interests; it serves as a clarion call for healthcare reform, ensuring that everyone can access necessary care without fear of financial ruin.

Published Comment:

By Don McCanne, M.D.

Although we desperately need reform, Dr. Adams’ recommendations would have a negligible impact on our system. With a well designed single payer system – an improved version of Medicare provided for everyone – we could provide accessible, affordable, equitable, high quality health care for all. The single payer model removes billions of dollars in administrative waste. It allows free choice of health care providers without the need for cost sharing barriers. It is affordable for all because it is funded through progressive taxes. All would pay less than they are currently paying under the current system, except for the very wealthy who would pay more but not so much that it would have any negative impact upon their lifestyles. (Keep in mind that the wealth of society is a product of the individual workers and the resources of nature and that the wealthy use capitalistic tools to segregate that wealth to their own ends. Returning some of that wealth in the form of health care for all should achieve the altruistic goal of health justice for all.)

HJM Comment:

By Don McCanne, M.D.

We can thank Jerome Adams for providing us a fine example of one of the reasons why we have such an expensive health care system that ranks so poorly (U.S. spends the most but ranks last amongst 11 modern nations, per the Commonwealth Fund). This reason here is that our political leaders frequently resort to garbage policy science when we know what policy would actually bring us a vastly superior system. Of course, that’s single payer.

When you see how our former Surgeon General was stung by our current system, and then he makes recommendations that are sort of an offshoot of market economics that he says would “ameliorate the healthcare system for all Americans,” you know that he has not learned anything. The market concepts he supports have kept us as the most expensive and poorest performing system of wealthier nations.

In contrast, single payer policies would accomplish the goals of universality, affordability, equity, accessibility, freedom of choice, prevention of medical debt and other features that people are looking for in health care today. This is evident around the world. Many economists have explained how a great excess of wealth is accumulating at the top, and the tax system can be used to lower health care costs for the rest of us, notably without threatening the extreme affluence of the wealthy.

But we, the people, have to do it. We have to elect legislators and government politicians who demonstrate to us that they do understand policy, rejecting policies that are for the billionaires with a few crumbs for the masses, but rather advancing policies for all of the people, so that we all have a right to housing, food, education, retirement, and, yes, health care.

https://healthjusticemonitor.org…

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Health costs threaten to overshadow Biden’s historic coverage gains, Axios, May 14, 2024, by Caitlin Owens

President Biden has come closer than any of his Democratic predecessors to reaching the party’s standing goal of universal health coverage, but unaffordable care costs may overshadow the achievement.

Voters feeling the pain of inflation are more concerned about their own health costs than whether everyone will have some level of coverage.

• Voters’ most common health care priority by far is lowering out-of-pocket costs, KFF polling found.
• “Certainly we have more people covered, whose concern has shifted from fear of being discriminated against (by insurers) to fear of not being able to access care affordability,” said Democratic strategist Chris Jennings.
• “Health reform efforts in the past have been largely framed around expanding insurance coverage,” said KFF executive vice president Larry Levitt. “Whenever the next health reform debate comes, it will likely be focused on the cost burden, including for those with insurance.”
• A Commonwealth Fund survey last year found that more than half of people who buy their own coverage on the ACA marketplaces or elsewhere said it was difficult to afford care.
• People have always been concerned about health care costs, but the salience goes up when I can’t pay for food and milk and gas and everything else,” said Harvard professor emeritus Robert Brendon, an expert on public opinion and health care. “The temperature about this rises because they’re having trouble paying their bills.”

The bottom line: “We’re always going to be (going) at the quality of health care and the cost,” said Wendell Primus, a former adviser to House Speaker Nancy Pelosi. “Those issues are not going to go away. Even if we solve them temporarily, they’re never going to go away.”

[HJM bolding]

Comment:

By Don McCanne, M.D.

So people are more concerned about their own health care costs than they are about whether or not other people are covered for their costs. This would be better phrased if we said that people are concerned about their own health care costs, but they also want to be participants in a thriving economy where everyone else is doing well.

What do you suppose they would think if they were offered a system that provided better coverage than they have now but cost them less? Do you think that they would object if that system offered the same comprehensive benefits to everyone else, but was made affordable by funding it through progressive taxation? Would the fact that the very wealthy paid more taxes that would have absolutely no negative impact on their lifestyles be a reason to reject a program that ensured that everyone had access to the health care that they needed? Of course, that is precisely what a well-designed single payer system would bring us. The cost might not ever go away, but we can readily manage it for everyone by the simple process of enacting and implementing single payer.

https://healthjusticemonitor.org…

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Medicare Advantage and Vertical Consolidation in Health Care, American Economic Liberties Project, April 30, 2024, by Hayden Rooke-Ley

[HJM Editor: Today’s excerpt is dense with policy, economic, and regulatory ideas. We’ve bolded major points. See the Comment for a summary of Rooke-Ley’s 3-part policy vision.]

From the Executive Summary:

A new wave of health care consolidation is underway. Health insurance and retail conglomerates are rapidly acquiring providers, from primary care practices and surgery centers to home-based and post-acute care. UnitedHealth Group (UnitedHealth), for example, is now the nation’s largest insurer and the largest employer of physicians. Humana is now the largest provider of “senior-based” primary care and in-home care. CVS Health, Walgreens, and Amazon, which have been aggressively consolidating the prescription drug supply chain, are now acquiring physician practices. And private equity investors—looking to consolidate industry segments and then sell to these conglomerates as an eventual exit—are accelerating these rollups.

With dominant market power, the new health care conglomerates dictate which physicians patients can see, which medications are prescribed to them, and which insurance plans they enroll in. By acquiring medical practices, these corporate employers shorten visit times, require more clinical coding and box-checking, and replace physicians with lower-cost clinicians. Meanwhile, by coordinating across lines of business, conglomerates like UnitedHealth squeeze out independent practices and community pharmacies. They can also shuffle money between subsidiaries and use other financial tactics to skirt regulations and exploit payment loopholes, increasing health care costs.

This paper details the causes and costs of this new frontier of consolidation …. In short, sweeping changes in health care financing policy are causing insurers and retailers to restructure as vertically integrated conglomerates. While technical, how the government pays providers and insurers fundamentally shapes the business strategies of health care companies. As the government continues to privatize Medicare and Medicaid, it is significantly overpaying insurance companies to administer benefits. With this excess capital, insurers are acquiring providers, gaining control of key points in the delivery system that enable them to capture greater government payments and minimize spending on patient care. To take one prominent example, control over primary care clinicians allows these corporate owners to manipulate billing and coding practices to make patients appear sicker to the government, thereby increasing payments.

Government policy over the last two decades has transformed health care financing. In an attempt to solve health care’s value problem— high spending and poor health outcomes—policymakers have steadily abandoned “fee- for-service” financing … [in favor of] “capitation-based” financing. In this model, the government pays a fixed budget to a “risk-bearing entity”—an insurance company, hospital system, or group of physicians—to manage the total health care costs for a patient. The risk-bearing entity turns a profit if it keeps costs below the established budget … In this paper this policy [is] referred to as [the] “Capitation Consensus.”

Medicare Advantage, the privatized version of Medicare that now covers more than half of Medicare beneficiaries, is the most prominent example of the Capitation Consensus. But this financing approach has spread across public health care programs: nearly all of Medicaid has moved to capitation-based financing, and Medicare’s prescription drug benefit, Part D, operates entirely on capitation. In the last decade, traditional Medicare— the historically fee-for-service model of Medicare—has been integrating versions of capitation through accountable care organizations and other value-based care models. Despite high hopes, the shift to capitation has yet to deliver on its primary objective of cost reduction. Most concerning is that Medicare Advantage now costs taxpayers anywhere from $75 billion to $140 billion annually in over-subsidization relative to traditional Medicare.

Part II … explains how the Capitation Consensus is driving vertical consolidation. With excess capitation payments, Medicare Advantage insurance conglomerates are plunging capital into provider acquisitions, and retailers and private equity investors are following suit. As noted above, owning physician practices enables conglomerates to inflate the perceived disease burden of patients, thereby enhancing capitation-based payments from the government. Vertical consolidation also enables patient steering: conglomerates can push patients to receive care at their own provider subsidiaries. In doing so, these companies squeeze out local providers, such as independent physician practices and community pharmacies. Steering also generates “captive revenue,” which allows conglomerates to game federal regulations requiring that government payments are spent on patients, not profits. …

… Part III … argues for … at a new “industrial policy” for health care … suspicious of concentrated corporate power—whether horizontally or vertically combined … promote the autonomy and collective power of clinicians [and] protect the medical profession from corporate influence … minimize [corporate] financial strategies that increase prices and administrative costs … [embolden] policymakers, particularly in Medicare, to exercise greater control of public money and directly rationalize the production and allocation of health care capacity. … [and] build robust health care infrastructure—owned by clinical providers and local communities …

Comment:

By Jim Kahn, M.D., M.P.H.

This is exciting work. Hayden Rooke-Ley offers a policy vision consistent with, and extending, the Biden administration’s pro-public regulatory philosophy. For too long, US health policymakers and regulators have accepted the “Capitation Consensus” that enabled and served as cover for the corporate takeover of insurance and then providers – as a result tolerating rising prices and profits coupled with fading access and outcomes. This can change.

In the Executive Summary excerpted above, Rooke-Ley describes how widespread dysfunction arose from the “Capitation Consensus.” In the full report, he also calls out pharmacy benefit managers (PBMs). This corporate mechanism, supposedly to negotiate lower drug prices, has been co-opted by insurer ownership, permitting manipulation of the formulary, prices, and rebate structures to benefit the vertical conglomerates while financially penalizing patients and independent pharmacies.

Rooke-Ley calls for a new “industrial policy” for health care: an integrated framework to structure the sector towards public aims, not corporate interests. As the Federal Trade Commission (transformed by visionary Chair Lina Khan) and Department of Justice pursue vigorous interventions in various economic sectors, this report offers a compelling roadmap for a broad activist approach in health care. It advocates fundamentally remaking regulation, policy, and financing.

I spoke with Hayden about his policy vision. It has 3 core elements:

(1) Combat corporate consolidation and elevate the power and autonomy of clinicians and their patients. This has regulatory components: Strengthened antitrust enforcement, e.g., forcing break-up of vertical consolidation; and supporting clinicians by fostering unionization and banning restrictive contracting practices like noncompete agreements. On the policy side: Congress can prohibit insurance company ownership of providers, similar to the New Deal era Glass-Steagall Act for banks. States can update and repurpose existing bans on the corporate practice of medicine to limit private equity and insurance company control of medical practices. Investment can be incentivized toward physician and public ownership of hospitals and practices.

(2) Use public utility regulation to foster healthy and fair competition: Rooke-Ley persuasively argues that price competition is harmful in health care: it needlessly fuels consolidation, undermines small providers and community pharmacies, and disadvantages patients on public entitlement programs like Medicaid. Congress could standardize prices, generating immense savings and encouraging providers to focus on delivering the best clinical care. For example, it could treat hospitals as critical public infrastructure, migrating to standard payment rates and ultimately global budgets. On the payment side, more ambitiously, Medicare could get insurers (e.g., Medicare Advantage) out of the business of widespread prior authorization and claims adjudication, instead operating like traditional Medicare. Rooke-Ley also advocates for a “public option” Medicare Part D drug benefit that bypasses insurers and PBMs, with their collusive rebate schemes.

(3) Use public funds more responsibly to build and deploy health care resources. The Center for Medicare and Medicaid services could recapture known over-payments to Medicare Advantage and redirect the funds to expanded traditional Medicare benefits. It would use Medicare leverage to improve physician specialty mix and geographic distribution. For primary care, it could align compensation with specialties and explore global reimbursement.

I’m pleased to see a convergence of proposed actions that are consistent with the new anti-monopoly mindset of the Biden administration, and also with single payer. For example, under single payer insurers would not own providers, hospitals would use standard payment rates and likely global budgets, and public funds – the entire health care budget! – would be dedicated to efficient and effective pursuit of an appropriate balance of primary and specialty care. Thus, these proposed steps would advance key principles and practices of universal publicly-funded comprehensive, equitable, and efficient insurance.

Money as Medicine – Clinicism, Cash Transfers, and the Political-Economic Determinants of Health, New England Journal of Medicine, April 10, 2024, by Eric Reinhart

[HJM bolding]

Clinicism is the reduction of health to individualistic biomedical paradigms that overemphasize clinical perspectives and interventions (even though clinical care is estimated to account for only 10 to 20% of modifiable factors shaping health in the United States) while normalizing existing social conditions and neglecting to prioritize preventive policies that target other key drivers of health and disease. These include, for example, policies affecting labor and environmental conditions, poverty and associated housing and food insecurity, social isolation, and public infrastructures for community-building social care involving supportive interpersonal relationships. Despite its limitations, clinicism pervades US public health efforts, which are primarily led by physicians more familiar with biologic and clinical sciences than with political economy and associated social services. Many scholars, recognizing this shortcoming, have called for greater attention to social determinants of health, including research on structural violence and the causes of the causes, commercial determinants, and “capitalogenesis” of disease. Such paradigms, however, generally remain descriptive academic projects that have not been translated into prescriptive policy action and the political organizing such action requires.

One reason for this lack of application is that scholars, university and health systems administrators, and public health officials face incentives, imposed by philanthropic funders and politicians, to abstain from foregrounding the political-economic determinants of health or insisting on specific policies to address economic inequality. In many cases, acting otherwise would entail challenging policies that have been embraced since the 1980s by both Republican and Democratic administrations that have overseen historic increases in inequality while defunding public support systems, empowering in their place private businesses or charitable organizations dependent on wealthy benefactors, and fueling the growth of an inefficient health care industry providing inequitable and limited benefits.

Though the Covid-19 pandemic laid bare the consequences on long-standing U.S. health policy norms and partisanship, it also temporarily disrupted the status quo by provoking overwhelmingly popular emergency measures that illustrated both the potential of supportive social policies to improve health and the necessity of approaching health, safety, and economic policy as intertwined. One early pandemic policy in particular, cash transfers, demonstrated the promise of a policy tool that could enable health scholars, clinicians, administrators, and public health officials to collectively overcome undue clinicism and expand health policy beyond just health care, rebuild trust in public health institutions, and directly address the political-economic determinants of health.

Beyond a staggering global death toll, one of the most concerning consequences of failed pandemic control was the rapid expansion of poverty. In 2021 alone, after three prepandemic years of annual reductions in the global poverty rate, an estimated 115 million people – nearly all in formerly colonized countries – were pushed into extreme poverty (i.e., subsisting on less than $2.15 per day), which brought the global population living in extreme poverty to nearly 700 million people. But in the United States, where estimates suggest that poverty was the fourth-leading risk factor for death, the pandemic led to sharp reductions in poverty owing to the expansion of eligibility for public aid in addition to emergency cash disbursements to large swaths of the population. Federal household subsidies in 2021 – nearly $570 billion in pandemic stimulus checks plus improved unemployment insurance and child tax credits – led to a historic 50% reduction in the child poverty rate and a 15% decrease in overall poverty.

The changes to the child tax credit that contributed to this shift were particularly effective – and instructive for health policy. Suddenly, the lowest-income families were receiving the same government benefits afforded to middle-class families, bureaucratic obstacles were largely eliminated, and more cash was directed to the households and local economies that most needed it. For many of the 40 million U.S. residents living in poverty, this provision of public support in the form of basic income didn’t merely reduce poverty; it had a dramatic stabilizing effect and substantially improved their health and experience of everyday life.

Financial insecurity is a major driver behind cycles of poor mental health, disease, violence, crime, and incarceration – all of which, in turn, further entrench poverty, destabilize families, undercut public health and childhood education, and constrain people’s life opportunities. Historically, most U.S. policymakers have ignored this reality, constructing one of the most insufficient, inefficient, and onerous welfare systems among wealthy countries, exacerbating instability for people living in poverty and making receipt of public support unnecessarily restrictive, time-consuming, unpredictable, and stigmatizing. This failure has wide ranging consequences for the country as a whole, affecting everything from public health to economic growth and the declining competitiveness of the U.S. workforce.

Guaranteed basic income, by providing financial predictability to people and families who have been deprived of it, has the potential to mitigate much of the economic, medical, social, and psychological harm that inadequate U.S. welfare programs alongside tax breaks for the rich have enforced. People who care about addressing poverty should stop talking about basic income as simply an antipoverty policy. Investments in such programs also return major benefits for shared public health, public safety, and collective economic prosperity – population-wide gains that improve quality of life for everyone. We can’t effectively build any of them without building all three.

Many studies have shown that cash-transfer programs lead to substantial reductions in homicide, assault, intimate partner violence, property crimes, recidivism, and overdose deaths.

As the popularity of federal initiatives such as Social Security, child tax credits, earned income tax credits, and unemployment insurance reflects, the United States has a long history and widespread support for using cash transfers to mitigate and prevent financial hardship. The truth is that cash-transfer programs don’t represent a radical shift from conventional US policy; they’re a continuation and expansion of what have long been America’s most effective and popular government programs. What has often been missing from public perception of such programs is recognition of their importance not only for their direct beneficiaries, but also for everyone else.

Delivering effective clinical care and ensuring robust public systems for social care are interdependent and synergistic projects. It is difficult to care for patients as effectively as possible without addressing root political-economic causes of sickness and death, from poverty, malnutrition, homelessness, and mass incarceration to health care exclusion. In the United States, medical institutions have often neglected this reality and sometimes even leveraged their political influence to oppose investments in social care that they saw as threats to their economic interests. This attitude has undermined both public health and the medical profession, which is now facing a related crisis of demoralization and attrition. For the sake of the profession and our patients, it is time to reassert a concept of medicine that goes beyond the clinic alone to advance supportive social policies without which our work cannot succeed.

Comment:

By Don McCanne, M.D.

At Health Justice Monitor we have previously visited the astute writing of Eric Reinhart, once in JAMA when he explained why physicians need to become a progressive force in transforming our health care system and again when he explained in the New York Times how physicians are being demoralized by forces primarily interested in extracting profits from the health care system.

We now revisit his writing in the New England Journal of Medicine wherein he makes the very important political-social-economic case that the health of individuals and society is not just the result of mere “clinicsim” or the overemphasis of clinical perspectives and interventions, but rather should be the result of delivering effective clinical care synergistically with robust public systems for social care, with guaranteed basic income and other appropriate, proven cash-transfer programs that result in major benefits for shared public health, public safety, and collective economic prosperity – population-wide gains that improve quality of life for everyone.

We are spending a lot of money on health care but we are falling terribly short. So what lessons can we learn by applying this “social” approach of Reinhart?

We should include everyone.

It should be affordable for each individual.

The services should be comprehensive and accessible.

The stewards should design it to provide needed services for the people, not profits for investors.

Essentially it would be a social program designed by the people’s stewards to serve all of the people.

https://healthjusticemonitor.org…

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Rethinking Health Care from a Global Perspective: Looking Abroad, The Commonwealth Fund Blog, May 2, 2024, by Aaron Carroll

All other high-income countries have adopted a universal health coverage system, and many middle- and low-income countries are also moving in this direction.

The American health care system is broken. Life expectancy is dropping, maternal mortality is on the rise, disparities abound, and it costs way, way too much. But when we discuss fixing it, the debate is a pendulum swinging between two extremes: maintaining the status quo and adopting a single-payer system. But what if we’re asking the wrong questions? What if the answers lie not in the extremes but in the nuanced experiences of other countries?

At its core, the concept of insurance is a social contract. We pool our resources so that no individual must bear the brunt of an unexpected health crisis alone. This serves two goals: people do not avoid care because of costs, and unexpected illness doesn’t lead to financial ruin.

The Affordable Care Act expanded health coverage to millions of Americans in the U.S., but 26 million remain uninsured. All other high-income countries have adopted a system of universal coverage, and many middle- and low-income countries are also moving in this direction. In the past few years, I’ve had the privilege of visiting some while on a Commonwealth Fund/AcademyHealth study tour. Let’s look at how they achieve their goals.

[HJM bolding]

Switzerland entirely eliminates government entitlement programs like Medicare and Medicaid; everyone is on private insurance from birth to death. Plans are tightly regulated and decoupled from employment. Out-of-pocket expenses are relatively high to combat the moral hazard (i.e., people are more likely to spend an insurance company’s money than their own), but the system ensures everyone has some coverage. The private insurance market is highly competitive, with more than 60 insurers offering basic health insurance. Insurers cannot earn profits from basic insurance but can offer supplemental insurance for additional services and amenities….

Canada has a single-payer system. The country’s Medicare system is funded mainly through general taxation, and the federal government sets national standards for health care in all provinces. The provincial and territorial governments, however, are responsible for managing, organizing, and delivering health care services for residents. Medicare covers all medically necessary services provided by hospitals, physicians, and dentists but does not include prescription drugs, eye care, or dentistry for adults.

Australia’s system functions much like Canada’s if people stay within the public delivery system. However, it differs from Canada in that patients can opt for a private system; doing so incurs costs. This dual approach allows people to choose better access based on their needs and willingness to pay more. The public system, also known as Medicare, covers most of the costs of hospital and physician services and some preventive and community health services. It’s funded by general taxation, a specific income-based tax, and copayments by those seeking care. About one-third of Australians have private health insurance. Such insurance can provide access to private hospitals and specialists and cover services not included in Medicare, such as dental care, optical care, and physiotherapy.

New Zealand’s system is like Australia’s but with unique features, such as a stronger focus on community-based care and public health initiatives. This approach aims to reduce the burden on hospitals and provide more holistic care. The public system offers universal coverage for a range of services, including hospital care, primary care, prescription drugs, mental health care, and disability support services. The system is funded mainly by general taxation and copayments. A private system also plays a supplementary role by offering faster access to elective surgery and specialist consultations, as well as covering services not funded by the public system, like dental care and cosmetic surgery. About one-third of New Zealanders have private health insurance.

In France, the insurance provided by the statutory system sets a good baseline for all, but people are encouraged to spend more if they wish. The public system, known as Social Security, covers most of the costs for hospitals, physicians, long-term care, and prescription drugs. The system is funded primarily by payroll taxes, a national income tax, and tax levies on specific industries and products. The government sets the national health strategy and allocates budgeted expenditures to regional health agencies responsible for planning and service delivery. Patients are responsible for coinsurance, copayments, and balance bills for physician charges that exceed covered fees. However, almost all citizens have supplemental insurance to help with these out-of-pocket costs and dental, hearing, and vision care. Private insurers provide this supplemental insurance, most of them nonprofit.

In England, the National Health Service (NHS) provides health care to all residents, covering hospital, physician, and mental health care without any cost at the point of care. The NHS is funded mainly through general taxation, and the government sets a global budget for health spending. This global budget allocates resources to health services and trusts responsible for local planning and care delivery. There are trade-offs in terms of wait times and sometimes even quality. Still, this approach effectively removes financial barriers to care and eliminates any risk of health care–related bankruptcies.

Comment:

By Jim Kahn, M.D., M.P.H.

Dr. Carroll gets it right – other wealthy nations use predominantly public (or not-for-profit private) systems to assure universal “basic” medical coverage, with limited and variable supplemental roles for private insurance.

Here are a few additional features, regarding the patient and provider experience:

Patients:

• The “basic” insurance is quite comprehensive and standard. Thus the population broadly has high quality consistent coverage. Voluntary private insurance spending is optional and at the margin, just <1% to 13% of total health spending.
• Deductibles are imposed in only 14% of wealthy nations, and only a few hundred dollars – FAR less than the thousands in the US. In 90% of these nations, there is either no cost-sharing all, or exemptions for poorer individuals and annual caps. Medical bankruptcy is not a thing.
• In the vast majority of wealthy nations, patients have free choice of physicians. No restrictive networks.

Providers:

• Providers know that patient care is broadly and consistently covered, using standard payment rates. This simplifies their lives – no long hours on billing and prior authorizations. No moral hazard.
• Providers use a standard drug formulary, and standard or at least well-integrated electronic health records. Again, simplicity … enhancing their clinical focus.
• Two-thirds of these nations use global budgets for the system (and for hospitals). Thus, no pressure to manipulate data to justify higher capitation rates or to stint on care.

Who wouldn’t want to emulate the other wealthy nations’ successful approaches? Oh, yeah, the profiteers … insurers, PBMs, private equity, and pharma. We must wrest control of our health care, following the model amply proven around the world.

https://healthjusticemonitor.org…

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This Date in UCSF History: National Health Insurance Ahead?, Synapse, UCSF Student Voices, April 23, 2024

(Originally authored by Dr. Philip R. Lee — a UCSF professor of social medicine and director of the Institute for Health Policy Studies — and published in Synapse on April 24, 1986.)

Twenty years ago, states throughout the country began to implement federal legislation (Title XIX, Social Security Act) establishing a national program for medical care for the poor (Medicaid). In the same year, 1966, the federal Medicare program began providing hospital and medical insurance for the elderly.

With these two public programs, the public sector began to fill the major gap in private health insurance.

Private health insurance was largely provided on a group basis, through employment, with employers paying the bulk of premiums.

In the 1960s and early 1970s the idea that access to health care was a merit good or a right of citizenship was widespread.

It seemed only a matter of time before the remaining gaps would be filled by universal health insurance, albeit with a mixture of public and private payment mechanisms.

In the 1970s and early 1980s, as costs of health care rose rapidly and as efforts to contain costs seemed ineffective, the idea took hold that national health insurance was impossible and that health care was not a merit good.

Instead, many advocated that health care should be treated like other goods and services, and that price competition and the marketplace should be the primary approach to resolving the problems of cost, access and quality.

Policies established by Congress and the Reagan administration have strongly supported this approach.

Many states, including California, have adopted pro-competitive policies. The results of the recent policy changes have been mixed.

The rate of increase in health care costs has slowed, hospital admissions have declined, length of hospital stay has been shortened and hospital occupancy has been reduced. All this seems to be for the better, but patients have found themselves discharged from hospitals “sicker and quicker.”

Posthospital services, described as a “no-care zone” by UCSF Professor Carroll Estes, have been unable to cope adequately with the changes.

The number of people who are uninsured or underinsured has risen rapidly and local governments, such as San Francisco County, have found themselves obliged to care for increasing numbers of sick, disabled and poor.

Three future scenarios seem possible given the current environment:

• Continued reliance on price competition and the marketplace with the evolution of a “three-tiered” system of care consisting of fee for service, HMOs and public sector.
• A variety of incremental strategies to fill the gaps in coverage at the state level through mandated private insurance coverage, state funds to cover the uninsured and an expansion of Medicaid.
• Publicly funded national health insurance, along the lines of the Canadian model.

Although the odds are against national health insurance, this proposal would provide the most equitable solution to health care access with effective means to control costs while assuring freedom of choice for consumers and providers.

Personally, I believe it is the preferred solution.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

Philip Lee was an icon of health care justice, perhaps most noted for his role in implementing Medicare. Particularly noble was his use of Medicare funding as a lever to eliminate segregation in the nation’s hospitals and, by extension, throughout the medical system. Over his career, he remained a champion of health equity and justice for all. Thus, his commentary authored 38 years ago comes as no surprise to us.

Let’s review the challenge he described from today’s perspective, nearly four decades later. Of the three scenarios Dr. Lee described, the US followed a mix of free market and incremental changes; not the national health insurance option he preferred. Dr. Lee was prescient. As a result, we accumulated decades of fraught experience – high costs, low health care access, and high mortality.

Dr. Lee’s “publicly funded national health insurance, along the lines of the Canadian model” has proven to be quite effective in other wealthy nations. We should have chosen the option that, as he describes, would combine equity, choice, and cost control. Health justice for all, efficiently.

Clearly the market approach and mandated private insurance succeeded in creating wealth for health care investors but was certainly ineffective in ensuring affordable, comprehensive care for everyone.

Philip Lee bestowed on us this powerful message of health justice. We should act on his advice. It’s not too late.

https://healthjusticemonitor.org…

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Study: Proposed changes to Medicare, Medicaid could cost thousands of lives, Yale News, April 22, 2024, by Mallory Locklear

Proposed changes to the United States’ Medicare and Medicaid programs could lead to thousands of additional deaths each year, a new Yale study reveals.

Recent proposals to reduce program costs include a recommendation to raise the eligibility age for Medicare from 65 to 67 – put forward by a 2022 report from the House of Representatives’ Republican Study Committee – and a proposed work requirement for Medicaid coverage – a recurring Congressional consideration during federal budget negotiations.

While neither of those have yet been adopted, one major change to Medicaid is already underway: A provision authorized at the start of the COVID-19 pandemic that required states to keep existing Medicaid recipients enrolled in the program expired last year. Since then, states have begun disenrolling Medicaid recipients who no longer qualify or are unable to complete the renewal process.

Such changes will drive up the number of uninsured people in the U.S., said Alison Galvani, the Burnett and Stender Families Professor of Epidemiology (Microbial Diseases) at Yale School of Public Health (YSPH) and senior author of the study. The study was published April 22 in the Proceedings of the National Academy of Sciences.

The Congressional Budget Office has assessed two strategies for raising the eligibility age over time – by two months or three months each year until the eligibility age reaches 67. According to the new study, the approaches would result in an additional 17,244 deaths or 25,847 deaths respectively during the transition.

A separate proposal to institute work requirements for Medicaid recipients, meanwhile, would lead to an additional 613 deaths per year among U.S. adults, the researchers report. Further, the ending of continuous Medicaid enrollment in 2023 could lead to 7,900 additional deaths each year.

They found 456,966 people with diabetes under the age of 65 could lose access to health care following the end of continuous Medicaid enrollment, and 325,613 seniors would lose care if the Medicare age were raised.

“Working in the field of public health, it can be frustrating to see policymakers propose strategies that ignore evidence-based solutions capable of saving lives, boosting prosperity, and reducing health care costs,” said Galvani.

In a previous study, Galvani and her colleagues found that a single-payer universal health care model would save more than 68,000 lives and $450 billion annually, while the current proposal to raise Medicare eligibility age would save a maximum of $25.5 billion across five years and cost thousands of lives.

“It’s disheartening to see people in positions of power who have access to all of this information argue that retractions in health care are for the benefit of the country,” she said. “If policymakers want to save lives and costs, our analyses have shown single-payer universal health care is the solution.”

Comment:

By Don McCanne, M.D.

No comment need be appended to these excerpts since Alison Galvani and her team have said it all. Ridiculous proposals that reduce health care and cost lives should be rejected, especially when we know that the single-payer universal health care model, structured properly, would save both lives and money. If only Congress and the President could get on our wavelength.

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Congresswoman Pramila Jayapal, Email to supporters, April 25, 2024

Republicans HATE Medicare for All and they’re doing everything in their power to protect Big Pharma and our private, for-profit health care system.

This 100% free and accessible calculator compares the information you give for current spending on health care and your Medicare for All spending based on a progressive tax model proposed to fund the program. All you need to do is click here to get started ››

Use the Medicare for All Calculator ››

You may be asking yourself, what would Medicare For All accomplish?

The answer is: SO MUCH! Medicare for All will pay for all medically necessary care. Just look at everything it would cover:

• Inpatient, outpatient, emergency, and preventive care
• Dental, vision, and hearing care
• Prescription drugs
• Lab and diagnostic services
• Medical devices
• Reproductive health care such as abortion, prenatal care, infertility treatment and more
• Gender affirming care
• Physical therapy and rehabilitation
• Emergency and necessary transportation
• Long term care supports and services
• Hospice care
• Mental health care
• Telehealth
• AND MORE!!!

Our calculator is an accessible tool for disassembling Republican disinformation and fear mongering about Medicare For All. Using this calculator is incredibly easy and FREE. So please, take a moment and use our new Medicare For All calculator! ››

Comment:

By Jim Kahn, M.D., M.P.H.

The many economic analyses which demonstrate that single payer would reduce US health care costs fall short in one crucial way: they don’t indicate how any particular person or family will fare financially. Understandably, people want to know – how will this kind of program affect my costs? Since there will be some new taxes, maybe I’m at risk of paying more.

That’s the question the on-line calculator is designed to answer. Full disclosure – I led the technical team that worked with Congresswoman Jayapal and her staff to implement this calculator.

The calculator uses estimates from the Congressional Budget Office of how much new revenue the federal government would need to fully fund Medicare for All as specified in Rep. Jayapal’s bill. We designed a tax strategy to generate that revenue. It includes a 1.65% payroll tax; a progressive income tax starting at 1% at $178,000 for joint filers and $89,000 for single filers, and rising to 11%; a 15% tax on corporate profits; and a 3% wealth tax on individuals with >$30 million in assets.

The calculator asks for the user’s prior year costs – premiums and out-of-pocket spending. And asks for income; this determines the new taxes. And then, simple math, the calculator compares the two, yielding net savings (or costs).

We did a California calculator in 2022. This national calculator is very similar, with a refined tax strategy and two additional questions. As we reported in HJM for California, “Four thousand individuals reporting current healthcare spending and income reveal that … nearly 9 in 10 will save money, more than $5000 per year on average, with single payer.”

We’re eager to see the results on the national level. So — visit and use the site!

Geek comment: we’ll be able to explore the impact of different tax strategies on the distribution of savings and costs.

We hope the calculator will be a valuable organizing tool – to inform, energize, and advocate for Medicare for All. Please share information about the calculator widely via email, social media, and other channels.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.