PNHP

We’re heading for the wrong debate on reform

We’re heading for the wrong debate on reform

New Coalition Will Push Back on Repeal of Obama Health Law

By The Associated Press
The New York Times, December 9, 2016

Supporters of the 2010 health care law will launch a political coalition Friday to block its repeal.

The initial goal is to stop Congress from repealing the law without simultaneously passing a replacement for some 20 million people covered through subsidized private health insurance and expanded Medicaid.

Called “Protect Our Care,” the group brings together organizations that helped pass the Affordable Care Act, also known as “Obamacare.”

On the list are the NAACP, liberal advocacy groups like Families USA and the Center on Budget and Policy Priorities, the Service Employees International Union, which represents many health care workers, and the Center for American Progress, a think tank closely aligned with the Obama White House.

http://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

The conservatives want to repeal much of the Affordable Care Act (ACA) and replace it with something similar. The centrists want to preserve ACA pretty much as it is. Although the specifics are important since many people could lose their coverage and the effectiveness of health plans could diminish further, in the global perspective we’ll still be left with a highly dysfunctional health care financing system that will not cover everyone while perpetuating inadequate coverage for many of those who are insured.

The national dialogue leading up to ACA early on was a debate between making modest adjustments in the financing system we had or replacing it with a much more effective and equitable system that would truly cover everyone while making health care affordable for all.

But very soon the Democratic Party leadership along with representatives of a multitude of supposedly liberal organizations (many through HCAN) coalesced around reform that would greatly benefit insurers, the pharmaceutical industry, and other vested interests. Those supporting comprehensive reform through a single payer national health program were quickly booted out of the process, and the media became silent on single payer. That ended the debate, and we moved on to providing some beneficial tweaks to the existing dysfunctional system, when instead we should have had an honest dialogue over the weak, inadequate policies of what became ACA and the profound, sweeping benefits that characterize the single payer model.

Here we go again. Our health care financing system is still in shambles with tens of millions remaining uninsured and the insured having increasing difficulties in obtaining care in the narrow provider networks while facing financial hardship because of the insurers shifting ever more risk onto the patients. And the “Protect Our Care“ coalition of centrists wants to make this a debate between protecting the shambles versus making them even worse through “replace” policies that would further weaken health care coverage.

No!! The debate needs to be between accepting or tweaking a system in shambles or moving on to a well-designed single payer system – an improved Medicare for all – affordable, accessible health care for everyone.

The same people who took control last time and led us down the wrong path are now regrouping as the “Protect Our Care” coalition with a mission to protect a program in shambles. We cannot let them get away with it this time. We need to form a large coalition of healer activists to lead us to the high-performance system we desperately need. And, yes, we need to be sure that members of the media understand the difference.

Obama’s tepid palliation for America’s health scourges

The Obama Years: Tepid Palliation for America’s Health Scourges

By Steffie Woolhandler, MD, MPH and David U. Himmelstein, MD
American Journal of Public Health (AJPH), January 2017

President Obama inherited an economy in crisis, burgeoning inequality in wealth and health, and a legion of medically uninsured Americans whose ranks had grown by 11 million under the previous administration. He staunched the bleeding but provided no cures.

The Affordable Care Act (ACA; Pub L No. 111–148), Obama’s signature achievement, covered millions, but leaves 9% uncovered. It minimally regulated insurers and imposed a modest new tax on the wealthy but accelerated the corporate takeover of health care and endorsed high-deductible insurance plans that offer illusory protection. It provided $11 billion in new funds for community health centers and public health agencies but drained money from safety-net hospitals and failed to reverse the downward trend in funding for public health.

Conclusions

Could Obama have done better? Not by waging policy battles largely inside the Washington, DC, Beltway. Even during Obama’s first two years in office, when the Democrats controlled Congress, the lobbying clout of insurers and pharma (generous donors to Democrats as well as Republicans) made fundamental reform unwinnable in an inside game. The compromised ACA legislation, crafted to appease these corporate interests, offered nothing to the majority of Americans dissatisfied with the health care status quo, precluding grass roots mobilization and allowing Republicans to rally opposition. It is striking that, in a 2016 Gallup poll, 51% of Americans wanted to repeal the ACA, but 58% (including 41% of Republicans) would replace it with single-payer reform (findings that accord with a recent Kaiser survey).

The Sanders and Trump campaigns (and, indeed, Obama’s historic 2008 victory) demonstrated the electorate’s hunger for new directions. America has taken bold and difficult steps in the past: the abolition of slavery, women’s suffrage, Social Security, civil rights, and marriage equality, to name a few. All were gained through powerful, persistent social movements that eventually got their message through to Washington.

Our health and health care deficits are man-made scourges, not products of nature. Curing them will require broad popular mobilizations, not just a well-intentioned president.

http://ajph.aphapublications.org…

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Comment:

By Don McCanne, M.D.

Although this AJPH editorial was written a couple of weeks before the surprise results of the presidential election were known, it does not change the message. Curing our heath care deficits will require broad popular mobilization, not just the wishes of a president, no matter his or her intentions.

The Obama Years: Tepid Palliation for America’s Health Scourges

By Steffie Woolhandler, MD, MPH, and David U. Himmelstein, MD
American Journal of Public Health, January 2017

President Obama inherited an economy in crisis, burgeoning inequality in wealth and health, and a legion of medically uninsured Americans whose ranks had grown by 11 million under the previous administration. He staunched the bleeding but provided no cures.

The Affordable Care Act (ACA; Pub L No. 111–148), Obama’s signature achievement, covered millions, but leaves 9% uncovered. It minimally regulated insurers and imposed a modest new tax on the wealthy but accelerated the corporate takeover of health care and endorsed high-deductible insurance plans that offer illusory protection. It provided $11 billion in new funds for community health centers and public health agencies but drained money from safety-net hospitals and failed to reverse the downward trend in funding for public health.

Aside from the ACA, Obama’s health record is mixed at best. He made some progress on environmental regulation, and the terrible threat of climate change has at least been acknowledged. But the yawning gap between rich and poor—in both wealth and health—has widened.

Continue reading:
http://ajph.aphapublications.org…

Postal workers union president calls for single-payer system

‘We are sick of a criminal system based on profit that leaves people hanging without the health care they deserve’

The following is an unofficial transcript of the remarks delivered by Mark Dimondstein, president of the American Postal Workers Union (APWU), AFL-CIO, to a protest rally outside the national offices of the Pharmaceutical Research and Manufacturers of America (PhRMA) in Washington, D.C., on Nov. 18. The protest, which drew more than 150 people – physicians, medical students, unionists and health reform activists – denounced the greed of the pharmaceutical drug industry and called for a single-payer national health system. It featured several rally speakers, one of whom was President Dimondstein, whose union represents more than 200,000 USPS employees and retirees, and nearly 2,000 private-sector mail workers. He was introduced by Dr. Robert Zarr, president of Physicians for a National Health Program, which organized the protest. A 5-minute video of Mark Dimondstein’s remarks can be viewed here.

President Mark Dimondstein’s remarks
Mark Dimondstein
It’s nice for me personally to be seeing doctors and medical students when I’m not sick. [Audience laughter, applause.] But we are sick of a system based on profit, a criminal system based on profit, that that leaves the people of this country and humanity hanging without the kind of health care that we all deserve.

Sisters and brothers, the people that I represent, for the most part, do have health insurance right now. But every day it’s going up, every day we have to pay more, every day the benefits go down, every day we’re in a fight with the insurance companies.

And for those who don’t know, the price of future health insurance is being used to choke the public Postal Service that is being demanded to put $5 billion a year into a fund for future health benefits for workers that aren’t even born yet.

So it’s hurting all of us, it’s hurting all of us, sisters and brothers.

And when we go to the bargaining table, guess what: Management always wants, and it’s not just arguing, they want our health benefits, if we can even keep them, to be less and less, and more and more coming out of the wages and benefits of the workers.

So we would all benefit – all of us – from a system of single payer and Medicare for All.

Now, we’re in front of PhRMA. I did a little thinking last night. Big Pharma wants to convince all the people of this country that you have to have this obscene system of profit-making, and CEOs that make $43 million, and lobbyists and enriching – you mention obscene profits – because that’s what’s going to drive the innovation of life-saving drugs.

You’re all in the medical field, so you know who Dr. Jonas Salk was, don’t you? [Shouts of “Yes,” applause.] When he was working on a polio vaccine, which was an epidemic in this country and the world, he purposely decided that his work was not going to be based on personal gain. And when he was asked, “Who has the patent?” You know what he said? He said, “There is no patent. You can’t patent the sun.” You can’t patent the sun.

That patent, by figures today, that figure would have been worth $7 billion to the pharmaceutical industry, and he said no. And you’re here in the tradition of Dr. Salk, practicing medicine and fighting to have a system of practicing medicine that is good for the patients and good for the people of this country.

And we all have stories. We all have family and friends. My wife and I were good friends with the real Norma Rae, Crystal Lee Sutton, an American heroine. And when she got sick, and was fighting brain tumors, the insurance company of her husband cut off the benefits. And she could not afford the life-saving drugs that she needed, and she died at a fairly young age.

When my wife was sick, fighting a life-threatening thing, the medicine she needed, the shot, was $5,000 a pop. We had health insurance. What about all the people that don’t?

And when we say that Big Pharma is criminal, that’s what we mean, because people die on the altar of profits, sisters and brothers. And you know that better than anybody.

We’re very friendly with the Canadian Union of Postal Workers. And when we meet with the Canadian Union of Postal Workers they brag about their health care system. They pull out their medical card – and it’s different by each province – they say, “Here it is. We go anywhere we want to. We have full choice of physicians. We have cradle to grave benefits. And we never see a bill because it’s part of the public good.”

Sisters and brothers, you’re out here fighting for the public good in your way, we feel we’re fighting for the public good in our way, in terms of defense of the public Postal Service. Together, we can fight for the kind of country we need.

It’s not an accident, to me anyway, in my thinking, that the Bernie Sanders campaign electrified this country. And what was one of the main demands of that that campaign? [Shouts of “single-payer health care.”] Single-payer health care. And in a way we should look at that primary season in this election as a referendum on those kind of issues, because the people of this country are ready for a Medicare-for-all single-payer system.

And with advocates and fighters like you, sisters and brothers, working hand in hand with unions like ours and the communities of ours, guess what? We can win, can’t we? [Cheers.]

Sisters and brothers, it’s great to be here with you. Solidarity forever, as we say in the union movement. And carry on your great fight with the great spirit you have here today. Thank you all. [Cheers, applause.]

Timothy Jost provides the facts behind the policy options for ACA reform

Taking Stock Of Health Reform: Where We’ve Been, Where We’re Going

By Timothy Jost
Health Affairs Blog, December 6, 2016

Almost from the moment of its inauguration in 2009, the Obama administration has struggled, often against adamant resistance, to enact and implement the Affordable Care Act (ACA). The 2016 election has brought to power opponents of the ACA who will control the presidency, both houses of Congress, and many state houses and governorships. ACA repeal, or “repeal and replace,” seems to be a very real, indeed likely, possibility. It is important, therefore, to take a sober look at what the ACA has achieved in its nearly six years of existence, and what repeal, or repeal and replacement, might look like.

(Use the link below to see a precise explanation of what ACA has achieved and what repeal and replace might look like.)

Summing Up

The ACA has made many Americans better off, and can boast of important achievements. In particular, it has ensured that Americans cannot be denied coverage or have their coverage limited because of health problems. Millions of lower-income Americans are receiving health coverage through Medicaid and the marketplaces who would otherwise be unable to afford coverage. But many still face unaffordable cost-sharing burdens and narrow networks, and many middle-income individuals can no longer afford coverage in the individual market.

While there are real opportunities for the new administration and Congress to improve the ACA, it is essential that they not precipitously undo its achievements. Repeal must await a clear plan for replacement. And the timing of repeal must take into account not only the time it takes to adopt replacement legislation but also the time it takes to write the rules, formulate guidance, and create and staff programs to administer a replacement program. If there is anything we have learned from the last six years, it is that implementation is hard work and takes time.

Careful and objective analysis must be given to replacement proposals and their effects. Many of these are not new but rather resurrect policy initiatives of the past that proved problematic in important respects. They have track records that can be studied. The effects of other proposed provisions can be modeled.

What preliminary analysis of Republican replacement proposals shows is quite clear: they would provide considerably less help for lower-income Americans and people with health problems, and could mean increased costs for these groups. They might at the same time lower costs and provide more assistance for middle- and higher-income Americans. They would shift costs from the federal government to the states. They would shift costs from the government to individuals and families, and to providers. They would make health care less accessible and less affordable to those who have been helped by the ACA, but might make it more affordable to some whom the ACA has not helped.

Elections have consequences, and, arguably, to the victors go the spoils. But transparency is important; no one should be under any illusion that an ACA replacement will make everyone better off — it could cause serious harm and disruption to some who were helped most by the ACA. If Congress and the administration are to embrace this harm and disruption, it is vitally important that the American people understand the consequences.

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Submitted comment:

By Don McCanne, M.D.

Timothy Jost provides an invaluable service by by bringing truth to the dialogue on reform. Those who are satisfied with benefits gained through the Affordable Care Act will have to concede that it has still fallen significantly short of many goals of reform. Those who would replace many or most of the features of ACA will have to be honest about the severe deficiencies of their leading proposals, likely leaving many people worse off. Either way, we will still not end up with the high-performing system that the $3.2 trillion we are spending on health care should be bringing us.

Although it was not the intent of this article to discuss other options for reform than those on which the current political dialogue is focused, nevertheless one other model should be under discussion and that is a well-designed single payer national health program. For the same amount that we are already spending, we could have a high quality system that is truly universal, comprehensive, accessible, and affordable for everyone. At the time of another pending upheaval in our health care system a model that would actually work to achieve these goals clearly should be on the table. Many of the perverse features of a fragmented, dysfunctional multi-payer system discussed in Jost’s article would simply go away.

http://healthaffairs.org…

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Comment:

By Don McCanne, M.D.

There will likely be considerable heat in the discussions ahead on repealing and replacing the Affordable Care Act. Based on current observations, much of it will be clouded with failure to adhere to the actual facts which are based on sound health policy science. This article will be particularly helpful as a resource since Timothy Jost is meticulous with the facts as he explains what has happened and what might happen under the various proposals for replacement.

By reading this fairly long article, you can reinforce your understanding of the issues so that you can help bring truth to the national dialogue on reform. Also you should save the link and make it available to others who wish to have an unbiased understanding of the facts without having to wade through rhetorical embellishment.

When the facts are known, it will be clear that neither the status quo under ACA nor the replacement plans currently under consideration will be adequate to ensure that everyone would have affordable access to essential health care services. That is why we need to be sure that a model that would give us this assurance – single payer – is back on the table, front and center, during our national dialogue on reform.

More evidence of burden of high-deductible plans

The Financial Burdens Of High-Deductible Plans

By Salam Abdus, Thomas M. Selden and Patricia Keenan, from the Agency for Healthcare Research and Quality
Health Affairs, December 2016

Abstract

The increased prevalence of high-deductible health plans raises concerns regarding high financial burdens from health care, particularly for low-income adults.

From the Introduction

The prevalence of high-deductible health plans within employer-sponsored insurance has more than doubled since the mid-2000s. However, no recent research has measured the actual financial burdens associated with high-deductible health plans, and we know of no prior nationally representative studies examining these burdens by income level. In this study we attempted to fill that research gap by examining the association between high-deductible health plans and high out-of-pocket burdens among people at various income levels with employer-sponsored insurance.

From the Discussion

This study examined the association between high-deductible health plans and high out-of-pocket burdens among those with employer-sponsored insurance by income level. Two key results stand out. First, the frequency of high family out-of-pocket burdens increased sharply with plan deductible levels among low-income enrollees (those with family incomes below 250 percent of poverty), reflecting both higher health care spending and higher premium contributions. In contrast, there were much smaller differences in high burden frequencies by deductible level in the higher-income groups. Second, regardless of deductible level, those in the low-income group were far more likely to have high burdens compared to those in the higher-income groups.

http://content.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

This is one more highly credible study that demonstrates that high-deductible health plans are creating great financial burdens amongst enrollees in employer-sponsored health plans. These burdens are especially large for low-income employees – a group that already suffers from high financial burdens.

The nation continues to push forward with expanding deductibles in health plans in spite of evidence that they are creating great harm by increasing financial burdens on individuals and families and by impairing access to essential health care services and products.

Why does the policy community continue to support high deductibles? Because it slows the rate of increases in the premiums charged for insurance plans – protecting the insurers’ market, though at a cost of placing a greater burden on patients.

By replacing the private insurers with a single payer system we would not have to be concerned about how high premiums are since a single payer system is equitably funded through the tax system and premiums go away. Furthermore, the greater costs that result in higher premiums would be far better controlled though the patient-friendly policies that are inherent in a well-designed single payer model.

Instead of making people suffer more, let’s just get rid of high-deductibles and the private insurers who create them and move on by enacting an improved Medicare for all.

Misinformation fueled Obamacare anger, Tucson physician finds on cross-country ride

By Stephanie Innes
Arizona Daily Star, December 6, 2016

PNHP Note: Detailed findings from the bicycle tour mentioned in this article were published in the journal Academic Medicine. “Opposition to Obamacare: A Closer Look,” was authored by Paul R. Gordon, M.D., M.P.H.; Laurel Gray; Alex Hollingsworth, Ph.D.; Eve C. Shapiro, M.D., M.P.H., and James E. Dalen, M.D., M.P.H., Sc.D.

If President-elect Donald Trump wants to reform health care in the U.S., he might do well to consult Tucson physician Dr. Paul Gordon.

Gordon, 61, this year cycled 3,255 miles over three months, listening to Americans talk about the Affordable Care Act (ACA), which is also known by its unofficial yet popular name, “Obamacare.”

The University of Arizona College of Medicine Tucson professor expects to publish some of his findings and observations in academic journals.

A lot of people he met along the way were parroting sound bites, Gordon found. Others said they don’t want to pay for other people’s health care. At the same time, he found the people he encountered were kind and generous with sharing their thoughts, with offers of help to fix flat tires, and to provide lodging and meals.

“We heard stuff that was not present in the survey data,” said Gordon, who rode through rural areas of Maryland, Pennsylvania, Ohio, Michigan, Wisconsin, Minnesota, South Dakota, Montana, Idaho and Washington state.

Some people he met liked the fact that young adults can stay on their parents’ health insurance until the age of 26; that insurance companies can no longer deny them coverage due to pre-existing conditions; and that federal subsidies are available to help people pay for insurance. But others had no idea those three things all happened as a result of the ACA and are part of the law.

Anger

“Given what we heard, I wasn’t all that surprised with how the election went,” said Laurel Gray, 26, medical student who accompanied Gordon on part of the ”Obamacare Listening Tour” to assist with research. “The anti-ACA lobby was very effective at painting an inaccurate picture of what the legislation is.”

A lot of people were angry, she said.

“When you are passing through these rural areas and seeing the reality of what life is like and what it has been like for the past 10 years, it’s very different. I hadn’t realized what a bubble I’d been living in, in Tucson.”

Gordon, who teaches and practices family medicine, and his wife, Tucson pediatrician Dr. Eve Shapiro, have long been supporters of universal health care. That means they’d like to see all Americans have equal access to health care through a single payer system.

But that’s not what the Obamacare Listening Tour was about.

“I never corrected. I just listened. By listening I quickly gained their sense of trust,” Gordon said. “I was just there to listen, not judge.”

Between three and eight people were riding with Gordon at any given time, including Shapiro, his two grown children and Gray, the UA student, who was a social worker before she went back to school to become a physician.

Misinformation

Gordon recalls how much a musician he met in rural Ohio disliked the individual mandate, which was part of the 2010 law, that all Americans have health insurance. The musician doesn’t mind that car insurance is mandatory because owning a car is optional. But being alive isn’t optional and that’s why mandating health insurance is unfair, he told Gordon.

Gordon also tells the story of a hotel manager he met in Knoxville, Maryland who hasn’t seen a doctor in a long time, even though he has employer-sponsored health insurance. He finds the system too complicated, so he avoids it.

And then there was Henry, the South Dakota resident who told Gordon that Obamacare “sucks” but wasn’t clear on the details of it.

“There was so much misinformation,” Shapiro said. “It was sound bites. Everything was Obama’s fault.”

She also noticed a large number of people who, “hate government telling them what to do.”

Complicated system

Gray went through her own learning curve.

“This was my first year needing my own health insurance. I’d always been on my parents’ plan,” she said. “When I started the tour I was embarrassed by my huge gaps in knowledge. I learned a lot.”

Some people Gray met said they could not afford health insurance. In some cases, though, she wondered whether health insurance was not their financial priority.

One certainty Gray took back to school this year, where she is a second year student, is that medical students have an obligation to be politically informed about the system in which they operate.

Gordon and Gray never set up any of their talks with people in advance. Typically they would ride for a few hours and stop at a convenience store along the way, get something to eat or drink, and talk to the people there.

The “Obamacare Listening Tour” jerseys the team wore invited conversation. Gordon and Gray would then dictate and summarize what they’d heard as a voice memo, which they later transcribed.

“At a minimum it informed me of people’s understandings of health insurance and health in general,” Gordon said. “And it helped me to be a better teacher and practitioner. A great lesson is that of listening. We need to listen to our patients. We can’t necessarily fix it, but we can at least listen.”

Gordon himself was never a fan of Obamacare because it includes the insurance industry, and much of the insurance industry is a business that prioritizes its stockholders.

In a single payer system, physicians can still be independent but there’s not another layer of overhead and administrative costs, he explained.

“Health care is complicated. But when you have a single payer system it’s not complicated at all,” he said.

“Damn politicians”

Gordon recalls a 75-year-old woman he met in Spokane, Washington who had similar sentiments as she drank a beer and watched a baseball game.

“Health care is a right,” he recalled her saying. “It’s true. Just raise taxes … But the damn politicians don’t have the balls to raise taxes.”

At this point, no one can predict what will happen to the Affordable Care Act moving forward. But Gordon says it will be hard to remove some of the pieces people don’t like, such as the individual mandate, without increasing costs.

Next up: Gordon would like to cycle across Canada to hear from Canadians firsthand what they think of their health system. He’s interested in doing the same in Taiwan, which also has a government-run single payer system.

http://tucson.com…

Medicare for all helps hold down costs

By Robert R. Stuber, M.D.
St. Joseph (Mo.) News-Press, Letters, Dec. 6, 2016

Headlines can be deceiving. The Dec. 5 News-Press contained a deceptive headline under “Clips and Quips.” The headline read, “Columbia Daily Tribune on the trouble with basic universal health care.” For those who read headlines only, this headline was very deceptive, as the detail of the item said just the opposite and at one point said, “Everywhere else in the developed world, single-payer systems provide better health outcomes at lower cost.”

The Tribune goes on to advocate that all citizens should have ready access to good preventive health care at an affordable price through insurance overseen by government.

The Tribune concludes, “This does not mean government would take over provision of services. It does not mean individuals could not buy additional coverage, just as we do now with Medicare augmentation.”

Not one senior would give up his/her Medicare coverage. The program has been invaluable to seniors, helping to increase their life expectancy from 65 to 77.

Furthermore, prior to Medicare enactment in 1965, many seniors died as paupers, their life savings having been wiped out by health problems associated with advancing age.

Trump has appointed Rep. Price as the head of Health and Human Services. Price has been a loud voice in Congress against universal health care. He advocates privatizing Medicare. He is totally disconnected from what is occurring in the rest of the civilized world, where one payer systems prevail.

Medicare for all is nondiscriminatory, fair, and would help to contain the rising cost of health care in this country. The free market competitive climate that has been the bedrock of our current health care system has failed miserably in cost containment and in providing access to care for all Americans.

Robert R. Stuber, M.D., resides in St. Joseph.

http://www.newspressnow.com…

Another reason to dump Medicare Advantage plans

NBER Working Paper No. 22876; Insurers’ Response to Selection Risk: Evidence from Medicare Enrollment Reforms

By Francesco Decarolis, Andrea Guglielmo
National Bureau of Economic Research, December 2016

Abstract

Evidence on insurers behavior in environments with both risk selection and market power is largely missing. We fill this gap by providing one of the first empirical accounts of how insurers adjust plan features when faced with potential changes in selection. Our strategy exploits a 2012 reform allowing Medicare enrollees to switch to 5-star contracts at anytime. This policy increased enrollment into 5-star contracts, but without risk selection worsening. Our findings show that this is due to 5-star plans lowering both premiums and generosity, thus becoming more appealing for most beneficiaries, but less so for those in worse health conditions.

From the Conclusions

The reform that, starting in 2012, allowed Medicare enrollees to switch at any point in time to the highest quality, 5-star plans could have backfired. By undermining the use of rigid open enrollment periods, a pillar of most insurance markets, this policy could have exacerbated the adverse selection faced by 5-star plans, potentially triggering premium spikes or even plan exit. The fact that this did not happen and that, despite the substantial growth in within-year enrollment in 5-star contracts, their risk pool did not worsen creates a puzzle.

This paper shows that a relevant force behind these facts is the sophisticated response adopted by suppliers. Both 5-star insurers and their competitors responded to the new policy. The 5-star insurers lowered their premiums, while, at the same time, worsening the amount of coverage offered by their plans. This contributed to expand their enrollment base, without worsening their risk pool.

In terms of policy, our results are both encouraging and problematic. On the one hand, the flexibility in product design that insurers retain in Medicare Pact C and D has allowed the 5-star SEP to achieve the goal of bolstering enrollment into 5-star plans. More generally, such flexibility is likely to help making the market sustainable for insurers. On the other hand, however, the very presence of such flexibility implies difficulties in designing rules capable of steering the market toward any public goal. In the context of the 5-star SEP, the reduced generosity of 5-star plans could negatively affect the well being of the weakest beneficiaries and could also represent a diminished allocative efficiency in the market.

http://www.nber.org…

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Comment:

By Don McCanne, M.D.

This study adds one more bit of evidence to the abundance of studies that show that private Medicare Advantage plans will always game the system to benefit themselves to the detriment of patients.

Specifically, this program that allowed patients to change to a five-star Medicare Advantage plan during a special open enrollment period potentially exposed the insurers to adverse selection – having to accept patients with greater health care needs. Instead the insurers were able to reduce their premiums and the amount of coverage, thus expanding their enrollment bases while avoiding worsening of their risk pools.

What was the net result? This made the market more sustainable for insurers but at a cost of negatively affecting “the well being of the weakest beneficiaries,” and diminishing “allocative efficiency in the market.”

Instead of wasting taxpayer funds on embellishments that benefit the private Medicare Advantage insurers, let’s dump them and redirect our efforts to improving the traditional Medicare program so that it benefits patients instead – making it a program that would be ideal for all of us.

Repealing Obamacare? Here’s A Better Idea: Medicare For All

By Rose Ann DeMoro
The Huffington Post, Dec. 5, 2016

Now that the dogged opponents of the Affordable Care Act have caught the Obamacare bus, transforming U.S. healthcare is back on the political agenda.

Repeal of the ACA will not curb the persistent, systemic inequities of our profit-focused healthcare system.

Tens of millions, even those with health insurance, still struggle with unpayable medical bills due to rising deductibles and co-pays and skyrocketing prescription drug costs and hospital charges.

Insurance networks sharply restrict patient choice. Millions remain without any health coverage, or simply avoid getting the care they need because they can’t afford it — at great risk to their health. Disparities based on race, gender, age, or where you live remain rampant.

Even advocates of repeal are fearful of the impact of throwing millions off the expanded Medicaid coverage or eroding the ACA crackdown on insurance industry abuses, such as barring coverage for those with pre-existing conditions.

One widely-promoted theme is to replace the tax subsidies the ACA provides to buy private insurance on the ACA exchanges with tax credits or health savings accounts to buy insurance on the open market. But those offer consumers even less protection from skyrocketing premiums or being forced to settle for bare bones junk insurance plans with limited benefits and higher out of pocket costs.

Another proposal is subsidizing federal funding of Medicaid expansion with state block grants. That, too, is problematic, opening the door to severe state budget cuts that would leave many lower income people and families without needed coverage.

Then there’s the Paul Ryan plan to privatize Medicare — a sure-fire way to impoverish millions of seniors forced to fend for themselves on the inefficient, more expensive private market.

The rightwing policy wonks label these approaches “consumer-driven free market health solutions.”

If the well funded, “grassroots” campaign in response is led by the Beltway Foundations and NGO’s to only defend the troubled ACA, then, yes, that’s precisely what will happen.

But the “free market” is exactly what created the healthcare crisis in the U.S. in the first place, creating a health care system largely based on ability to pay that ranked first in the world in spending and far behind most industrial nations in access, out-of-pocket costs and a variety of quality benchmarks.

Instead, let’s build the demand to protect, improve and expand Medicare. It’s the standard by which any healthcare system should be measured. If the Trump administration and the Republican-controlled Congress want to define what the healthcare system should be, let’s start with a truly patient-based approach.

Nurses’ credo for transforming the U.S. healthcare system is to establish a single standard of safe, therapeutic care for all, based on the clinical judgment of doctors, nurses, and other providers.

Only an improved Medicare for all can guarantee healthcare for all based on patient need. Eliminating private insurance and the high premiums, co-pays and deductibles will save families thousands of dollars, free up millions for businesses, increase wages for workers, and save hundreds of billions for taxpayers.

Gone would be the 20 percent waste that is endemic to a system based on private profit. No longer will taxpayers bail out for-profit insurance companies and corporate hospital chains and greedy nursing home operators.

Rather than guarantee high executive salaries and trapped customers, we can expand Medicare through increasing the existing fair share financing.

Here’s a checklist for reform:

• Complete choice of doctor.

• Demonstrated low overhead – Medicare is well known for administrative costs of just 3 percent compared to far higher figures for private insurers due to profits and paperwork.

• Control drug prices? (Yes, if given authority to negotiate bulk discounts with prescription drug corporations.)

• Popular, fair healthcare program supported by nurses, doctors, and a majority of Americans!

Improved Medicare for All checks all the boxes. If Ryan really believes repealing the ACA will “leave no one worse off,” the only way to achieve that is Medicare for all.

California, with Democrats in control of the governor’s office and state legislature, is one state that can set a national model of how to do reform right by adopting a Medicare for all type system.

Medicare remains one of the most popular social reforms in U.S. history. Expanding it to cover everyone is an idea favored by 58 percent of Americans, as a May Gallup poll demonstrated. It’s the real healthcare reform we need.

Rose Ann DeMoro is executive director of National Nurses United (AFL-CIO) and the California Nurses Association.

http://www.huffingtonpost.com…

Trump’s health care policy appears heavy on complexity, light on mercy

Letting the states decide how to insure residents might lead to a cobweb of unwieldy regulations

By Daniel C. Bryant, M.D.
Portland (Maine) Press Herald, Dec. 5, 2016

Will Donald Trump make our country’s health care system great again? Of course, for many it was never that great in the first place, but it is important to consider what changes may lie ahead during a Trump presidency. For this, we can turn to his website, where he promises to:

• Repeal the Affordable Care Act. Though Mr. Trump has suggested he may keep some features of the ACA, this may mean that 20 million people will lose their health insurance and millions more will find it increasingly hard to find affordable policies with reasonable coverage.

• Replace the ACA with health savings accounts. In the HSA scheme, individuals with high-deductible plans can set aside thousands of dollars of income a year, tax free, to pay future health care costs.

This, of course, limits HSAs to those with extra money to set aside, who will then be faced with the recurring quandary of whether a medical problem “deserves” their depleting their account or should be ignored because something worse might come along.

• Return health insurance regulation to the states. Dealing with 50 different sets of insurance regulations will be a challenge both to businesses with employees living in multiple states and to the companies that provide insurance to those businesses.

And people with costly medical problems will be tempted to move to states that require insurers to offer good coverage, thus burdening those well-intentioned states; while businesses will be tempted to move to states with low coverage requirements and premiums, thus forcing poorer policies on their employees.

• Maximize flexibility for states in administering Medicaid. Like the above, this “states’ rights” emphasis would give states so inclined a tool for modifying their demographics to their economic advantage: namely, by keeping out the poor and the sick.

• Enable people to purchase insurance across state lines. The resulting competition might well reduce premiums, but in order to maintain their bottom lines, for-profit insurers would have to compensate by reducing coverage or provider reimbursement. And it will be tricky, indeed, for insurers to sell group and individual policies across state lines if every state has a different set of regulations.

• Re-establish high-risk pools. By segregating the sick or likely-to-get-sick into “pools,” we shift some of the extra cost of their care to them, and away from the already more fortunate. The balance of the cost must then be paid by the government, which may or may not be willing to do so.

This all flies in the face of the basic idea of insurance, which is to spread cost over the fortunate as well as the unfortunate, not concentrate it. And what is even worse, it perpetuates a two-class system – normal people, and the sick and poor.

• “Modernize” Medicare. This is too vague a prescription to try to interpret at this point; it could mean anything from lowering the age limit and increasing coverage, to phasing out the program altogether.

Reviewing Mr. Trump’s likely health care policies, we can note two themes, both of concern – complexity and inequity.

Complexity, and its associated financial costs, would come from the co-existence of millions of HSAs, millions of individual and employer-sponsored insurance plans and a variety of Medicaid and other governmental programs, all operating within the competing regulations of the 50 different states among which people and businesses are constantly moving.

Inequity, and its associated social costs, would come from the vastly different access to health care that people of different means and locales would have.

The Affordable Care Act, too, is complex, and, though much more equitable than Mr. Trump’s policies, may well not survive. As for the system that the president-elect’s policies would lead to, it will be unlikely to survive either because of its own complexities, and should not because of its inequities.

In the aftermath of both Barack Obama’s and Mr. Trump’s efforts at health care reform, we will be left then to design a new system, preferably the one we should have had all along – a simple and equitable system of the single-payer, Medicare-for-All type, similar to those that every other industrialized country has adopted.

No, Donald Trump will probably not make our health care system great again, but he may, if inadvertently, help to make it great at last.

Daniel C. Bryant, M.D., of Cape Elizabeth is leader of the Portland chapter of Maine AllCare (maineallcare.org), an organization devoted to getting universal health care in Maine.

http://www.pressherald.com/2016/12/05/maine-voices-trumps-health-care-policy-appears-heavy-on-complexity-light-on-mercy/

Faster growth of national health spending

National Health Spending: Faster Growth In 2015 As Coverage Expands And Utilization Increases

By Anne B. Martin, Micah Hartman, Benjamin Washington, Aaron Catlin, the National Health Expenditure Accounts Team
Health Affairs, December 2016

Abstract

Total nominal US health care spending increased 5.8 percent and reached $3.2 trillion in 2015. On a per person basis, spending on health care increased 5.0 percent, reaching $9,990. The share of gross domestic product devoted to health care spending was 17.8 percent in 2015, up from 17.4 percent in 2014. Coverage expansions that began in 2014 as a result of the Affordable Care Act continued to affect health spending growth in 2015. In that year, the faster growth in total health care spending was primarily due to accelerated growth in spending for private health insurance (growth of 7.2 percent), hospital care (5.6 percent), and physician and clinical services (6.3 percent). Continued strong growth in Medicaid (9.7 percent) and retail prescription drug spending (9.0 percent), albeit at a slower rate than in 2014, contributed to overall health care spending growth in 2015.

http://content.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

As of 2015, our national health spending is $3.2 trillion or 17.8 percent of our GDP. That is a per capita spending of almost $10,000 ($9,990). Coverage expansions as a result of the Affordable Care Act certainly contributed to this 5.8 percent increase in spending.

The final sentence in the conclusion of this article: “While the 2014–15 period is unique, given the significant changes in health insurance coverage that took place, health spending is projected to increase as a share of the overall economy over the next ten years and will be influenced by the aging of the population, changing economic conditions, and faster medical price growth.”

Changing demographics are expected, predictable, and manageable, but faster price growth remains a problem unique to our fragmented system of financing health care. We could fix that with a publicly-financed and publicly-administered single payer national health program, an improved Medicare for all.