PNHP

Sen. John Marty’s “Healing Health Care”

Sen. John Marty’s “Healing Health Care”

The Case for a Commonsense Universal Health System

By John Marty
MNHealthPlan.org, October 2016

During my 30 years in the Minnesota Senate, I have seen firsthand the failure of our political system to seriously address health policy. In the United States, we squander outstanding health care resources — providers, clinics and hospitals, medical research and technology — on a broken system that makes it difficult and expensive for many people to get the care they need.

Why would any society make it difficult for its people to access health care?

I wrote this book because I am tired of waiting while our political process spends billions of dollars but merely tinkers at the edges of our health care problems.

* First we take a few steps back and look at the mess we have. By doing so, we identify the problems, develop principles for a healthy health care system, and map out a logical plan based on those principles.

* Then we work through our civic process and political system, make the case for our proposal, and then work to implement that plan.

This proposed Minnesota Health Plan and the principles that underlie it are nothing more than what any caring society would desire in order to ensure good health care for all of its people.

A Call to Action

If twenty-first century progressives had been leading the nineteenth century abolition movement, we would still have slavery, but we would have limited slavery to a 40-hour work week, and we would be congratulating each other on the progress we had made.

Epilogue: It’s Time for the Minnesota Health Plan

Our current system, even with MNsure and the Affordable Care Act, still leaves many people without health coverage. Equally troubling, many Minnesotans who have health coverage still cannot afford the care they need.

Health insurance coverage fails to guarantee that people have access to health care, because insurance frequently excludes coverage for needed care such as dental, chemical dependency treatment, mental health, or long- term care.

Health insurance also requires significant out-of-pocket expenses, and it buries people and businesses with a thicket of confusing medical insurance applications and paperwork.

Despite our excellent medical providers and medical technology, Minnesota’s system is so dysfunctional that many families cannot access it even when they have insurance.

It’s time to stand up to the strong, well-financed opposition from the insurance industry and the pharmaceutical lobby.

We must replace health insurance for some with health care for all.

When European nations, Canada, and Japan are able to deliver comprehensive health care to all of their people, with better health outcomes, for roughly half the cost per person that we are currently spending, it is not an insurmountable challenge.

The Minnesota Health Plan would be an efficient health care system based on, and governed by, principles that ensure that all people receive high quality health care.

Minnesota has some of the best medical education, training, research, and technology in the world. It’s time we adopt a health care system to match.

“Healing Health Care” by John Marty can be downloaded for free at the following link:
http://mnhealthplan.org

Numerous excerpts from “Healing Health Care”:
http://mnhealthplan.org…

Senate, State of Minnesota: S.F. No. 2060 – Minnesota Health Plan:
http://tinyurl.com/MHP-2016-bill

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Comment:

By Don McCanne, M.D.

“Healing Health Care” by Sen. John Marty is not only a description of a health care reform proposal for Minnesota, more importantly it is a discussion of policies that all of us desperately need to improve the functioning of our health care financing and health care delivery systems. It is a basic primer that all concerned about health care reform could use.

“Healing Health Care” can be downloaded for free at the link above. It is an easy read of less than 150 pages. For those who do not have the time, it would be well worth reading the excerpts at the second link above. They will provide some of the essence of the message in his book.

Minnesota Health Plan

New book outlines transition from the MNsure mess to a single-payer system

By the editors
The Timberjay (Tower, Minn.), Oct. 5, 2016

A new book by Minnesota state Sen. John Marty offers something that few politicians have ever provided to the public before — a straightforward plan to transition to a single-payer health care system in the state.

If there’s one thing, above all else, that passage of the Affordable Care Act has demonstrated, it is that any health care reform that maintains the existing private health insurance system is doomed to fail. While the ACA provided a brief respite in the spiraling cost of health care, premiums are now making up for lost time. Health officials here in Minnesota are already warning consumers that they are in for sticker shock when new MNsure rates are announced in a few weeks. Most plans are expected to see increases approaching 35-50 percent.

Despite skyrocketing premiums, Minnesotans are increasingly getting less in terms of coverage. To keep premium increases to a minimum, Minnesotans are opting for high deductible plans that require families to pay thousands of dollars before real insurance coverage kicks in. Even then, they still have co-pays and other charges. And many of the plans provide no dental coverage and only limited coverage for mental health care.

The problems inherent in the ACA are no justification for going back to the bad old days, when insurance companies could simply refuse to insure those in poor health, or when they were allowed to pocket huge profits by simply denying care even to those they had agreed to insure. In those days, we had 50 million uninsured Americans and our health care costs were spiraling out of control.

That leaves the obvious question. Where do we go from here?

Sen. Marty, in his new book, released at no charge in digital format this week, lays out a road map for the implementation of what he calls the Minnesota Health Plan, a comprehensive, single-payer health insurance proposal that he argues will provide significantly enhanced medical access for all Minnesotans, without spending any more than the $50 billion that Minnesotans and their employers currently pay for health care premiums and medical services every year.

The single-payer system would direct far more money towards actual care, however, since it would save the 15 cents on every health care dollar that goes to administering what is without a doubt the most inefficient health insurance system on the planet. That 15 percent amounts to seven billion dollars a year that Minnesotans and their employers spend on bureaucracy, whether it is administrative staff at hospitals, insurance companies, or in the government.

Complexity breeds inefficiency, as those who have struggled with the MNsure process are well aware. Yet it doesn’t have to be that way. As Sen. Marty notes, the cost of signing up seniors for Medicare is just a tiny fraction of the cost of getting Minnesotans signed up for coverage through MNsure. It’s not that government is inherently inefficient. Indeed, the Medicare system is far more efficient than any private insurance company. It’s that when government systems are set up to benefit special interests— like the insurance industry in the case of the ACA—that common sense and efficiency regularly disappear out the window.

The transition to a statewide single-payer system may well be possible, since the ACA does allow for waivers, which would essentially allow states to utilize federal health care dollars to develop alternatives to the current system, as long as they meet certain standards, which the Minnesota Health Plan, as envisioned by Sen. Marty, certainly would. In addition to federal funding, the cost of care under the Minnesota Health Plan would be paid for primarily by a payroll tax and individual premiums, similar to the way that Medicare is funded today.

Those who say a single-payer system isn’t viable are deploying mere rhetoric in place of reality. Many other developed countries manage to provide a successful single-payer system for their citizens, and so do we. Medicare, after all, is a single-payer health care system, and it’s one of the two most popular programs (the other being Social Security) run by the government.

Would the Minnesota Health Plan face political opposition? Without a doubt. Many politicians maintain their office by defending powerful special interests, and few are more powerful than the insurance lobby.

But one thing is certain. You don’t win if you don’t try. We ended up with the Affordable Care Act, with all its flaws, because the Obama administration opted to avoid a battle with the insurance industry, not because the administration could argue that theirs’ was a better plan.

Perhaps it took the misfire of the Affordable Care Act to open the door to something better. If so, Sen. Marty’s new book is pointing a way forward. It’s definitely worth a read.

http://timberjay.com…

Why You Should Vote Yes for Amendment 69, the ColoradoCare Health Plan

By Michael Roberts
Westword (Denver), Oct. 5, 2016

Of the nine amendments and propositions that will be on Colorado’s ballot next month, Amendment 69 is the most sweeping. Also known as ColoradoCare, the proposal would create a Colorado-specific health-care program with a goal of covering every citizen in the state with health insurance. It’s not quite a single-payer plan, since it wouldn’t supersede federal programs such as TRICARE, which focuses on veterans. As such, Owen Perkins, director of communications for the ColoradoCare Yes campaign, calls it “Medicare for all.”

Below is a transcript of our conversation with Perkins.

Westword: What are the reasons that folks should vote for Amendment 69?

Owen Perkins: Different people have different priorities about what they think is best about ColoradoCare. For me, it’s about getting us to the threshold where we can make sure everybody’s covered, everybody’s got access to health care. The Affordable Care Act did a good job of getting us closer. We went from over 800,000 uninsured to under 400,000. But that’s still kind of disgraceful to have nearly 400,000 people uninsured and uncovered in Colorado. So the ability to get everybody covered and everybody into the system is essential, I think, for a prosperous society like the United States and for Colorado. And to fall short of that is unacceptable.

The fact that we can do it while maintaining the benefits and saving billions of dollars a year is a tremendous bonus. And I think for a lot of people, the cost savings is the number-one reason. Ultimately, a lot of people look at their pocketbook, and for an individual or family in Colorado, they’ll be saving anywhere from thousands to tens of thousands of dollars. The overwhelming majority of Coloradans will be saving under ColoradoCare. That’s a big point for a lot of people — a good reason to pass ColoradoCare.

One things we’ve discovered, somewhat to our surprise, is that the frustration with the current system is nearly universal. I don’t think I’ve heard anyone try to make the case for the current system — the corporate-insurance, industry-based model. Everyone knows that it doesn’t work and that there are all kinds of problems with it. I think the only debate is about whether this is the right solution or not. A lot of us get tired of people who profess to want to make change but resist making the change when [they] actually have a viable solution in front of [them]. And I think that’s where we are now. I’m hoping Coloradans will take that opportunity to act on it.

How will ColoradoCare be instituted? What kind of Colorado-specific structure will be put in place?

It is a structure that will be entirely Colorado-specific, and it’s a big structure. It ends up involving thousands or tens of thousands of jobs that will be created. ColoradoCare becomes a payment system, basically. The exchange (Connect for Health Colorado, the health-insurance marketplace created under AFA) would go away, and you’d anticipate that a lot of people who’ve grown skilled at working for the exchange, if interested, would be well qualified to work for ColoradoCare.

The amendment creates a board of trustees, and then the board begins hiring the staff and putting an entire system into place: CEO, CFO, a staff, health-service information people. But it’s all on the coverage end of things as opposed to the provider end of things. ColoradoCare doesn’t encompass the providers; they don’t work for ColoradoCare. They stay in their private practices or work for hospitals or groups.

The process will take a couple of years. If it passes in November, the anticipation is that it will go into effect in January 2019. You get that time to build up, and there are a few things that are important that happen during that time. It could pass with 90 percent of the vote — I don’t anticipate that, but it could pass with an overwhelming majority — and end up not going into effect if it doesn’t get waivers from the federal government.

One of the things that happens in 2017 is, that’s the earliest anyone can apply for a waiver from the Affordable Care Act. The Affordable Care Act, I think very intelligently, created a mechanism that allows states to opt out of the act if they can create their own system. That encourages their innovation in finding a more efficient and cost-effective way to deliver and cover health care in states.

So we would be among the first states, if not the first state, to apply for a waiver from the Affordable Care Act, and that standard is very challenging. We need to show we can cover as many people or more as the Affordable Care Act at the same price or lower, with the same benefits or better. That’s, I think, an appropriately challenging standard, and to me, it’s encouraging that we’d have to meet that standard. It would have to be approved by the federal government — by the Health and Human Services Department — in order to move forward. That’s why I say we could get 90 percent of the vote, but if we’re not approved for the waivers by virtue of meeting those standards, we don’t move forward at all.

I never used to mention this, since I think it’s sort of a ridiculous situation — the idea that the federal government would grant the waivers but not give us the full funding. It seems ridiculous. They are encouraging states to be innovative and pursue the waivers through the Affordable Care Act, and it would seem bizarre to encourage states and approve the waiver and then not give the funding to make it work. But if that happens, which the Colorado Health Institute is supposing it would — and which I think that’s an irresponsible supposition — and we didn’t get full federal funding, it would not move forward. It has to get that approval and that funding from the federal government to be implemented. It requires about $13 billion of federal funding that Colorado currently gets; it requires that we get that funding in order to move forward. (Click to read the Colorado Health Initiative analysis of ColoradoCare.)

Would people be mandated to use ColoradoCare? Or could they still use private health care, or health care through their business or employer?

They won’t be mandated to use it, but they’ll still be covered. Every Colorado resident will be covered by ColoradoCare, but they can still choose to use private insurance instead, in much the same way that everyone in Colorado has access to public-school education but many choose to go to a private school and pay twice — pay the taxes for the public school and the tuition for a private school.

Everybody will be covered by ColoradoCare. For most people, that will mean they’ll be contributing a portion of their salary or their income. If people are making below the poverty level or if they’re seniors and have exemptions, they might not be paying anything and still be getting ColoradoCare. And if they’re unemployed, they’ll be getting ColoradoCare. But they don’t have to use it, and it doesn’t dictate that the private-insurance industry goes away. The private-insurance industry can stay as long as it wants. I would imagine initially that those who oppose ColoradoCare, many of them may keep paying for private insurance. But I would think that over time, they’ll realize, “I’m paying twice and my neighbor is getting great coverage from ColoradoCare — the same kind of coverage I’m getting. So I think I’ll stop paying twice for it.” And eventually, you might have the private-insurance industry essentially closing up shop in Colorado. But it doesn’t mandate that.

How do you guarantee that ColoradoCare provides service that is equal or better to the current system?

A lot of the coverage that establishes that minimum of meeting the current system — to ensure that it meets that standard — is in the language of the amendment. Some of it is about getting the Medicaid waiver, which is additional to getting the Affordable Care Act waiver, and that’s actually significantly more money than the Affordable Care Act — because ColoradoCare will essentially take over Medicaid here. ColoradoCare would be required to sustain any benefits that Medicaid offers. So anybody who’s eligible for Medicaid benefits would get those benefits under ColoradoCare.

It’s basically written into the language of the constitution. And within the constitution, you essentially want it to be a blueprint for ColoradoCare. I don’t think anyone wants the constitution micromanaging health care. So you want to find this balance of what needs to be covered, but not putting, for example, the cost of that coverage into the constitution when you know that changes over time — or the reimbursement rates, or things like that.

You get as much as is appropriate into the constitution. And I think it’s appropriate to have it in the constitution. That’s where we go to protect our rights. And I’m one of those who feel that health care should be a right, and is a right. Certainly we as a society, and me as a member of the society, I feel we have a responsibility to cover all of our residents, and if our society is taking that responsibility, I think concurrent to that, I believe everybody has a right to care. But micromanaging that in the constitution would be a little overkill.

Your opponents have three major objections to ColoradoCare. Among other things, they see it as risky putting all of this information into the state’s constitution, because that makes it difficult to change. But at the same time, they talk about the lack of specificity in the amendment, which they see as only an outline or a framework for a system — one that leaves too many questions unanswered. Could this have been done in the legislature, through statute? Or does putting it in the constitution make it more of a permanent pledge to the people of Colorado that their health care will be covered?

The latter. You do want that significant pledge. And I think we all know too well how fickle the legislature can be and how it can change as majorities change and how special interests can affect the legislature and result in something unwieldy.

That’s essentially what happened in Vermont. Vermont started with this ideal notion of getting a single-payer, universal plan to cover all their residents and then left it to the legislature to come up with how to do that. And the result, with so many legislators feeling the obligation to represent various special interests with aspects of the legislation, it became unwieldy. The costs escalated because of all the changes they tried to add, and the governor vetoed it. So you had the state accept something and then the legislature screwed it up. (Click for more information about Green Mountain Care, the failed Vermont single-payer plan.)

Those options — for the legislature to mess it up or the governor to veto it — are not an option when the people of Colorado put it into the constitution. It’s a question for them. We strongly believe this right should be defended and put into the constitution.

Obviously, this is making a change to the constitution. But I give the people of Colorado tremendous credit for making good decisions, for the most part, about what goes into the constitution. And if they make the challenging decision to accept this and put it in, I think they’ll be well situated to make changes in the future, if need be.

For example, the board can’t change the payroll-deduction rate without a vote of the people of Colorado. There are those who think they’ll never vote for an increase. But I think if they vote for this in the first place, they’re showing the ability to take on a challenging idea. The ballot language is very challenging for us, and if they can accept that, they can accept the idea of making changes in the future, if need be.

Our constitution, both nationally and in Colorado, has always been a living document. Vitally important things exist as amendments. The Bill of Rights, for example. And it’s essential that things get in when they need to get in.

Sometimes, there’s a baffling dichotomy on the opposite side of objecting to the idea that this is any way connected to government, by putting it into the constitution and collecting taxes, but at the same time also objecting to what they see as there not being enough government involvement or government oversight. But when the voters are educated about the issue — when they take the time to learn about it — they’ve shown the ability to make really wise, responsible choices. I’m comfortable with them doing it again in this case. But it is a challenge to get them educated about it, letting them know about it.

Your opponents say the measure calls for $25 billion in new taxes, and to provide some context, they note that the entire state budget is around $27 billion. They also say the new taxes would result in Colorado having the highest income-tax rate of any state in the country. Is that accurate, or an exaggeration?

It’s kind of a half-truth. The full truth is that it is $25 billion. That’s what’s called for in the language on the ballot. But the part they’re leaving out is that the $25 billion replaces the $30 billion we currently pay for health care in Colorado. That’s vitally important to understand.

I mentioned Vermont and the way they started with the ideal. Where Colorado started was with the practical, with the real. We looked at what we currently spend on health care, which is $30 billion. Families, firms, businesses, individuals currently pay that much on health care in premiums, deductibles, co-pays. We said, “Okay, $30 billion is what we spend. How do we create a better system with that budget?” And in part, when you go to a real universal health care system and get everybody into the pool, you end up saving money. We were able to find the more efficient model — take away the corporate-insurance-industry for-profit model and replace it with a Medicare-for-all model, which is based on Medicare, and takes the 20 percent administrative cost that’s associated with the corporate-insurance industry model and cuts that down to the 4 percent administrative cost Medicare uses. That eliminates 16 percent of the budget right there. It’s not where all the savings come from, but the overall savings are about $4.5 billion a year.

To talk about a $25 billion tax increase, that’s what the language of the ballot asks for — so there’s certainly truth in that. But to leave out the fact that we’re replacing the $30 billion we currently spend on health care is grossly negligent.

Our total cost of health care and income tax would be significantly less with ColoradoCare in place than it is now. That’s what we really need to look at. We’re eliminating insurance premiums, deductibles, co-pays for primary and preventive care and lowering them for other care and setting up the ability to waive them for financial-hardship co-pays. So you’re eliminating a lot of costs and replacing it with another cost that ends up being $4.5 billion less.

Your opponents also talk about a 10 percent payroll tax, which they describe as an important piece of the financing mechanism. A tax on all payroll incomes, two-thirds to be paid by the employer, one-third to be paid by the employee. But there’s also an additional 10 percent tax on non-payroll items, which would include things like savings, investments and capital gains. Is that accurate? And if so, why does that make sense in the context of the overall plan?

Yes, for most people, it’s a 3.33 percent payroll deduction, with the employer kicking in 6.67 percent. And for most people — and we’re talking about over 80 percent of Coloradans — that’s less than they’re paying now. The average Coloradan is paying closer to 12 percent — considerably higher than 3.33 percent. And the average employer is kicking in around 13.5 percent for employee health care. So both of those costs that people are currently enduring are replaced at what, for most people, is a lower cost of 3.33 percent. And that’s where the $25 billion comes from.

That’s part of the simplification process of eliminating a system that is bogged down in bureaucracy, because there are all the insurers and all the different plans each insurer has, which can add up to hundreds of options, and which create this unbelievable bureaucracy in medicine. And the number of bureaucrats in health care has skyrocketed since 1970, as opposed to the number of providers, which has stayed fairly consistent, growing at a smaller, more natural pace. But this explosion of bureaucratic entanglement in health care has created a kind of cottage industry for bureaucrats in health care. You eliminate that and go to a Medicare model where it’s all going to one place and they’re reimbursing without that profit motive — and when you eliminate the profit motive, you eliminate the incentive for denying coverage that so much of the insurance industry is consumed with right now. You get, essentially, an independent, nonprofit cooperative that’s owned by the people of Colorado and doesn’t profit from it — that exists to make a good environment for patients and providers. Their goal ends up costing less when you take out that profit motive that corporations are focused on.

We’re seeing millions of dollars going to the Coloradans for Coloradans campaign, and the vast majority of their funding comes from corporations — and most of that’s related to the health-care industry. Big Medicine, Big Pharma — and a huge percentage of that is coming from out of state. (Figures from September 19 show that $3,935,950 of $4,003,067 contributed to opposition group Coloradans for Coloradans came from corporations and business entities. The top four, whose contributions exceed $2 million, are from Ohio, California, Connecticut and Tennessee, respectively.) And that’s natural, because that’s their profits we’re talking about, and which they’re trying to defend. But those profits come at the expense of patient care in Colorado. So this is a real commonsense attempt to put patients over profits in the same way that Medicare does it. And Medicare has, for a long time, been considered the most popular and efficient government program out there. To use that as a tried-and-tested model makes immense good sense….

A lot of national organizations have been encouraging their supporters to support ColoradoCare, including Bernie Sanders and Our Revolution (a political organization created in late August). I think that’s a huge chunk of donations to ColoradoCare. It’s something we’ve anticipated coming for a long time. Bernie endorsed at the end of August. We anticipated he would as soon as he was through with his race. And he put it as a priority for the political-action group that he started. It’s one of I think seven ballot issues they’ve targeted around the country — things that fulfilled his vision and were in sync with his platform…. It’s one of the two or three biggest platform planks that has a chance to be enacted, and it’s here in Colorado.

Bernie Sanders knows and has said that if Colorado passes it, it will have an effect beyond Colorado. The reason the insurance industry is pouring millions of dollars into defeating it is not because of the money it will lose in Colorado, but because of the fear that other states will begin following that trend, just as they did with women’s suffrage, with child-labor laws, with minimum wage, with marriage equality, with interracial marriage, with recreational marijuana, and on and on. These things start at the state level and then reach a tipping point nationally as they become accepted.

The same thing happened in Canada with universal health care. It started in one province there — Saskatchewan — and then everyone saw how well it worked there. But rather than everyone moving to Saskatchewan, as the opposition claims will happen in Colorado if ColoradoCare passes, they moved that great idea from Saskatchewan to their own provinces and adopted it, and very soon had national universal health care. That’s what a lot of people expect will happen if Colorado passes it. And I think that’s what the insurance industry fears — getting a national, single-payer system. (Click to read more about the history of health care in Canada.)

To clarify, we’re not single-payer. Because Medicare still runs, and so does TRICARE for veterans, that keeps this from being purely a single-payer plan. But it’s similar. It’s understandable that people get it confused. But basically, it’s a Medicare-for-all program that does for Colorado what Medicare does for seniors. If you live here, you’re covered.

Are you pitching ColoradoCare not only as something that’s good for Colorado, but also as something that could go national? Or is it more important from your perspective that voters here look at how it will benefit them?

I think it’s more important for voters to look at how it benefits them in this state. So we probably don’t pitch the national aspect. But they’re one and the same. What’s good for Colorado is good for the nation. It makes the same economic sense; it’s the same moral-responsibility argument. It doesn’t really need to be separated. A lot of detractors say, “I’d like to see it on the national level, but I don’t want Colorado to start it on the state level.” But that’s how it’s going to happen. It’s going to start on the state level, and all the arguments for doing it nationally pretty much apply to starting it on the state level. It’s good for Colorado in terms of fulfilling our moral imperative as a society and saving us billions of dollars as a state and thousands or tens of thousands for individuals and families. It’s good any way you look at it.

As you’ve noted, your opponents are very well financed. Has it been a challenge to get your message out in the face of their resources? Or are you finding that word of mouth is working? And are you optimistic about the outcome?

It is a challenge. I think we’re all optimistic in that we know from polling that when people know about ColoradoCare, they like it and would vote to support it. The challenge is making sure they know about it. We have done a pretty good job all the way through in keeping up. It’s been a phenomenal grassroots effort. Our budget has been minuscule compared to the opposition…but the bottom line is, we need to make sure people know about it and understand it.

I think as we’ve gotten into the home stretch and those millions of dollars from the opposition have come into play with on-air ads, on TV for the most part, it’s been more challenging to keep up with. But the recent influx of donations will allow us to get on the air. We haven’t been on the air yet, but we’ve had something like 485 past and future presentations and speaking engagements and debates all over Colorado. I think about 125 of those have been debates. Reaching out, speaking to groups anywhere from a dozen to 500, has been effective. We’ve certainly been on the ground, knocking on doors and making phone calls. Every kind of grassroots tactic we can use to get the word out we’ve used, including a real aggressive volunteer effort to write letters to the editor and also to earn a lot of media attention. That’s helped us keep pace with the opposition, which has ten times the funding we have.

These last weeks, TV ads play such a big part — and it’s always tricky to figure out how they’re going to play. I think we’ve seen a lot of elections where TV advertising backfires. And certainly, I’ve heard from a lot of people who say the more they see of these ads, the less they trust them.

So, yes, it’s a challenge. But we know that when people know about it, they like it. And that gives us the drive to keep going, keeping doing everything we can to make sure Coloradans know the facts about it.

http://www.westword.com…

PNHP has published a brief evaluation of the ColoradoCare ballot initiative, here.

Canadian Medicare on trial

Could this be the beginning of the end for the Canadian single-payer system?

By Danielle Martin
DEMOCRACY, October 3, 2016

There’s an old joke that Canadians like to tell: What’s a Canadian? A gunless American with health care.

It’s only funny because we half-believe it’s true; despite the many things we have in common with our friends south of the 49th parallel, Canada’s single-tier, publicly funded health care system has long been a point of differentiation—and pride—for most Canadians. A 2012 poll found that our health care system—known in Canada as “Medicare”—was almost universally loved, with 94% of those surveyed calling it an important source of collective pride. The notion that access to health care should be based only on need is a deeply ingrained Canadian value.

But we can’t take our Medicare system for granted.

The challenges to Canadian Medicare have always been ideological and political. But, as of this month, they are also legal.

In the western province of British Columbia, a trial underway in that province’s Supreme Court is challenging the very foundations of Medicare: providing care based solely on need, and not on ability to pay.

Cambie Surgeries Corporation and the Specialist Referral Clinic, represented by Dr. Brian Day, an orthopedic surgeon in Vancouver, are suing the government of B.C., trying to knock down the laws that protect our single-payer system. If successful, some Canadians will be able to pay out-of-pocket or through private insurance for hospital and physician services—and doctors will be able to charge them whatever the market will bear.

The essence of the claim is that, because wait times for some elective surgeries in that province are longer than we would like them to be, doctors should have a constitutionally protected right to provide them more quickly and at a higher price. This would be done by charging some patients privately, either out-of-pocket or through private insurance. They allege that existing limits on charging patients privately infringe on patients’ rights to life, liberty, and security of the person under Section 7 of the Canadian Charter of Rights and Freedoms.

It is also worth noting recent efforts at tackling the main driver of this constitutional challenge: wait times for non-urgent surgery. These have come from within the public system, and include wait time targets, centralized intake for people with a common problem, and inter-professional health-care teams so that surgeons’ time does not create a bottleneck. Such initiatives show tremendous promise for reducing waits deemed unreasonable, but governments need to implement them, and health-care organizations and doctors need to help accelerate this kind of reform.

It may be that the Cambie plaintiffs will be unsuccessful in their quest to dismantle the essence of Medicare, but clearly the stakes for ordinary Canadians are very high. Like all developed countries, Canada struggles to control growth in health-care costs, meet the needs of an aging population, and provide timely care of the highest standard. Whether we continue to work to do so for all Canadians, or only some, will, in part, be determined by the outcome of the Cambie case.

Danielle Martin is a family physician in Toronto and Vice President, Medical Affairs and Health System Solutions at Women’s College Hospital.

http://democracyjournal.org…

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Comment:

By Don McCanne, M.D.

The single payer model in Canada is closest to the ideal model of public financing/private health care delivery supported by Physicians for a National Health Program (PNHP). That model is now under legal challenge in Canada. If the Cambie lawsuit succeeds, the very concept of providing health care based on need rather than ability to pay will have suffered such a blow in the international community that we may never achieve that goal in the United States.

The trial will last an estimated six months and then will surely be appealed to the Supreme Court of Canada. Now, more than ever, Canadians need our moral support. And, oh yes, we need theirs.

Bill Clinton Is Right, For-Profit Healthcare Is the ‘Craziest Thing in the World’

Beneath the misleading headlines and corporate spin, former president gave a robust argument in favor of single-payer system

By Lauren McCauley
Common Dreams, October 4, 2016

Bill Clinton gave a robust argument in favor of a single-payer healthcare system on Monday night—but you wouldn’t know it if you read the news, or paid any attention to Republican nominee Donald Trump.

Speaking at Hillary Clinton campaign rally in Flint, Michigan, the former president discussed the importance of expanding access to Medicare and Medicaid while lambasting the for-profit insurance model that overcharges people and reaps enormous profit.

“The insurance model doesn’t work here,” he said, “it’s not like life insurance, or casualty insurance. It doesn’t work.”

“The current system works fine,” Clinton continued, referring to President Barack Obama’s Affordable Care Act (ACA), “if you’re eligible for Medicaid, if you’re a lower-income working person; if you’re already on Medicare, or if you get enough subsidies on a modest income that you can afford your health care. But the people that are getting killed in this deal are small business people and individuals who make just a little too much to get any of these subsidies.”

“Why?” he asked, “because they are not organized, they don’t have bargaining power with insurance companies and they are getting whacked.” As Clinton explained, insurance companies assessing risk for a small pool of people “overcharge, just to make sure, and make a whopping profit off the people least able to pay.”

“So you’ve got this crazy system where all of a sudden 25 million more people have health care and then the people who are out there busting it, sometimes 60 hours a week, wind up with their premiums doubled and their coverage cut in half. It’s the craziest thing in the world,” he continued.

Adding his voice to the growing call for a public option to be added to ACA, he said that the “simplest thing” is to let those individuals not eligible for subsidies buy into Medicaid and Medicare—a plan which is supported by Democratic nominee Hillary Clinton and her former challenger Sen. Bernie Sanders, as well as Obama.

After corporate media spun the remarks with the “grossly inaccurate” headline, “Bill Clinton calls Obamacare ‘the craziest thing in the world,'” Trump’s campaign predictably seized on the moment, issuing a statement that read: “even Democrats like Bill Clinton are coming to realize just what bad public policy ObamaCare really is.”

But as Clinton himself pointed out, allowing the market to take over has left the United States with the most expensive health insurance system, with the least number of people covered. According to the most recently available U.S. Census Data, 29 million people went uninsured in 2015, including 3.7 million children, and despite ACA, deductibles and other out-of-pocket costs continued to rise.

As proponents have argued, the “simplest thing,” in fact, would be to forgo the public option and enact a government-run, single-payer healthcare system, under which all citizens are covered.

Dr. Ida Hellander, director of policy and programs with Physicians for a National Health Program (PNHP), said that “when people talk about the public option, they are acknowledging that it’s the public part of the program that’s working.”

Clinton, she told Common Dreams, “seems to understand that but he’s not going all the way there,” likely because Secretary Clinton has also stopped short of calling for a single-payer model. However, she points out that this is not the first time the former president has voiced support for a universal system.

Agreeing with Clinton’s statement that “the insurance model doesn’t work here,” Hellander added: “The profit-driven, market-based healthcare model based on private insurance doesn’t work, and it will never work.”

http://www.commondreams.org…

Extend Medicare to everybody

By Jack Bernard  
The Citizen (Fayetteville, Ga.), Oct. 4, 2016

Megan McArdle, a well-known national writer for Bloomberg View, has put forth herself as an impartial expert on our healthcare system. However, I have found this piece (9-7-16, Citizen and 8-31-16, Bloomberg View) and other McArdle columns lacking in balance and solutions, not that what she says is necessarily wrong about the current situation.

For example, what she does not say is that the most recent data show that the ACA, Obamacare, has drastically reduced the number of uninsured. According to the National Center for Health Statistics, in the first quarter of 2016 there were “21.3 million fewer persons than in 2010” who were uninsured. That is quite an accomplishment, even though it still leaves 12% of our adult population uninsured, a bit less than 30 million people.

On the other hand, most of what she says about the ACA is true. It is a highly political “Rube Goldberg” rigged mess. Problems such as adverse selection, driving up costs for insurers who will then be forced to leave the market or raise rates, were entirely predictable. Years ago, my letters that were published in the Washington Post and USA Today indicated that virtually all of this would occur.

However, her analysis is incomplete. Although she briefly alludes to certain ACA provisions as halfhearted watered down versions of what works in Europe, she does not say is that the basic coverage and cost problems in the USA are due to our fragmented private insurance system.

It was and is this same system, via corporate lobbyists, that throws money at politicians so that nothing (including access, quality or cost) gets in the way of the corporate profit motive. It was corporate money and clout that pushed the ACA through Congress. Remember who funded the ads.

As she says, it’s the “political calculation,” and it is both parties who are guilty … aided and abetted by the relatively recent naive (read the decision to see how SCOTUS believes money has little effect on our politics) and disastrous Supreme Court decision known as Citizens United. How a supposedly conservative court can encourage the buying of our politicians is just beyond me.

But, my biggest problem with McArdle is that she appears to have no suggestions to clean up the malfunctioning system long term. A recent McArdle single payer (Medicare expansion) piece in Bloomberg purposefully misunderstands and excuses away the basic problem, our irrational healthcare financing and delivery system. In fact, the aim of that entire article seems to be to blindly accept the mess that we currently have because, in her words, “the politics is impossible” and there is a problem with “constitutionality,” whatever that means to her.

Further, she makes the incorrect assumption that single payer advocates believe that Medicare expansion will “magically transport us to the land of cheap health care.” I have been involved with single payer for many years and I know of no advocate who has said it will be easy. In fact, that very difficulty is the reason that both Obama and Trump have said that they could not support single payer, although both have made positive statements about it.

Let’s start with what McArdle gets right in her Bloomberg column. The U.S. spends a lot more per capita than any other country on healthcare, per her chart in that piece, and a lot of public dollars on a variety of government healthcare programs. And, our system does not deliver better results, an inconvenient fact which she ignores but that many healthcare experts know to be true.

We spend much more of our GDP on healthcare than other developed nations. When I became Director of Health Planning for the state of Georgia in the mid-1970s, we spent about 8 percent of GDP. We are now at about 18 percent … and still growing. What this means to the taxpayer is that we cannot make investments in other long-term priority areas, like education or alternate energy models, that are vital for the future of the nation.

With our current fragmented system, key players (providers, insurers, big pharmaceuticals) hold all the winning cards. That can only be changed if there is one payer, Medicare, with enough clout to force change. McArdle ignores this fact and others, incorrectly stating that private insurers (20 percent admin/marketing overhead) are just as efficient as Medicare (3 percent).

McArdle’s unstated conclusion in that piece and this current one as well is to just acknowledge that change is too hard to accomplish. So, let’s just complain and do little.

That position is a cop out and one that hurts this nation economically … and morally. What we need are leaders willing to look at the facts, fight the entrenched special interests and pass Medicare for All.

Jack Bernard resides in Peachtree City, Ga.

http://thecitizen.com…

Insurance decisions raise stress

By Carol Paris, M.D.
The Tennessean, Letters, Oct. 4, 2016

I’ve just received my letter from Blue Cross Blue Shield of Tennessee informing me that they have reached “the difficult yet necessary decision” to withdraw from the Nashville market.

In one more year I can finally get some piece of mind; I will turn 65 and qualify for Medicare. What about my daughter and her family and all the other Tennesseans affected by this decision?

Once again, needless time will be spent exploring diminishing options and undoubtedly deciding to accept more risk (and stress) in the form of higher deductibles and co-pays so that monthly premiums can be worked into the already strained family budget.

This stress has become an epidemic in this country and it has a name: PIISD (pronounced “pissed”), Private Insurance Induced Stress Disorder. If you avoid seeking medical care because of cost, if you can’t afford to take needed medication as prescribed because of cost and worst of all, if you avoid talking about this because you feel ashamed and alone, you meet the diagnostic criteria for PIISD.

Although the majority of the American population has gotten PIISD, we have not decided to demand the cure, an improved and expanded Medicare for all. What is it going to take?

Dr. Carol Paris resides in Nashville.

http://www.tennessean.com…

Harvard’s shameful stance on insurance for low-income employees

Harvard’s low-income workers deserve affordable health insurance

By Micah Johnson and Sanjay Kishore
STAT, September 30, 2016

There’s an outbreak of a hidden epidemic — unaffordable employer-based health insurance, especially for low-income workers — at Harvard, a place where it should never occur.

As medical students at Harvard, we were deeply troubled to learn that our university was proposing changes to dining workers’ health plans that would make essential health care unaffordable. After months of negotiation, the dining workers’ union voted to authorize a strike, which will launch on Wednesday if a deal is not reached. The campus has rallied around the workers, circulating a petition of support signed by 2,500 students, including us, in advance of federal mediation held earlier this week.

In the dining workers’ fight with Harvard, we see a microcosm of current challenges for health insurance across America.

The affordability of health insurance plans comes down to two factors: premiums and out-of-pocket costs. How affordable are employer plans? A team of Harvard medical students compared the plan Harvard proposed for the dining workers to what would be available on the Massachusetts health exchange.

For a family of three earning $30,000, the Harvard plan requires an employee to contribute a premium of $233 a month, while the health exchange has plans that require no premium at all. Harvard Medical School faculty and the World Health Organization have defined any health spending over 10 percent of annual income as a catastrophic expenditure. The Harvard plan comes perilously close to this with premiums alone. The cherry on top? Harvard’s plan also has higher co-pays than the exchange plans.

It is shocking that these low-income workers would be better off financially if they were not offered employer-sponsored insurance.

This may seem confusing. After all, exchange plans have been lambasted for their soaring costs. But the sobering truth is that the situation is worse among employer-provided plans. A recent Urban Institute study showed that total premiums were lower in exchange plans than in employer-provided plans in more than 80 percent of major US markets. In Boston, the premiums for exchange plans were 35 percent less expensive than employer plans. The gap would likely be even larger for lower-income employees, who would be eligible for more robust subsidies in the exchange plans.

Harvard’s proposal for its dining workers threatens to widen health disparities along lines of race and class. Many of the dining workers are immigrants, over half identify as people of color, and nearly half earn less than $35,000.

Innovation in health care is more likely to happen when big employers, rather than low-income workers, feel the burden of health care costs. Institutions like Harvard hold tremendous untapped power to implement novel programs and pressure health systems to make badly needed reforms.

Not every creative intervention will work. But only by moving beyond the status quo will we learn which new ideas have real benefits. Simply making poor families pay more for essential services like insulin prescriptions and hospital admissions is an unacceptable cop-out.

As physicians in training, we cannot stand by as the world’s richest university forces its most vulnerable employees to choose between dinner and a doctor’s visit. Harvard can do better, and this “better” can have a ripple effect on other unions, other universities, and other workplaces across the nation. Employers like Harvard must pursue real innovation, not simply balance their budgets on the backs of those least able to afford it — and least likely to survive it.

Micah Johnson and Sanjay Kishore are second-year students at Harvard Medical School.

https://www.statnews.com…

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Harvard students freak out as dining hall workers prepare to strike: ‘I don’t need to worry about where my food is coming from’

By Meg Wagner
New York Daily News, October 4, 2016

Harvard’s dining hall staffers are about to go on strike, much to the dismay of starving, stressed-out students.

“I understand it’s for legitimate purposes, but I’m worrying about midterms right now,” freshman Sofia Garcia told the Washington Post. “I don’t need to worry about where my food is coming from.”

It’s unclear if students — who pay a whopping $36 a day for unlimited dining hall access — will be refunded for any lost meals.

Union negotiator Michael Kramer said the 750 workers demand “the ability to earn at least $35,000 a year and a health insurance program that does not shift costs onto those who can least afford it.”

The university countered that the workers receive “some of the most generous hourly wages and benefits” for food service workers in the region and that it is proposing “modest” health care changes already accepted by thousands of other unionized university workers.

http://www.nydailynews.com…

***

Comment:

By Don McCanne, M.D.

Creeping deterioration of employer-sponsored health insurance seems to lie in the background as concerns are directed to many other more obvious deficiencies in America’s dysfunctional health care financing system. But creeping deterioration is occurring and the seriousness of it is demonstrated by Harvard – an employer that should be carrying the banner towards comprehensive reform but instead is shamefully joining the trend toward shifting unaffordable health care costs onto its employees, seriously impacting affordability and access especially for its lowest wage employees.

It is gratifying to see that two of Harvard’s medical students, Micah Johnson and Sanjay Kishore, are joining in the effort to publicize the plight of low-income Harvard employees in their stalled negotiations over maintaining essential health benefits.

But Harvard defends itself by saying that the reductions are modest and commonplace, while Johnson and Kishore suggest that we need to experiment with creative intervention. And student Sofia Garcia simply doesn’t want to worry about where her food is coming from during the strike.

We have decades of creative intervention and that has only resulted in the highest costs and the most dysfunctional health care financing system of all industrialized nations.

This problem is much greater than being simply a negotiating point in a labor dispute. Harvard, their students, and everyone else needs to demand enactment of a health care financing system that will make health care affordable and accessible for all of us – a single payer national health program. Harvard’s dining hall staffers might still need to negotiate for decent wages, but at least they would have affordable and accessible health care permanently.

Ask Minnesota if the individual insurance market is stable

Individual health plan premiums to jump at least 50 percent in Minn.

By Christopher Snowbeck
StarTribune, September 30, 2016

Health insurers are hiking premiums and limiting enrollment in Minnesota’s individual market next year, with regulators saying the emergency measures were needed to avert a market collapse.

The moves are a clear sign that the market for some 250,000 people who buy coverage for themselves is dysfunctional and needs reform, said Commerce Commissioner Mike Rothman during a Friday news conference.

While rate increases of more than 50 percent aren’t fair to consumers, Rothman said, things could have been worse. He described a period this summer when all health insurers in the state seemed prepared to abandon that segment of the market.

The premium jumps and enrollment caps are confined to the individual market, where about 5 percent of state residents buy coverage. The market includes the MNsure exchange and has undergone significant changes with the federal Affordable Care Act.

Premiums will jump by an average of 50 percent to 67 percent, depending on the insurer. Regulators also are taking the unusual step of letting most health plans limit the number of enrollees they’ll cover.

The caps will pressure consumers to shop early during the coming open enrollment period, since some plan options could disappear once insurers hit their limits. And regulators say the policies being sold for next year will feature tighter controls on the doctors and hospitals that enrollees can use.

The premium hikes and enrollment caps amount to a “finger in the dike” that’s meant to buy time while the state figures out what to do, said Jim Schowalter, chief executive of the Minnesota Council of Health Plans, a trade group for insurers.

“What I think no one really appreciated until today was the trouble that the insurance market is in,” Schowalter said. “This announcement is another sign that how people are getting their own insurance isn’t working.”

“These rising insurance rates are unsustainable and unfair,” Rothman said. “Middle-class Minnesotans, in particular, are being crushed by the heavy burden of shouldering these costs.”

http://www.startribune.com…

***

Comment:

By Don McCanne, M.D.

We keep hearing that ACA is working as intended, that all we need to do is enroll more younger, healthier individuals in the plans and all will be well. Ask the people in Minnesota how it is going. And they certainly are not the only state with problems.

Our politicians on the one hand tell us that all we need is a couple of patches, and on the other hand tell us that we should dump the system and let the markets work. Well, the system is not amenable to patches – we need comprehensive reform of the financing infrastructure – and the market cannot possibly work when prices far exceed the discretionary income of most of those who need health care.

The current patches in Minnesota include large premium hikes, and allowing the insurers to put limits on the total number of enrollees. Those patches might help the insurers, but for patients they make insurance less affordable and less accessible. Wasn’t reform supposed to take care of patients?

Regular readers know what would work – a well designed single payer national health program. Everyone would be covered by a system that would be affordable for each one of us. Minnesota should be leading the way on this.

Let’s aim to be happier with ColoradoCare

By Chris Schwab
The Coloradoan, Letters, Oct. 3, 2016

I guess I’m supposed to laugh when I see the cutie-pie anti-Amendment 69 ad that has been popping up on TV — but the only reaction I seem to be having is my blood pressure rising. The big-money, fact-distorting ad tries to scare us with the specter of state bureaucrats running health care — but leaves out the fact that health care is now run by for-profit corporate bureaucrats who fundamentally make their money by not providing health care — a huge, huge incentive to provide as little money as possible for care and keep as much as they can for themselves.

Before taking the heavily biased advice of some superficial ad on TV, you might want to try a few things first: Google “best medical systems in the world.” I believe you will find a vast majority of systems more in line with what Amendment 69 is proposing 1 than with the system we have now that siphons off money for sky-high administration costs. While you are at it, you might try googling “happiest countries”; see any correlation? Finally, get the advice of boots-on-the-ground medical professionals such as those at Physicians for a National Health Program, my son the doctor, and my daughter the pharmacist — all who are sickened by seeing health care money not going for actual care.

I would love to see the pro-Amendment 69 people counter with their own ad — maybe something with vampires? Vote yes on Amendment 69! Hey, even Donald Trump has been quoted as being in favor of the concept. 2

Chris Schwab lives in Fort Collins.

http://www.coloradoan.com…

Endnotes

1. PNHP has published a brief evaluation of the ColoradoCare ballot initiative, Amendment 69, here.

2. During the Aug. 6, 2015 Republican primary debate, Donald Trump claimed that single payer “works in Canada.” This is true. During the Oct. 9, 2016 general election debate, Donald Trump claimed that Canadian Medicare was “catastrophic in certain ways.” This is false. For more information on myths related to Canadian health care, click here.

The Affordable Care Act presents challenges for college students

By Aldebra Schroll, M.D.
KevinMD Blog, Oct. 1, 2016

The school year is back in session, and our student health center is busy.  As a college health doctor, I have been able to watch the rollout of the Affordable Care Act (ACA) among this population. Since its passage, more of our students are now insured, but many unique challenges still persist for this population.

Young adults have historically demonstrated high rates of un-insurance. An estimated 30 percent of those 19 to 25 years old were uninsured prior to passage of the ACA. They may have been working in jobs that did not offer coverage. Often, they had been excluded from health care when they aged out of their parents’ plan, or they were denied access due to pre-existing conditions.

Referred to as the “young invincibles,” young adults are considered an important part of the insurance marketplace. This population is generally healthy, not requiring a great deal of medical care, thus providing a balance by subsidizing the older, usually sicker population. The concern is that without the young adults buying health plans, the insurance exchanges will be burdened with the cost of an older, sicker population producing what has been called a “death spiral” where in the cost of insurance rises beyond what people can afford.

Since passage of the ACA, young adults have benefited with an expansion of health insurance coverage allowing them to stay on their parents’ plan until the age of 26. An estimated three million young adults have gained coverage through their parents’ health insurance plans. However, that assumes the parents have a health plan. I frequently find our students have been uninsured and had no regular access to health care in the years prior to arriving at college.

For those who are covered under a family plan, there is a cost in terms of privacy. College students are young adults; many of whom prefer to have their medical needs managed without parental knowledge or oversight. Those who remain on their parents’ healthcare plan into young adulthood often express concerns about their privacy. This is particularly apparent when addressing issues of sexual health, psychiatric care or treatment for alcohol or drug abuse. Although their medical chart remains private; if they use their insurance for a referral, testing or treatment, the explanation of benefits (EOB) will go to the primary insurance holder, usually a parent. At an age when medical providers are trying to encourage this population to take on the responsibility for their health; this is a persistent challenge.

Furthermore, I have found the policy to rescind insurance coverage at the age of 26 to be arbitrary. Many of our graduate and even undergraduate students are still enrolled at this age. Suddenly they find themselves uninsured, which can lead to major interruptions in their health care management, particularly for those who have an emergency, need hospitalization or specialty care.

Another concern for this population is cost sharing and issues of underinsurance. Cost sharing for silver plans is about $3,000 and over $5,000 for the bronze level plans. When considering the increasing costs of higher education, the added expense of health care can stretch the budget of a student, creating another stressor.

Expansion of Medicaid has also aided young adults; particularly in those states that agreed to accept the Medicaid expansion. Unfortunately, twenty states have chosen to “opt out” of the Medicaid expansion. This has led millions of citizens to find themselves in the “coverage gap.” They do not qualify for tax credits to purchase a plan; while at the same time, they are ineligible for coverage through Medicaid. This is a common dilemma for students who are working while attending college.

For our students who are eligible for Medi-Cal, the California State Medicaid program they often wait several weeks to get enrolled and then find there are no local providers taking new patients. For those who are enrolled in managed care Medi-Cal in their county of origin but attending school in another county, sometimes hundreds of miles away, they find themselves out of network, limiting their access to care. This issue also arises when students enroll in a private plan, then relocate to attend college far from home.

Meeting the needs for students with mental illness is a growing concern for campuses across the country. Greater numbers of students arrive on campus, having previously been treated for mental health issues. Finding appropriate specialists that are in network and taking new clients is a constant struggle for a semi-rural campus such as ours.

Many of our students remain uninsured for a variety of reasons. They may not understand or see the need to get coverage. Some find “shopping” for options on the state website to be daunting. They are also confused thinking that having access to our student health services is the same as insurance.

Despite the implementation of the ACA, our current health care delivery system is convoluted, creating a maze of challenges to those seeking care. It is inefficient and enormously costly, rife with bureaucratic waste. A single-payer national health system would provide comprehensive health care through a system that covers all medically necessary care, with simple enrollment and allowing the free choice of doctor. Such a plan, often referred to as “Medicare for all” would save an estimated $400 billion a year by eliminating the costly administrative expenses associated with the private insurance industry. Anticipated benefits include the elimination of the insurance networks that bind people to a particular geographic area. Further benefits are anticipated through job growth; as employers would no longer carry the burden of providing health care insurance.

The Affordable Care Act was a laudable attempt at guaranteeing health care access to all. However it has fallen far short. Millions remain uninsured; those who obtained coverage must deal with high co-pays, deductibles, and limited networks. The college-age population has many unique challenges as they transition to adulthood and take on the responsibility for managing their health care needs. This population could benefit greatly in a single-payer health care model offering affordable, comprehensive coverage, with geographic flexibility while ensuring their privacy.

Aldebra Schroll is a family physician.

http://www.kevinmd.com…

How would a Medicare buy-in and a public option be designed?

Designing a Medicare Buy-In and a Public Plan Marketplace Option

By Linda J. Blumberg and John Holahan
Urban Institute, September 2016

Medicare is an attractive basis for developing an insurance alternative (either a direct buy-in or a public option based in some way on Medicare rates) because the program generally has lower provider payment rates and lower administrative costs than private insurers. However, Medicare’s structure and cost-sharing requirements are different from private insurers’ as well. A Medicare-related proposal could provide more plan choice for those eligible, which would have a significant effect where few or even only one insurer offers coverage in the nongroup insurance market. Depending upon how the proposal is structured, it could reduce costs for younger adults in the private insurance market as older adults leave the risk pool. However, designing such programs raises myriad issues, each with specific implications for costs and benefits to different age groups.

Medicare Buy-In for 55- to 64-Year-Olds

We assume that a Medicare buy-in option would offer enrollees the same covered benefits and cost-sharing structures offered to current Medicare beneficiaries. Even so, a buy-in directly into the existing Medicare options would lead to questions necessitating policy decisions:

*  Would potential enrollees have the choice of traditional Medicare, Medicare Advantage, or both?
 
*  Would eligibles be able to choose between a Medicare option and Marketplace-qualified health plans for which they are currently eligible, or would Medicare be their only option outside of employer-sponsored insurance?

*  Would enrollees be allowed to make separate purchase decisions for Medicare Parts A, B, and D, or would they have to purchase all if they purchase any? How will consumers respond to offers of coverage that, unlike private insurance options, have no out-of-pocket maximum? Would Medigap or some other supplemental plans be available to the 55- to 64-year-olds?

*  How would the unsubsidized cost of coverage be determined? For example, what premium would be charged to individuals with high incomes? Would 55- to 64-year-olds be charged the same premiums as those age 65 and older, even though the premiums would not reflect the cost of coverage for those enrolled? Or would actuaries set premiums based on the benefits provided and cost-sharing requirements for each component? Would the high income surcharges in the current Medicare program apply to the buy-in population?

*  Assuming that 55- to 64-year-old enrollees would not pay the same premiums as current-law Medicare enrollees, would premiums reflect the health care costs of only the 55- to 64-year- olds enrolling? Or would premiums be set to reflect enrollees’ health care costs being shared by others? For example, their costs could be shared with other nongroup market enrollees or perhaps with current-law Medicare enrollees, but that would require the development of a mechanism for achieving it.

*  Would the 55- to 64-year-olds buying in to Medicare be eligible for financial assistance similar to that for Medicare beneficiaries today (e.g., 75 percent of Medicare Part B costs for all but the high-income beneficiaries? Would they be eligible for ACA-like financial assistance, advanced premium tax credits and cost-sharing reductions? Or would no financial assistance be offered at all? If subsidies are provided, how would they be structured? Would actuarial differences between Medicare and Marketplace silver coverage be taken into account, affecting both advanced premium tax credits and cost-sharing reductions?

*  Would 55 to 64 year olds with access to an affordable employer insurance plan be permitted to enroll in a Medicare buy-in option?

A Public Option for All Age Groups

A public option is a qualified health plan that would be sold through the ACA’s government-created Marketplaces (either federal or state). The public option would bear health insurance risk like other insurers, complying with the ACA’s insurance reforms (e.g., modified community rating, guaranteed issue, and essential health benefits) and offering coverage in the same actuarial value tiers.

A public option avoids complexities associated with a Medicare buy-in for 55- to 64-year-olds. Because the option would be structured and operated in much the same way as any other Marketplace-qualified health plan, it would not have different actuarial values, cost-sharing structures, or premium structures than other Marketplace options. The appropriateness of applying a Marketplace subsidy structure to a Medicare product would not be an issue, and risk-sharing questions across different age groups would not arise. Yet several design decisions would remain:

*  How would provider payment rates be set? Would they be set consistent with Medicare rates, set consistent with Medicare rates plus some percentage, or based on some other fee schedule? Many states have self-insured plans for their employees; this is another potential platform for creating a public option offered in a state Marketplace.

*  If rates are set at the Medicare level (or at some other level that falls below those paid by private insurers), what leverage would the plan have to ensure sufficient provider participation? How does a state’s leverage compare with that of the federal government in this respect?

*  Should public options be set up in all geographic areas or only those with high premiums, high premium growth, or otherwise weak insurer or provider competition? If the latter, who will judge appropriate locales, and by what metric will an area’s appropriateness be assessed?

From the Summary

Regardless of the approach taken, providers are likely to resist new insurance options that may move more patients into plans paying lower rates. While this is to be expected, it highlights the perpetual quandary of health care cost containment. Health care spending and its growth cannot be reduced without either paying less, on average, per unit of service rendered or reducing the quantity of services provided. No matter the strategy for containing costs, achieving that goal will take money out of the pockets of providers. To protect providers financially means abdicating cost-containment efforts of any type.

http://www.urban.org…

***

Comment:

By Don McCanne, M.D.

There is considerable enthusiasm for expanding on the advances of the Affordable Care Act by adding a Medicare buy-in for those 55 to 64, and by adding a public option – an insurance program run by the government competing with private health plans. What is lacking in this discussion is a precise description of either proposal considering that there are a multitude of policy options that must be decided on in order to construct these programs.

In this Urban Institute paper, Linda Blumberg and John Holahan discuss some of the design options, and there are many more. Each option has its own advantages and disadvantages, so it is inevitable that the eventual design would forge a compromise between benefits and deficiencies. Building these two programs on top of our highly fragmented financing infrastructure inevitably perpetuates inefficiencies.

Each program would require an act of Congress. We need only to look at the insurance industry influence in the legislative process that developed the designs for the private insurance exchanges under ACA, for the Part D Medicare drug program, for the private Medicare Advantage plans, for the privatization  of the Medicaid programs, for the previous public option proposals that never got off the ground, and for the co-op model that is failing in the marketplaces, and it will be obvious that the Medicare buy-in and public option will be designed to maximize the leverage of the private insurance industry at a cost to potential enrollees and taxpayers. The insurers will introduce features that are designed to make public programs noncompetitive or even cause them to fail.

When you hear people advocate for a Medicare buy-in or for the public option – and those people are everywhere – demand that they show you their model that was distilled from the multitude of policy options. (Be sure to read the Blumberg and Holahan paper so that you understand at least some of the issues.) Without such a model, the design will default to the private insurers.

Once advocates present their definitive model then analyze it to see how well it meets our reform goals. Will it ensure that everyone is covered? (No) Will it slow the increase in health care costs? (No) Will it ensure that everyone has free choice of health care professionals and institutions? (No) Will it remove financial barriers to care? (No) Will it fill in all of the gaps in coverage of our traditional Medicare program? (No)

Efforts to enact a single payer national health program are rejected because the program supposedly is not politically feasible. Does anyone really believe that a Medicare buy-in and a public option would be politically feasible in a Congress dominated by conservatives and neoliberals? It’s not the goal of a single payer model that needs to be changed; it’s the politics. That takes work. A lot of it.